Challenging Dogma - Spring 2008

...Using social sciences to improve the practice of public health

Wednesday, April 23, 2008

Revising the Mpowerment Project: Critical Suggestions to Improve the Effectiveness of One of the Best HIV Prevention Programs- Nicholas Deputy

Over half a million people have died from the acquired immunodeficiency syndrome (AIDS) in the United States since the epidemic began in the early 1980s (2). Homosexuals were often targeted as the cause of the disease, but were also the first activist groups to prevent the disease from spreading (1). The prevention programs that they created were aimed at educating and spreading awareness about the severity of the human immunodeficiency virus (HIV) that causes AIDS (1). These interventions grew to incorporate town and city centers where men who have sex with men (MSM) can go to get HIV testing and to join a support group. These centers also provided the standard information to promote a healthy lifestyle that incorporates safe sex. While these resources are essential to an effective intervention, real progress wasn’t made until the Mpowerment Project and other similar programs were put into place in the 1990s (9). This program has had a lot of success in reducing the numbers of new HIV cases diagnosed by using a diffusion of innovations model (22). Using this technique, the Mpowerment Project attempts to change social norms through social outreach events and education on HIV prevention (9). Informal outreach goals are also incorporated into this program, which include casual conversations about safe sex among friends and acquaintances in order to promote safe sex as a norm (8,9). Community centers were also established, as in traditional interventions, to form a community where young MSM can congregate for social, educational, and recreational events (9).
While the Mpowerment Project and other similar programs have had a lot of success, the incidence of HIV and AIDS has been increasing in the past several years (1,3). Between 2001 and 2005, there has been a 13% increase in new cases, which is thought to be due to unsafe sex practices in MSM (7). Many of these cases have been found to be in young MSM, which indicates a failure of the Mpowerment Program to create an effective prevention program (3,7). This failure revolves around the perceived threat of HIV and AIDS by young MSM, social considerations for the target population, and who is specifically apart of the target population.
Many young MSM currently do not feel an immediate threat from HIV or AIDS (5). These men have grown up in a time where HIV has had a treatment available, and so they are unaware of how severe the disease can be (5,6). The Mpowerment Project does educate about HIV, but it doesn’t put the risks in terms of what young men value most. Young MSM in present day are also faced with more social stigmas than older MSM have not had to face. Stigmas such as homophobia and family acceptance pressure young MSM to be accepted by the general population. The pressure that these stigmas place on young MSM can often cause them to ignore safer sex practices in order to maintain discretion (13). The Mpowerment Project works to create a small safe community for MSM, but doesn’t attempt to change the social stigma that is present outside of that community. The Mpowerment Project also does not include minoritiy MSM in its target population, who are thought to be those most at risk of having unsafe sex (7). Despite the initial strength of the Mpowerment Project, its several failures could be corrected by putting a more proximal frame on HIV, by addressing social stigmas outside of its own community, and by working to include minorities who are at most risk.

The Importance of a Frame
For any public health intervention, a frame is created regardless of whether public health officials consciously spent time creating one. A frame is described as a conceptual base that is used by the mind to help understand a notion (11). Anytime a word, image, event or anything else is perceived by the mind, it begins to create a frame so it can understand the perception and what it is referring to (17). In public health, framing is used to create context around an issue in order to make the intervention more appealing. For example, creating an underlying deception frame around smoking can make teenagers feel that smoking companies are deceiving them with advertisements. This underlying feeling will then cause teenagers to stop or not try smoking because they don’t want to be deceived (23). This kind of customized frame has been proven to make selling a product (public health, in this case) more effective (7,12).
AIDS in itself already has a frame associated with it, one that does not imply an immediate threat or convey the severity of the life threatening disease. The Mpowerment Project does not attempt to alter this frame or stress the threat associated with HIV. If the Mpowerment Project, in addition to attempting to normalize safe sex practices, adjusted the frame and made HIV seem more like a tangible threat, it would create a powerful message. This message would then discourage young MSM from engaging in unsafe sexual practices and make the Mpowerment Project more effective in reducing the incidence of HIV.
The impression that most young MSM have about HIV is that, while it is ultimately a deadly disease, most people are not affected by it (5,7). The advent of HAART, highly active antiretroviral dug treatment, has caused many young MSM to believe that HIV and AIDS is now a treatable disease (5, 6). Because of this misconception, they do not realize the importance of safe sex practices and sometimes decide to forego them (6,7). In order to counter this belief, the Mpowerment Project needs to reframe the issue in order to make it seem more relevant. Reframing issues are particularly effective when they involve an emotional aspect and such a frame could be created that depicts the harsh side effects of HIV/AIDS therapy (19). An example of this kind of frame could include images of young MSM having to take multiple medications a day, or the side effects of aggressive treatments. Another approach could include images of popular gay figures who have died from HIV and AIDS in order to remind young MSM that there is no cure for this virus. A new frame of this issue that incorporates the severe risks and images of popular loved ones who did not survive HIV and AIDS would discourage unsafe sexual activity. Including this new frame in the Mpowerment Project would make it a more effective intervention among young MSM.

The Impact of Social Stigma
The Mpowerment Project encourages the creation of a community within the program to create a sense of connection and belonging among young MSM(9). While this community is set up to provide a place that allows young MSM to be at ease with one another, the project does not address social factors that occur outside of this community. These social factors, which center around social stigmas, do not directly increase the risk of spreading HIV or AIDS, but cause young men at risk to not receive the intervention they need (14). Having to face these social stigmas is one of the largest challenges that MSM have to deal with, and this more distal, but equally important factor is not addressed by the Mpowerment Project (13). Several studies prove that the impact that social stigmas have on MSM hinder an individual’s participation in HIV/AIDS interventions, and thus increases their risk (13,14,15,20). Additionally, findings indicate dealing with stigma might lead to depression, poor self-esteem and in some cases cause a direct increase in risky behaviors (13). The Mpowerment Project does not address this issue, and thus does not address an important factor that contributes to an increase in HIV incidence.
Two of the most common stigmas that MSM must face are homophobia and family acceptance. Homophobia particularly affects MSM because an individual who knows that his community is afraid of him is in turn frightened of his community. Having a homophobic community can cause an individual to fear for his own safety and in order to any danger to himself from his community, he may hide the fact that he is a MSM. Hiding his sexuality makes it particularly difficult to then attend gay targeted outreach projects where the Mpowerment Project is working. This ultimately results in a MSM not receiving the intervention because of his community, and therefore puts him, and others in his situation at a higher risk of engaging in unsafe sexual practices. The family acceptance stigma is similar to that of homophobia. Most MSM believe that their family will not accept them if they admit to their sexual practices, and so they hide them. This prevents them from being able to be targeted by the Mpowerment Project, and therefore puts at higher chance of practicing unsafe sex.
In order to reduce the impact of these stigmas, the Mpowerment Project needs to not only target the homosexual community, but the whole community. Their campaign to raise awareness and normalize condom use should also attempt to encourage the acceptance of homosexuals. Once this is accomplished, individuals will be able to attend the interventions and begin changing their behavior. Through this addition to the Mpowerment Project, the program will increase its effectiveness and be able to decrease the incidence of HIV in young MSM.

Appropriate Targeting: Focusing on Minorities.
The Mpowerment Project has shown to have great success in all of the young MSM who were involved with it. Unfortunately, most of the participants involved were Caucasian (75% or more) and so minorities were not well represented (16). This disregard for minorities limits the Mpowerment Project’s ability to effectively change social norms in all young MSM. This neglect causes a large disparity between Caucasian young MSM and African American young MSM. In fact, it has been reported that approximately 3% of Caucasian young MSM are HIV positive, compared to approximately 14.1% of African Americans (14). This disparity could be treated if the Mpowerment Project targeted all young MSM, including minorities in its attempt to decrease HIV and AIDS incidence.
In order to effectively target these minority groups, considerations that affect non-minority MSM groups have to be considered, such as minority-specific stigmas, and different bar and club habits and locations. African American MSM have their own set of stigmas that impact their involvement. These stigmas are similar to those faced by the general majority, but are often more severe (20). Homophobia and sexual discussion in particular hold a stronger stigma in minority groups. As stated before, homophobia causes individuals to hide their sexuality, and therefore makes them unable to be apart of the Mpowerment Project. Because sexual discussion is also a strong stigma, there is even pressure in communities that are more accepting of homosexuality. In this kind of situation, no one talks about sexual activity, and so the major method of the Mpowerment Project is defeated because safe sex messages cannot spread.
In order to properly target minority groups, more research has to be done to investigate where minority MSM convene. These locations may not be similar to where majority MSM interventions can take place, such as in popular “main-stream” bars or clubs. When attempting to perform outreach in such a minority location, care has to be taken to not offend any of the different subculture. In order to make this transition easier, specifically recruiting minority persons could help to locate and understand potential minority outreach locations. By slowly accumulating minority MSM, attempts can be made to change the stigmas associated with being a MSM, as in the majority group. Doing this will make it easier for minority MSM, who are often the most in need of intervention, to participate in the Mpowerment Project and reduce the spread of HIV.

The goal of the Mpowerment Project is to reduce the transmission of HIV within the young MSM population by attempting to change social norms. This intervention has been very effective but has failed to consider changing trends in the MSM population that have begun to hinder the effectiveness of the program. Similar intervention programs have been criticized in the past for not altering techniques to accommodate new changes in culture (21). An intervention that does not recognize these changes and adapt to them slowly becomes ineffective. If the Mpowerment Project continues without adapting to these new trends it too will become ineffective and will not achieve its mission to decrease HIV incidence.
Adjusting current frames around HIV and AIDS, addressing stigmas, and beginning to target minority groups are all critiques that can be used to improve the Mpowerment Program. The use of framing theory has been proven to be effective in public health interventions as well as consumer marketing campaigns (11,18). Readjusting the frame around HIV will cause more young MSM to recognize the severity of HIV that was common during the beginning of the epidemic. Addressing stigmas will target a more distal cause of unsafe sex in the MSM community: it will allow MSM to feel comfortable with their sexuality and make them easier to target through the Mpowerment Project. Targeting minorities is also essential so that the subgroup most at risk will get the attention it needs to combat the high rates of unsafe sexual practices. Incorporating these suggested strategies will address the new concern about the increase in HIV incidence in young people. These new strategies provide a fresh look at the intervention that has been very successful so far, and will allow it to continue to be successful in the future.

1.) Wolitski, et al. Evolution of HIV/AIDS Prevention Programs --- United States, 1981—2006. Morbidity and Mortality Weekly Report June 2, 2006 / 55(21);597-603
2.) Centers for Disease Control and Prevention. HIV AIDS Basic Statistics. Division of HIV/AIDS Prevention. National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention
3.) No Author. “H.I.V. Rises Among Young Gay Men” The New York Times. Jan 14, 2007
4.) Crepaz, et al. Highly Active Antiretroviral Therapy and Sexual Risk Behavior. Journal of American Medical Association. 2004;292:224-236
5.) Chen, et al. Continuing Increases in Sexual Risk Behavior and Sexually Transmitted Diseases Among Men Who Have Sex with Men: San Francisco, Calif. 19990-2001. American Journal of Public Health. September 2002, Vol 92, No. 9. 1387-1388
6.) Katz, et al. Impact of Highly Active Antiretroviral Treatment on HIV Seroincidence Among Men Who Have Sex With Men: San Francisco. American Journal of Public Health. March 2002, Vol 92, No. 3. 388-394
7.) Jaffe H, et al. The Reemerging HIV/AIDS Epidemic in Men Who Have Sex With Men. Journal of American Medical Association. 2007; 298(20): 2412-2414
8.) Center for AIDS Prevention Studies, University of California, SanFranciscoThe Mpowerment Project. San Francisco, CA.
9.) Hays, et al. The Mpowerment Project: Community Building With Young Gay and Bisexual Men to Prevent HIV. American Journal of Community Psychology. June 2003, Vol 31, Nos 3/4
10.) Coppola, et al. Preventing without stigmatizing: The complex stakes of information on AIDS. Patient Education and Counseling. Volume 67, Issue 3, August 2007, Pages 255-260
11.) Chua, K. Introduction to Framing. American Medical Student Association Website. February 10, 2006.
12.) Bakker AB. Persuasive Communication About AIDS Prevention: Need for Cognition Determines the Impact of Message Format. AIDS Education Prevention. 1999 Apr;11(2):150-62.
13.) Preston DB et al. The Relationship of Stigma to the Sexual Risk Behavior of Rural MSM. AIDS Education Prevention. 2007 Jun;19(3):218-30
14.) Frost DM, et al. Stigma, Concealment, and Symptoms of Depression as Explanations for STI Among Gay Men. Journal of Health Psychology. 2007 Jul;12(4):636-40
15.) Harawa NT, et al. Perceptions Toward Condom Use, Sexual Activity and HIV Disclosure Among HIV Positive African American Men Who Have Sex With Men, Implications for Heterosexual Transmission. Journal of Urban Health. 2006 Jul;83(4):682-94
16.) Kegeles SM, et al. Mobilizing Young Gay and Bisexual Men for HIV Prevention- A Two Community Study. AIDS. 1999 Sep 10;13(13):1753-62
17.) Valleroy, et al. HIV Prevalence and Associated Risks in Young Men who Have Sex. Journal of American Medical Association. 2000;284:198-204.
18.) Dorfman, et al. More Than a Message: Framing Public Health Advocacy to Change Corporate Practices. Health Education and Behavior. June 2005; Vol. 32(3): 320-336
19.) Professor Siegel
20.) Choi, et al. HIV Prevention Among Asian and Pacific Islander aMerican Men Who have Sex with Men: A critical Review of Theoretical Models and Directions for Future Research. AIDS Education Prevention 1998, Supplement A, 19-30.
21.) Stall, R. How to Lose the Fight Against AIDS Among Men. BMJ 1994 Sep 17;309(6956):685-6
22.) Centers for Disease Control and Prevention. The Mpowerment Project: A Community-Level HIV Prevention Intervention for Young Gay Men. Division of HIV/AIDS Prevention. National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention
23,) Tengs, TO et al. The Cost Effectiveness of Intensive National School Based Anti-Tobacco Education: Results from the Tobacco Policy Model. Preventative Medicine. 2001 Dec; 33(6): 558-570.



Post a Comment

Subscribe to Post Comments [Atom]

<< Home