Anti-Smoking Campaign Amongst Youth in Nigeria: A critique of the Social Marketing Theory – ASHAYE AJIBADE OPEOLUWA

INTRODUCTION
Over the last decade there has been a significant increase of youth smoking in Nigeria. According to the World Health Organization (WHO), there was a ten fold increase in smoking among young women between 1990 and 2001.1 A survey conducted by the WHO in the southern part of Nigeria revealed a smoking prevalence of 23.9 % among male youths, 17.0 % among female youth and an overall prevalence of 18.1%. 2 Smoking is harmful to nearly every organ of the body; causing many diseases and reducing the health of smokers in general.3 The adverse health effects from cigarette smoking account for an estimated 438,000 deaths, or nearly 1 of every 5 deaths, each year in the United States.4, 5 More deaths are caused each year by tobacco use than by all deaths from human immunodeficiency virus (HIV), illegal drug use, alcohol use, motor vehicle injuries, suicides, and murder combined.4,6

Active smoking causes most leading causes of death worldwide: cancers, cardiovascular diseases, chronic respiratory diseases, and respiratory infections. Not surprisingly, smokers have a substantially reduced lifespan in comparison with never smokers. Tobacco smoking causes diminished health and several problems such as cataract and gingival disease. Smoking by women adversely affects nearly all aspects of reproduction. Even though the health effects of active smoking have been under investigation for decades, new adverse health effects are still being identified. As recently as 2002, the list of cancers caused by smoking was expanded to include cancers of the liver, stomach, and cervix, along with acute leukemia.7 Tighter controls need to be instituted in the control of tobacco so that the growing epidemic does not wipe out the working population of developing countries like Nigeria.

The issue of smoking and health is complicated by the fact that Governments of developing countries have been slow to arrest tobacco smoking because of the large government revenues derived from the manufacture and sale of tobacco products. Tobacco is grown commercially and is relied upon to bring in foreign exchange through export, or revenue for the government if sold on the home market. Consequently, in some nations the ministries of health and of agriculture are working at crossroads. Transnational tobacco companies take full advantage of the present lack of legislation in most African countries on the promotion and use of tobacco.

While countries in the western world are making attempts at reducing the levels of cigarette smoking, not much is being done in the developing countries. Thus, while there is a significant decline in smoking rate in the United States and Europe, in the developing world such as Nigeria, the smoking rate increases by at least 20% each year. There are social factors that help contribute to the increase in smoking in Nigeria.

The Federal Governments fight against Tobacco has largely been on the basis of the Social marketing theory which is a combination of theoretical perspectives and a set of marketing techniques. It is defined as the design, implementation, and control of programs seeking to increase the acceptability of a social idea or practice in a target group. While not trying to discredit its effort, the Nigerian Government needs to employ additional behavioral model changes in its Anti-tobacco control campaign in ways that will be acceptable to the youth.

SOCIAL MARKETING THEORY AND SMOKING

The Federal Ministry of Health in Nigeria adopts the Social marketing theory in its anti smoking campaigns. These campaign involves the use of Billboards are erected in several locations throughout the country bearing warning signs about the harmful effects of tobacco smoking. Most of these bills boards are not attractive and are not located in places where they can be easily seen by the youth. They are on major highways and in the health care centers, clinics and other health care delivery centers. It has however not been effective as evidenced by the growing prevalence of tobacco smoking amongst the youth population. The present billboards need to be overhauled and their content adjusted to messages that will appeal to the youth population. The messages appear coercive and judgmental thereby limiting its effectiveness. Also, youth do not like to be told what to do, they want to be able to make their own decisions and be responsible for it.

More appealing billboards and TV adverts need to be employed in the fight against tobacco smoking. Information is being given without the necessary skills to change behavior. It also assumes that behavioral change, is largely a result of changes in beliefs, and that people will perform behavior if they think they should perform it. However, according to Prochaska and DiClemente (1986), behavioral change occurs in five distinct stages, Pre-contemplation, contemplation, preparation, action and maintenance. The later (maintenance) is lacking in the anti-smoking campaign. They should be given skills necessary to effect changes in behavior and to maintain such changes.

SMOKING AS A GLAMOROUS HABIT
The issue of acceptance is paramount amongst youth; they want to be among, do not want to be the odd one amidst their group. Tobacco industries make the youth believe that smoking makes them look mature, independent and courageous. Most youths who want liberation quickly buy the entire ideas of tobacco companies. So as soon as thy get into their teenage years, they want to pick up habits that are seen to be for adults. With this declaration is made however subtly, that they have now become of age and can take decisions of their own as deemed appropriate. Instead of bunging correct information on relationship between cancer and tobacco smoking, the big tobacco companies buy over some reputed scientists to refute correct research about tobacco smoking and health. In most of the French-speaking West African countries, you see three of four youths sharing a stick of cigarette. They use it to express their love for each other. In mall, youths inter-viewed claim that cigarette makes them strong and gives them courage. Unfortunately it is a false courage.

The present antismoking campaign in Nigeria does little or nothing in portraying smoking as a harmful habit other than the billboards it erects and the health warnings it requires some cigarette companies to place on their packages. Youth learn more by modeling and not by being ordered or given rules. Rules may play a role but advertisements that depict acceptable social behavior by modeling will be more efficient. This can be in the form of peer modeling or modeling by adults or icons in the society. Youth tend to identify with this role models and their influence can be positively harnessed. Behavioral change in the youth could be maintained by ensuring that they belong to the right peer group, one that supports the promoted behavior (not smoking). In the past two decades social marketing campaigns have been conducted in developed countries as well, to bring about other kinds of behavior change: smoking cessation, diet, condom use, helmet use and other preventive health behaviors. There is a great deal of literature on some very successful programs in developing countries.8

SOCIAL ACCEPTABILITY AND SMOKING
Even though smoking is not socially acceptable in Nigeria, tobacco companies have made tremendous efforts in increasing the social acceptability of tobacco smoking in the youth population and in the country at large. They have employed Cultural sponsorship as a marketing strategy. They have done this by sponsoring youth programs like Sport competitions, Movie shows and talent hunts all to increase access to the youth. A good example is Benson and Hedges who now sponsors some festivals as a way of projecting and expanding its product and market. Their products are clearly displayed in such festival. In Schools, they sponsor inter-school cultural activities and inter-house sports competitions, giving the youth the impression that cigarette smoking gives them courage, equality with adults, and makes them feel like adults. An example is the British American Tobacco (BAT) which commands about 78% of the cigarette market in Nigeria. The tobacco firm took a number of blockbuster films, including the Matrix and Ocean's Eleven, around the country in a domed travelling theatre with 500 seats and a wide screen and called it the "Rothmans Experience It Cinema Tour". Posters for the films were overlaid with pictures of packets of Rothmans and free cigarettes were handed out to people buying tickets.

The anti-tobacco campaign has not demystified the various myths and legends associated with smoking. Smoking is widely thought to offer a number of benefits, as in other African markets, it is believed to aid/speed digestion and to prevent vomiting after eating. Smoking is also said to aid/speed excretion hence it is a common practice for smokers to have a stick when they go to the toilet. It is also believed to be a stimulant especially in cases of depression. This and many more beliefs that individuals hold drive their demand for tobacco smoking. The FGN and the Ministry of Health (MOH) will need to intensify its effort in disseminating appropriate health education messages. Wrong beliefs needs to be dispelled with appropriate health information as pertaining to tobacco smoking.

IMPLICATIONS OF SMOKING AMONGST NIGERIAN YOUTH
With annual cigarette import of the increase (20 million sticks in 1970 to 2.966 billion sticks in 2000) 9, it is imperative to create anti-tobacco campaigns that are effective in reducing the initiation of tobacco smoking especially amongst the youth and also to reduce tobacco consumption in the nation as a whole. Other control measures have been introduced without much effect. Such include the cigarette taxes and duties, enforcing anti- tobacco laws. This can be done by encouraging private companies’ participation in the fight against tobacco smoking encouraging them to sponsor anti-tobacco programs and also encouraging the numerous antismoking Non Governmental Organizations that are springing up in the country.

As seen with the Florida Youth Tobacco campaign, The Florida TRUTH anti-smoking campaign built a new product and branded it. The product/action was being cool by attacking adults who want to manipulate teens to smoke. The campaign reduced the price of the behavior (attacking adults) by selecting adults everyone agreed had been manipulating them. They created places where kids were found by means of a statewide train caravan and the founding of local "Truth chapters." And, of course, they used promotion - but promotion that went beyond the traditional media ads to having kids directly confront the tobacco industry and publicize this teen "terrorism" in the popular media. The Campaign routinely carried out surveys of its target audience that allowed the campaign to discover important micro-market segments (South Florida Hispanics) where impacts were lagging. The Truth campaign has been a dramatic success; it is now the model for the Legacy Foundation's national anti-smoking campaign. In just two years, from 1998 to 2000, the percent of Florida middle schoolers who smoked cigarettes in the past 30 days fell from 18.5 to 8.6 percent while the percentage for high schoolers went from 27.4 to 20.9. 10

The Present Anti- Tobacco campaign in Nigeria needs to employ the strategies used in the Florida Youth Tobacco Campaign (FYTC), merchandise like t-shirts, key holders, baseball caps, and other branded materials can be distributed via an official campaign van at teen functions; youth advocacy groups should be encouraged as they will serve as a peer groups that will positively reinforce the acceptable behavior of ‘not smoking’ and increase youth empowerment through community involvement. Facilities need to be put in place to reduce the availability of and youth access to tobacco products and reduce youth exposure to second- hand smoke. Unlike in South Africa, for instance, it is still legal and common in Nigeria for cigarettes to be sold individually which makes it easier for children to afford them. Stricter control measures need to be in place like it’s done in other parts of the world where one requires an ID to purchase tobacco products.

CONCLUSION
The antismoking campaign adopted by the Nigerian government will work effectively if other social marketing methods are used in the campaign. Community-based participatory research should be encouraged as this provides communities and researchers with opportunities to develop interventions that are effective as well as acceptable and culturally competent. Ads asked youth to directly confront the tobacco industry and publicize this teen activism in the popular media. There is still an opportunity to change the situation that exists in Africa especially NIGERIA by learning from the experiences of other public health interventions, such as those for the HIV epidemic. The interventions appear to have reduced the risk behaviors by utilizing the existing infrastructure such as antenatal clinic. Applying this model to the current situation, it may be possible to provide public health information on the risk of smoking and exposure to environmental tobacco smoke.

In many modern societies, smoking has been an acceptable norm. It used to be socially acceptable in Europe and the United States but is less so now. This is because large-scale tobacco control programs have been instituted in such countries with increasing effectiveness. The mass media provide effective tools for convincing youth not to smoke; because they can communicate prevention messages directly to young people and influence their knowledge, attitudes and behaviors (Hopkins et al, 2001). Mass media campaigns usually achieve long- term success but they must be framed in ways that are attractive to the target population especially the youth. Research has also shown consistently that tobacco counter – marketing campaigns are most successful when they are part of a broader, comprehensive tobacco control activity.

REFERENCES
1. Nigeria takes on big tobacco over campaigns that target the young
http://www.guardian.co.uk/world/2008/jan/15/smoking.britishamericantobaccobusiness
2. Smoking Prevalence. Adult (15 Years & Older), 1990. Southern Nigeria (survey year unknown); Okojie, O.H., Isah, E.C. and Okoro, E. (2000). www.who.int/tobacco/media/en/Nigeria.pdf
3. U.S. Department of Health and Human Services. The Health Consequences of Smoking: A Report of the Surgeon General. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2004 [cited 2006 Dec 5]. Available from: http://www.cdc.gov/tobacco/data_statistics/sgr/sgr_2004/index.htm.
4. Centers for Disease Control and Prevention. Annual Smoking-Attributable Mortality, Years of Potential Life Lost, and Productivity Losses—United States, 1997–2001. Morbidity and Mortality Weekly Report [serial online]. 2002;51(14):300–303 [cited 2006 Dec 5]. Available from: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5114a2.htm.
5. Centers for Disease Control and Prevention. Health United States, 2003, With Chartbook on Trends in the Health of Americans. (PDF–225KB) Hyattsville, MD: CDC, National Center for Health Statistics; 2003 [cited 2006 Dec 5]. Available from: http://www.cdc.gov/nchs/data/hus/tables/2003/03hus031.pdf.
6. McGinnis J, Foege WH. Actual Causes of Death in the United States. Journal of the American Medical Association 1993;270: 2207–2212.
7. Tobacco Free Japan: Recommendations for Tobacco Control Policy, 2005. Health Risks of Smoking.
8. DeJong, W. Condom promotion: The need for a social marketing program in America's inner cities. Am J Health Promotion, 1989;3(4):5-10.

9. SMOKING PREVALENCE. Adult (15 Years & Older), 1990. Southern Nigeria (survey year unknown); Okojie, O.H., Isah, E.C. and Okoro, E. (2000). www.who.int/tobacco/media/en/Nigeria.pdf
10. Social Marketing Institute; Success Stories – Florida Youth Campaign. http://www.socialmarketing.org/success/cs-floridatruth.html

Refugee Women's Health Screening in Massachusetts one Shot Deal-Paroma Mitra

Although women and children face the maximum brunt of war and strife, they are a small part of the overall picture of refugee health. Approximately 80% of the refugees are women or children. Refugees are persons who are outside their country of nationality and who are unable or unwilling to return to that country due to persecution or a well-founded fear of persecution because of race, religion, nationality, political opinion, or membership in a social group.(5) The current system does not emphasize on the specific needs of health care in female refugees. Female refugees are at maximum risk since in countries of conflict, they play more traditional roles and are dependent on their families for all types of support, namely physical, monetary, mental and emotional support. During times of conflict, losing or being separated from their families’ leaves them susceptible to all forms of injuries. Female refugees are also extremely vulnerable to sexual violence in the form of rape, genital mutilation and violation of other reproductive rights due to racial and ethnic discrimination Also, they tend to be overcrowded in camps which are unsanitary and hence they are extremely vulnerable to multiple diseases. When they enter a new country of refuge, they come with special needs of their own namely human needs namely physiological, psychological, social and spiritual.

Currently, the Massachusetts Department of Public Health carries out a basic physical examination of refugees. The primary aim of this physical check up is to ensure that refugees don not have any diseases that would prevent them from entering the United States. These exclusions would include certain communicable diseases and mental health associated with violence. The refugees are further divided into Class A and Class B where Class A deals with communicable diseases and Class B deals with physical deformity and violence leading to Mental Health (5). Whereas, there is provision for treatment including follow up for Class A there is no provision for help for Class B refugees. The current refugee and immigrant program is currently conducted under the Department of Public Health in Massachusetts effective since July 1995. According to the current figures, the number of immigrants entering the state is 1100 annually primarily from Africa and central and east Europe especially from regions of strife. (5) Looking at the background these women come from, a physical examination seems inadequate, real emphasis must be paid on issues like mental health, malnutrition, gynecologic health which forms the bulk of the needs of refugee women.

Current Refugee Physiological Care in Massachusetts
Physiological issues like access to health care and diet and nutrition are overlooked in the current Massachusetts outline. Physiology concerns the normal functioning of the human body hence correct physiological care essential to the well being of these women. When refugee women come in for their first physical examination in most of the cases an interpreter is provided to explain the procedure. An interpreter could also help explain the new health care system they are to become a part of. There are language barriers, limitations regarding transportation, the refugee health finances which women traditionally are not trained to understand in their country of origin. Most women are taught not seek formal care but culturally are expected to treat themselves at home.(1) Therefore, an effort must be made to set up interpreters who not only speak the language but understand the cultural background these women come from and provide with tools to access health care. Interpreters can also counsel about topics like diet and nutrition to women as in a study looking a refugee camps it was reported that particularly prone to diet related malnutrition therefore they must be counseled and given correct diet in regard to their status as women who are menstruating or women at child bearing age as current data shows in a lot of refugee camps there is food shortage hence countries of second asylum must make arrangements for adequate nutrition.(3) Mostly women in refugee camps suffer from some form of malnutrition as during times of conflict there is shortage of food supplies and males tend to be fed first. Also, the food supplies often land up being inadequate in essential nutrients leading to large number of diseases. Dehydration is also another common occurrence seen in women as the water shortage is quite common and lack of clean water is very frequent resulting in a lot of cases of dehydration and diarrhea. Efforts must be made to ensure correct nutrition which does not lead to further exacerbation of disease and pre- existing dehydration must be treated with adequately.

Mental Health as a Vital Factor
Mental Health problems are a part and parcel of every group of society but particularly seen in refugee women. Pre-existing mental disorder may already be present in women which may be triggered by stress due to their surroundings. Other women may be stressed due to what happened in their home country, their flight to a new one and relocation. A study measuring health variables of refugee women for resettlement (10) included biopsychosocial factors such as depression and anxiety as important primary variables as they are seen in about 58% and 24% of women refugees .The most common disorder seen is PTSD (post traumatic stress disorder). (3)In a Yugoslavia study 65% women developed post traumatic stress disorder due to physical and sexual torture. (Kang et all 1965) .Separation from their families leads to additional stress which may exacerbate PTSD. Mental health examination carried out in detail must be mandatory while dealing with refugees and they have special needs that must be addressed adequately to ensure their well- being and they must be followed up on as well by specialists who can deal with the particular sort of stress disorders seen in refugees.

Refugee Women and History of Sexual Abuse and Rape

There is a high prevalence of sexual abuse and rape in refugee women. (1) Especially seen in third world countries, women are traditionally expected to submit to the needs of men and men may take advantage of women already weakened by war for personal abuse and pleasure. It is often reported that soldiers are at the fore front of sexual abuse and often use it as a tool for controlling a population already weakened by war and strife. A study investigating basic women’s right has shown that limitation of sexual and reproductive rights may affect health. (7) It has also been reported that men in second country of asylum may take advantage of frightened and susceptible immigrant women.

Adequate measures must be taken to address this part of mental health and a country or a state granting asylum must provide adequate counseling and support in regard to this. Also health care providers must understand privacy issues and the question of chastity in these women; they may not be able to trust male health care providers completely. It is also important to understand that seeing violence towards others or seeing acts of violence increases sense of vulnerability amongst women.

Refugee Women and Gynecological Issues
Refugee women suffer genital trauma in terms of various degrees of female circumcision which lead to various gynecological and obstetric problems later. (3) There are three different kinds of circumcision, Type 1(seen in Niger, Eritrea, Uganda) which is removal of the clitoris and prepuce, Type 2(seen in Kenya, Somalia, Egypt) deals with excision of clitoris and prepuce along with part of labia minora and type 3(Northern Sudan, Somalia) deals with removal of clitoris and prepuce and sewing up the labia minora with thread and leaving a little gap for urine and menstrual blood. (3)

A lot of countries in Africa namely Somalia and northern Kenya both currently involved in internal strife have high prevalence rates of type 2 & 3 type of circumcision. A large concern of female genital cutting (FGC) is the environment in which it is done in. A lot of the time, a non- sterile blade is used to perform the procedure on young girls by a mid- wife. There is high incidence of hemorrhage and septicemia (3) leading to death. Also a major concern in women who have undergone a type 3 FGC, urinary system infections are very common due to stagnation of urine and they face a large number of urologic as well as gynecological problems. In older women who have undergone the procedure, increased cases of pyometritis, dysmenorrhea, dysparenuia, pelvic inflammatory disease and chronic cervicitis are seen.(3) There is also increased aversion regarding sexual activity leading to different psychological problems from ones discussed above. In addition to this, there is increased incidence of HIV and HBV transmission.

Gynecologic care must be provided to prevent these diseases as far as possible. Women must be regularly checked for gynecologic diseases, regular pap smears and health care surrounding care of the genital region must be given. Also, refugee women have a higher incidence of parity leading to increased cervical prolapse and stress urinary incontinence. Also, special prenatal care must be given to women who have undergone FGC. These concerns if raised by women must be addressed correctly and health care providers must be able to respect the values and needs of women.

Refugee Women and Social Interaction and Expectations
Women are expected to fulfill the “family role” and expected to recreate an atmosphere equivalent to the old home and country putting additional stress on them. (3) They have to adjust to a foreign country and society and are expected to adhere to the ways of the old society as well as cultural traditions in their homeland casting them into particular roles. Role strain occurs when individuals are expected to conform to a form of behavior expected of them which leads to increased amount of stress. (3) It is commonly known that foreign ways are rarely valued by the larger society. This causes excessive strain and burden on women. According to the social networking theory, the surroundings influence the behavior however a new environment does not always necessarily assure of change of behavior. To address this role strain, support groups consisting of members of the same background & society nay help new immigrants to adjust to the ways of a new country and life style. Women should be encouraged to mingle and work in the new society they are in. They are also expected to adjust to a new system in terms of facilities new home and away from parts of their family. The concept of resettling is not addressed currently a high- quality tools are required to measure relevant concepts required for resettling like education. (10)

In other states, the Baylor nursing home ( near Dallas, Texas) uses community outreach services and centers that is driven by human needs and serves the refugee communities nears Dallas, Texas that comprises of many different societies of refugees such as South- east Asians, refugees from Central America , refugees from Mexico and Saudi Arabia. 70% of the people serving in these communities speak the language of the refugee community and it gradually introduces concepts of all forms of health care. (4) Students are encouraged to mingle in the community they serve and teach basic health care prevention. Massachusetts may also incorporate a similar method of care. In another state, Ohio, the system talks about interlinking between various departments to provide for physical, mental and social care of refugees. (2) It has also paid some emphasis on different needs of women refugees and talks about coordinators that not only address physical examination but set up agencies to help refugees to understand the new system they are now a part of. . It can serve as a basic framework for a revised model of the current Massachusetts system. Based on the Social Learning Theory where modeling may cause behavioral change, having other refugee women to help counsel the incoming women may cause a change in their behavior and attitude towards a new system.

A simple electrical system which we take for granted may seem new and foreign to refugee women. Language too becomes a burden. Electrical appliances, laundry and other things we take for granted may not be as prevalent in third world countries. Women particularly may be overwhelmed as children tend to pick up these modes faster and hence they must be specially taught to use the facilities available in the new country. Women in particular according to a study(9) reveal themes of leaving the good life behind, worrying about their children, feeling ambivalent about marriage and lacking hope in the future. These concerns must be addressed to ensure their well-being.

There is a role change that is seen in refugees as in women may get jobs before their husbands and become the primary bread- winner of their families creating a new gender role. If this causes a strain on familial ties, it leads to additional stress on the women concerned. A way to deal with the stress may be via prayer and worship for many. Religion is a key part of life for many women and religious practices may be a part of everyday living for many. It may be a source of strength for many and religious beliefs must be respected in every aspect of care. A new society may not always compliment the old hence the well-being of the individual is compromised. A social advocacy approach is needed with both individual and collective strategies for responding to the lack of sensitivity shown many times. (8)

Conclusion

Refugee women deserve to be treated with special sensitivity and careThe more we learn and study about them the better we can address their issues. (9) They each have varying needs that must even be assessed at an individual level if possible. Women form the back bone of the family in most places and can become contributors to society if given the opportunity to do so. The best way to address the needs of female refugees is to increase the knowledge and sensitivity regarding special health care. One must understand that these women come from often a tragic and violent past to an unknown and uncertain future. The feeling of being degraded, dismissed or ignored may have serious repercussions on these fragile lives. Massachusetts has a large number of refugees many of whom come from violent pasts and it is in integral part of society’s responsibility to ensure their well being. The Commonwealth could modify their clinical program on a more needs based assessment and follow up rather than a purely physical assessment. This must also contain special assessments of women’s needs separately. New proposals are being made currently to incorporate women’s health into the main framework of the current refugee and immigrant health program. The Massachusetts government and Department of Public Health must look into providing health care as well as addressing the other issues describe above. It is imperative and urgent that the community act to provide basic needs to refugees (6). One routine physical examination is not enough to assess the needs of many of these women, mental, psychological and spiritual health must also be addressed simultaneously.


REFERENCES:-
1 http://www.theirc.org/special-report/rape-in-congo.html
2http://jfs.ohio.gov/refugee/docs/NEW%20HEALTH%20SCREENING%20PROTOCOL.pdf
3 http://www3.baylor.edu/~Charles_Kemp/refugee_health_problems.htm
4http://www3.baylor.edu/~Charles_Kemp/refugee_health_models.htm
5 http://www.mass.gov/dph/cdc/rhip/wwwrihp.htm
6. http://refugees.org/uploadedFiles/Investigate/Publications_&_Archives/WRS_Archives/2007/SilentSurge.pdf

7. Basic health, women’s health, and mental health among internally, displaced persons in Nyala Province, South Africa, Sudan. Kim G, Torbay R, LawryL. Massachusetts Veterans Epidemiology Research and Information center, Veterans Affairs Boston Health Care System, Boston, MA.Jan, 2005.
8. Listening to different voices. Hrycak N, Jakubec SL. Faculty of Nursing, University of Calgary, Calgary, Alberta, Jun 2006.
9. Pavlish C. Narrative inquiry into life experiences of refugee women and men. International Nursing Review. 54(1):28-34, 2007 March
10. Gagnon AJ. Tuck J. Barzun L. A systematic review of questionnaires measuring the health of resettling refugee women. Health Care for Women International.25 (2): 111-49, 2004 Feb.

AIDS Intervention Strategies in India: A Socio-Political Approach Explaining Why They Are Ineffective – Nandini Ravishankar

India, a country with a population of one billion, is experiencing a rapid and extensive spread of AIDS. When HIV infection was discovered in India in 1986, the health authorities set up the National Aids Control Organization (NACO), which was primarily funded by the World Bank and technically supported by the World Health Organization (WHO) (9).

The current AIDS estimate suggests that the national adult HIV prevalence in India is 0.36 percent, amounting to between 2.5 and 3 million people. This number has seen a drop of nearly 50 % from the previous estimate of 5.2 million people living with HIV/AIDS (9). However despite a decrease in the overall number of people afflicted with AIDS, the current numbers are considerably high with most of the affected population losing out on the productive years of their lives. The prevalence rate for men is 0.43% while for women it is 0.29%. Prevalence is also high in the 15-49 age group (88.7% of all infections) indicating that AIDS still threatens the cream of society, those in the prime of their working life (20,23).

However, despite the work being done to tackle the crisis, there are some hurdles that may hamper the progress of the current interventions. Disparities still exist in the effectiveness and applicability of the interventions to vulnerable populations. The strategies adopted by the National AIDS Control Organization (NACO) to mitigate AIDS in India have been ineffective because social and political pressures prevent the right groups from being targeted.

1. Adolescents are not provided with adequate education about HIV/AIDS

Social Learning Theory is based on the tenet that people do not learn behaviors in a vacuum, isolated from external interactions (1). The theory stressed that a large contribution to adopting behaviors stems from observing and then emulating the actions of others within an individual’s community. In Indian society, there is a high level of taboo associated with talking about sex. Much of the information is communicated through a non-verbal channel and there are estimates that about two-thirds of meaning is communicated nonverbally (13). When adolescents see their parents and other elders hesitating to talk about sex, it leads them to believe that sex is something to be embarrassed about and something that is negative in nature. Adolescents may also experience confusion as the message projected in the interventions may not be in line with their core values, the core values being ‘sex is not something to be discussed’. They are less likely to accept interventions that are against their core values and may thus dismiss the information and education provided.

As mentioned earlier, in India it is taboo to talk about sex and it is an even greater taboo for parents to talk about sex with their children. There have been many barriers that have been identified which impede parents from communicating with their children about sex and sexually transmitted diseases (STDs). Studies report that parents often feel inadequately informed, embarrassed and ineffective and have difficulty finding the right place and time for communication (12). Thus parents often do not talk about sex and the adolescent is reprimanded for asking questions about sex. Parental education allows the adolescent to incorporate the idea of sex in a way that is in line with their core values. This would enable the adolescent to be better informed and better adjusted to the concept of sex and sexually transmitted diseases. Parents can also tailor the presentation of information to the life circumstances and social and familial context of the adolescent (12).

In the absence of parental communication, adolescents often turn to other sources to get more information. Recent work has supported the position that peers are often responsible for the onset of risk behaviors in adolescents (25). This work implies that although teens acquire information regarding risk behaviors from parents, teachers and the media, peers may also play a crucial role in a child’s development by shaping his/her normative beliefs and interpretation of information regarding risk activities (24). Becoming a member of a peer group is one of the primary developmental tasks of adolescence (4). Peer groups influence adolescent socialization and identity by allowing young individuals to explore individual interests and uncertainties while retaining a sense of belonging and continuity within a group of friends (8). Although a key aspect of normal adolescent development, there may be costs associated with becoming a member of a group of people. Some have considered peer pressure the ‘price of group membership’ (3), which research has linked to a variety of potential problems including substance abuse, risk-taking behavior and delinquency as well as dating attitudes and sexual behavior. For many young persons, substance use, risk-taking behavior and sexual activity may represent efforts to ‘conform to the norms of the group and to demonstrate commitment and loyalty to other group members’ (15).

Another frequent source of information for adolescents is the media, which influences how adolescents think and is likely to have a great impact on their behavior. The modeling theory is particularly relevant to the study of mass communications because the portrayal or description of social life is a frequent subject in the media. The actors who portray real people in visual, auditory or print media often serve as role models for others to imitate (6). As seen with other behavioral influences, the negative consequences of risk-taking behavior are rarely mentioned in the media in a way that would provide adolescents with important information. In the current scenario, the message that adolescents get is that it is acceptable to indulge in risky sexual behavior without experiencing any negative consequences. This contributes to an increase in sexual risk taking behavior among adolescents as they believe in the ‘feel good’ message being projected without considering the reality of the situation (8).

2. Social Stigma attached to HIV/AIDS

In many Asian countries including India, homosexuality is still a taboo. The social ostracism is also evident from the fact that homosexuality is considered a crime by the Judicial System in India. The statute does not directly state the ban on homosexuality but follows a law that was set by the ruling British Government in 1860. The Indian Penal Code (Section 377) states that: “Whoever voluntarily has carnal intercourse against the order of nature with any man, woman or animal, shall be punished with imprisonment for life, or with imprisonment of either description for a term which may extend to ten years, and shall also be liable to fine”. The punishment for this crime ranges from 10 years to life imprisonment. The word ‘carnal intercourse’ being vague, it has often been used against homosexuality (21). To bring about change in the current status of the HIV/AIDS epidemic in India, drastic changes need to be brought about not only at the societal level but also at the judicial level.

Goffman (1963) defined stigma as any condition, attribute, trait of behavior that symbolically marked off the bearer as ‘culturally unacceptable’ or inferior with consequent feelings of shame, guilt and disgrace (10). There is a high level of stigma that is associated with HIV/AIDS and very often, people do not confess that they have the illness which explains why the heterosexual partner, in most cases the woman is afflicted with the virus as well. The spread of HIV in India has been at its peak in the Western and Southern part of the country (19). Stigma associated with HIV-AIDS negatively impacts people’s decision regarding whether and when to be tested for the virus (26). Stigma therefore is a crucial aspect that needs to be understood in the management of people with HIV/AIDS. Stigma not only exists in the general community but also exists within the homosexual community itself. Results of a study indicated that many HIV-positive gay men perceived a division within the gay community related to HIV/AIDS. Their perceptions that HIV-negative men held stigmatizing attitudes toward HIV-positive men included feelings of sexual rejection and discrimination (5).

Social stigma and ostracism against homosexuality are held not only by society, but by the families as well. Homosexual men often are faced with the difficulty of dealing with the cultural expectations of their parents. They experience parental pressure to get married, have children, carry on the family name and traditions and not bring shame to the family by individual behavior choices and nonconformity (2). As a result of these expectations, many homosexual men choose not to come out of the closet. This prevents them from obtaining and having access to the right preventive information regarding HIV/AIDS. The perceived failure of meeting parental expectations associated with the role of the son, as well as the shameful stigma associated with homosexuality often leads the gay son to hold negative emotions like guilt, shame, low self-esteem, social inhibitions and insecurities (2). Very often, homosexual relations are maintained in secret without the knowledge of the family and in such situations, safe sex and the use of condoms take a backseat as keeping the relationship secret becomes the first priority. Choi et al. (1998) also conducted another study where they found that family obligations and homophobia in the community, along with negative sterotyping, marginalization contributed to low self-esteem and in turn resulted in risk-taking and lapses to unsafe sex (2).

The law criminalizing homosexuality has led to interventions that are designed to tackle HIV/AIDS but have not taken into account the needs of the gay community. Few published research studies have delved into the lives, the minds and the hearts of gay men to understand their feelings, attitudes, experiences and values. As a result, the public health interventions have failed because they have not targeted the core values of one of their target audiences: the gay community (18). One example of a shortcoming evident in the HIV/AIDS intervention programs that stems from a lack of insight into the lives, feelings and experiences of gay men is the virtual disregard for risk reduction as opposed to risk elimination strategies and the reluctance to candidly discuss, rather than merely dismiss as deviant, unsafe sex. As a consequence of the failure of the interventions, a sense of hopelessness and complete lack of control has arisen among gay men (18). Because they do not really believe that they will use a condom each time, many men assume that they are destined to become infected and therefore see no point in using condoms at all (11). This is an important issue to consider when initiating HIV/AIDS interventions. The needs, feelings and attitudes of the gay community must also be included. Thus, to tackle the HIV/AIDS crisis in India, interventions must not only focus on the heterosexual population and youth but must also address the fears and concerns of the gay community.

While it is important to address the individual behavioral factors that contribute to HIV/AIDS, it is also important to contextualize the risk factors, that is, attempt to understand how people come to be exposed to the individually based risk factors to design more effective interventions. By this, interventionsists must use an interpretive framework to understand why people come to be exposed to risk factors and the circumstances that shapes their exposure to the risk factors (14). For example, it is important in the framing of interventions to contextualize the risk factors for HIV/AIDS which would give a better understanding of why some people cannot avoid the risk. In a patriarchal society like India, it is important to understand the reasons why commercial sex workers are unable to get the men to practice safe sex which consequently may lead to an increase in the levels of HIV/AIDS in the sex workers.

3. Political factors impede HIV/AIDS Interventions

In a developing country like India with a population of one billion, there are structural inequalities that come with the treatment of HIV/AIDS. There are often other diseases and illnesses which take precedence over AIDS and the social taboos often play a role in influencing political agenda as well (16). Parker (2002) reported that a range of structural inequalities intersect and combine to shape the HIV/AIDS epidemic. There is an increasing gap between the rich and poor states with regard to public resources available for health, with resultant disparities in health outcomes (16). A major political concern that interventions need to consider and address is the reduction in the role of the central government in health care delivery. With decentralization and privatization being the answer to fill the gap in health care delivery, safety nets for the poor, especially those in the rural areas are being threatened. According to the WHO, India continues to bear the burden of the highest number of tuberculosis patients (7). With TB being an overwhelming burden and the leading cause of death in the country, there is less emphasis and priority given to HIV/AIDS. NACO programs are also supplemented by state level agencies, with great variabilty in terms of emphasis given by each state to the HIV/AIDS crisis. Many states are still in denial about the spread of HIV/AIDS within the state and thus are unwilling to provide money to tackle the crisis (7). Thus in order to address these concerns, more HIV/AIDS interventions need to be conducted at the state level to ensure that all citizens of the country have access to the same level of services and state governments must be required to co-ordinate activities in accordance with NACO. The partisan views of the various political parties must be addressed and modified for any effective change to occur in HIV/AIDS interventions at the political level.

Framing according to Tversky and Kahneman (1981) is ‘focusing the attention of people within a field of meaning’. Framing theory suggests that how something is presented (‘the frame’) influences the choices people make. The agenda setting theory is also closely related to the Framing theory (22). This theory states that agenda setting not only tells individuals what to think of an issue but also how to think about that issue. The agenda setting theory states that in order to get people to pay attention to the information, they have to view it as important and relevant (27). Thus, the moral, core values and principles of the current ruling political party determine how the crisis of AIDS will be tackled. The framing and agenda setting theory explain why conservative political parties would be more likely to promote the thinking that commercial sex workers are the most high risk populations as this is in line with social thinking and is likely to garner them more election votes. Thus by projecting AIDS as an issue among heterosexual individuals, the conservative political parties ignore the presence of AIDS among the homosexual population.

The Health Belief Model (HBM) was developed to explain health-related behavior at the level of the individual decision maker. The Health Belief Model (HBM) proposes that individual health beliefs associated with a disease or medical condition (i.e. perceived vulnerability to HIV/AIDS) determines their likelihood of engaging in preventive health actions (eg: use of condoms to prevent exposure) (17). The interventions developed by NACO also operate on the same rationale. It is believed that as long as individuals are provided with the interventions, they will utilize it based on their health beliefs. However the model and the consequent interventions fail to take into account socio-cultural factors. According to Choi et al., HBM has limited utility in addressing environmental factors affecting HIV risk because they ignore the wider social context within which the individual must circulate such as the family, and any communities of which an individual may be a member (2). Furthermore, the model assumes that all behavior is the result of a cost/benefit analysis, of calculated rational thought following the principle of self-interest. The Health Belief Model views the individual as devoid of emotion even though interacting with the wider social environment may entail situational and emotional difficulties for the individuals that consequently affect HIV risk (2). As seen with the model, there is a tendency for those in power to operate with an ‘inside the box’ rationale and an unwillingness to explore new avenues for progress. Combined with the bureaucratic and political pressure, there is an increased likelihood of interventions being built on top of earlier interventions with few modifications. While this may work for a certain period of time, it is important to acknowledge that interventions need to change with the changing times.

Implications for Future Interventions and Policy Decisions

In the light of the above mentioned factors, future interventions undertaken by NACO must therefore take into account socio-political factors. The crisis of AIDS can be successfully addressed only when all individuals who are at risk of contracting AIDS are targeted to receive the interventions. By excluding a particular group or ignoring important factors that may impact the prevalence of AIDS, the current interventions exhibit a lack of informed implementation. Despite being the largest democracy in the world, India still faces political hurdles that diminish the effectiveness and applicability of public health interventions. With the AIDS epidemic being a threat to the population of the country, more steps need to be taken to tackle the concerns at the grass root levels. While the current interventions have been shown to be marginally effective, it becomes more imperative to develop interventions that don’t just follow what has been done before but which incorporate the concerns of the diverse at-risk populations. Changes must originate at the grass roots level and must address individuals in the rural and urban areas. Changes need to be brought about at the societal and the judicial level for the gay community to feel accepted and acknowledged. Only when interventions addressing all populations and all concerns are developed will the battle on HIV/AIDS be successful.

REFERENCES

1. Bandura A. Social Learning Theory. New York: General Learning Press, 1977.
2. Choi KH, Yep GA and Kumekawa E. 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 and Prevention 1998; 10:19-30.
3. Clasen DR and Brown BB. The Multidimensionality of Peer Pressure in Adolescence. Journal of Youth Adolescence 1985; 14:451-468.
4. Coleman J and Hendry L. The Nature of Adolescence. London and New York: Routledge, 1987.
5. Courtenay-Quirk C, Wolitski RJ, Parsons JT and Gomez CA. Is HIV/AIDS Stigma Dividing the Gay Community? Perceptions of HIV-Positive Men who have Sex with Men. AIDS Education and Prevention 2006; 18:56-67.
6. Defleur ML and Ball-Rokeach SJ. Socialization and Theories of Indirect Influence (pp. 202-227). In: Defleur ML and Ball-Rokeach SJ. Theories of Mass Communication. New York, NY: Longman, 1989.
7. Ekstrand M, Garbus L and Marseille E. HIV/AIDS in India. University of California San Francisco: AIDS Policy Research Center, 2003.
8. Gardner M. and Steinberg L. Peer Influence on Risk Taking, Risk Preference and Risky Decision Making in Adolescence and Adulthood: An Experimental Study. Developmental Psychology 2005; 41:625-635.
9. Godbole S. and Mehendale S. HIV/AIDS epidemic in India: Risk factors, Risk behavior and Strategies for prevention and control. Indian Journal of Medical Research 2005; 121:356-368.
10. Goffman E. Stigma: Notes on the Management of Spoiled Identity. New York: Simon and Schuster, 1963.
11. Green J. Flirting with Suicide. The New York Times Magazine 1996; 39-85.
12. Jaccard J, Dodge T and Dittus P. Parent-Adolescent Communication about Sex and Birth Control: A Conceptual Framework. New Directions for Child and Adolescent Development 2002; 97:9-41.
13. Burgoon JK. Nonverbal Signals. In Knapp ML and Miller GR, eds. Handbook of Interpersonal Communication. Thousand Oaks, CA: Sage, 1985.
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15. Newman PR and Newman BM. Early Adolescence and its Conflict: Group Identity versus Alienation. Adolescence 1976; 11:261-274.
16. Parker R. The Global HIV/AIDS Pandemic, Structural Inequalities, and the Politics of International Health. American Journal of Public Health 2002; 92:343-346.
17. Salazar MK. Comparison of Four Behavioral Theories: A Literature Review. AAOHN Journal 1991; 39:128-135.
18. Siegel M and Doner L. The Importance of Formative Research in Public Health Campaigns: An Example from the Area of HIV Prevention among Gay Men (pp. 66-69). In: Siegel M and Doner L. Marketing Public Health: Strategies to Promote Social Change. Sudbury, MA: Jones and Bartlett, 2004.
19. Thomas BE, Rehman F, Suryanarayanan D, Josephine K, Dilip M, Dorairaj VS, and Swaminathan S. How stigmatizing is the Stigma in the Life of people living with HIV: A Study on HIV Positive Individuals from Chennai, South India. AIDS Care 2005; 17:795-801.
20. National AIDS Control Organization. HIV Data. New Delhi: National Aids Control Organization. http://www.nacoonline.org/Quick_Links/HIV_Data/
21. The Indian Penal Code - http://nrcw.nic.in/shared/sublinkimages/59.pdf
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23. UNAIDS. 2006 Global Report on the AIDS Epidemic. http://data.unaids.org/pub/GlobalReport/2006/2006_GR_ANN1A-L_en.pdf
24. Cox AD and Cox D. Beyond “peer pressure”: A Theoretical Framework for Understanding the Varieties of Social Influence on Adolescent Risk Behavior. Washington DC: Social Marketing Conference, 1998.
25. Wentzel KR. Social Influences on School Adjustment: Commentary. Educational Psychology 1999; 34:59-69.
26. Chesney MA and Smith AW. Critical Delays in HIV Testing and Care: The Potential Role of Stigma. American Behavioral Scientist 1999; 42:1162-1174.
27. Edberg M. Communications Theory (pp. 67-68). In Edberg M. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett, 2007.

Product(RED): An Overindulgence of America’s Consumerist Sweet Tooth Fails to Promote Education and Social Change- Melissa Gambatese

What is Product(RED)?
The Product(RED) campaign was started by singer Bono and Chairman of Debt, AIDS, Trade in Africa (DATA) Bobby Shriver, with the intention of raising awareness and money for the Global Fund, a world-wide collaboration of governments, the public and private sectors and communities affected by AIDS, tuberculosis and malaria that aims to raise, manage and distribute money to areas of greatest need (1). To raise money through their campaign, Bono and Shriver enlisted the help of popular companies like GAP, Apple and Microsoft to produce products to be sold under the Product(RED) name. A percentage of the sale of each of these items is given to the Global Fund. The Global Fund then uses the money to help mainly women and children in Africa who are infected with or affected by HIV/AIDS in African countries (2).
In theory, Product(RED) is a powerful capitalist tool based on cause-marketing theory that could be used to raise awareness and money for an increasingly urgent health problem. While research on this campaign and other similar campaigns is lacking, this campaign falls short in three distinct ways. Primarily, it promotes consumerism in place of activism and direct philanthropic action. In addition, the campaign overly relies on framing, agenda-setting and social marketing theories to institute social change without providing the consumer with the necessary tools that he or she needs to do so. Lastly, there are better alternative campaign ideas that focus on direct donation and the encouragement of education and awareness over the use of the sale of products to raise money. In the end, the Product(RED) campaign must be renovated to include deeper, more prominent aspects of education and awareness, and a lesser emphasis on the purchase of non-essential items as a way of making an impact on a large-scale public health problem.
Consumerism and Philanthropy Don’t Always Mix
The Product(RED) campaign is based on a facet of corporate social responsibility (CSR) called cause-related marketing. According to Trimble and Rifon, cause-related marketing theory (CRM) “joins a corporation together with a specific cause, or a not-for-profit organization (NPO) that is affiliated with that cause.” (3) Once this link between corporation and cause is created, the corporation establishes a marketing campaign. Theoretically, the root of this campaign is a goal to educate and raise awareness within the consumers about the cause in order to benefit the NPO while “simultaneously benefiting the corporation” (3). The difference between this type of corporate philanthropy and direct corporate donation is that, in CRM, the corporation does not make a donation unless the consumers buy products that have been linked to the cause (3). In other words, “revenue producing activities,” such as the sale of a product or service, must first occur before the donation of money to the cause by the company.
Trimble and Rifon also explain that if the company fits well with the cause it has chosen to team with, the consumer is more likely to view this corporation in a positive light and therefore, purchase its products or services. Similarly, in his article, “Patina of Philanthropy,” Mark Rosenman declares that cause-related marketing “ties consumer’s desires to see a social good with the corporations’ desires to see higher profits” (4). In other words, linkage to a familiar, popular cause increases income for the corporation by mentally tying the corporation to a positive cause or social good in the consumer’s mind. The researchers warn, however, that campaigns based on CRM, like Product(RED), “do not always benefit the NPO, but often benefit the corporate donor” (3), an idea which many consumers are not aware of. Much criticism surrounding the Product(RED) campaign stems from the idea that the process of money flow from consumer to Global Fund to NGOs in Africa is not transparent, and that it cannot be said whether the money that Product(RED) is contributing to the Global Fund is actually going to programs for HIV/AIDS directly. According to the New York Times, the money raised by the Product(RED) campaign, which makes up less than 2 percent of the Global Fund’s total budget, simply allows the Global Fund to shift money internally to other programs and may not actually benefit HIV/AIDS programs (5). In addition, the Times uncovers a shocking secret; “Red’s contributions also do not necessarily go to the countries hardest hit by HIV and AIDS; they only go to the programs with proven success records” (5). While the money is supporting successful, proven programs, little money is trickling down into smaller, grassroots interventions that could have larger impacts in the future if provided with enough funding.
In the end, the Product(RED) focuses mostly on increasing short-term sales revenue, rather than encouraging long term, direct social change at the hands of the consumer (6). The campaign allows companies to market themselves as socially involved in order to increase sales. While money is being donated to the Global Fund, the path it takes to trickle down within the Fund is ambiguous and unknown to the consumer.
Too Much Agenda, Not Enough Efficacy
Health behavior models that are alternative to traditional models can be extremely successful in encouraging groups of individuals to change their behavior for the better (7). Agenda-setting, framing and social marketing theories utilize the tools and techniques of consumer advertising to get the public’s attention on certain issues. The CRM approach, which is the foundation of the Product(RED) campaign, employs these alternative models to ensure that consumers will buy products. However, these alternative models can often fail to provide groups of individuals with the tools they need to support a specific cause outside of the campaign.
According to a review of Albert Bandura’s Social Cognitive Theory, the model places emphasis on cognitive, reflective processes in which humans make decisions. A traditional model, Social Cognitive Theory highlights the fact that humans are not passive beings, but rather are “self-organizing, proactive, self-reflecting and self-regulating” (8). In addition, the model argues that are individuals are not merely shaped by their environment; instead, humans make decisions by combining environmental, personal and behavioral factors together (8).
The Product(RED) campaign and its use of consumerism attempts to use this nuance of human decision-making to its advantage by skewing the perception of its customers and increasing the effect that environmental factors have in proactive decision-making. Using Bandura’s model, when an individual wishes to contribute to a charitable organization, he/she proactively utilizes his/her environmental, personal and behavioral factors to make the decision (8). However, by putting products in the middle of this decision of which charity to choose, the individual is forced to take additional steps before he/she reaches a decision about the charity. First, the individual must evaluate the corporation that is tied to the charity. Secondly, the individual must consider the type of product being sold and how much of the cost of the product will be donated. Lastly, the individual then considers the charity that will hopefully benefit from the sale of the product. By adding in these extra steps, the Product(RED) campaign shifts the focus of proactive decision-making from the actual charity and its cause and onto the value of the corporation and its product. By skewing the process, the selection of a charity is secondary and ultimately passive, because the corporation makes the decision as to where the money goes.
Most importantly, however, is how the Product(RED) campaign does nothing to support the concept of self-efficacy, an idea that is central to the social cognitive model (8). Self-efficacy refers to an individual’s beliefs that their actions can lead to certain desired changes in their behavior (8). Self-efficacy also states that if an individual does not believe that their actions will produce the desired outcome, their motivation to act to achieve this desired outcome is minimal (8).
CRM does not provide consumers the tools they need to directly contribute to or evoke social change (9). Rather than emphasize education, awareness around issues and what one can do to contribute, CRM theory simply focuses on consumerism. Consumerism is not what solves problems, however. Richard Kim of CBSNews.com urges campaigns such as Product(RED) to “spare [him] the fantasy that shopping till you drop somehow affects radical change” (10). In Kim’s article, Shopping is Not Sharing, he makes the argument that sustainability and success of continuous charitable aid cannot hinge on something as transient as consumerism (10). Consumerism does not empower the consumer to become actively involved in a social cause. It does not inspire advocacy or a feeling of self-efficacy in battling public health issues directly, as Bandura so persistently emphasized as crucial to successfully changing behavior.
In addition, Product(RED) does not provide alternatives for individuals who cannot afford to purchase products in order to donate. Many of the Product(RED) products are expensive, which may be a huge barrier to participation in social change or charity donation for a consumer with little money. Confidence in the ability to donate can be negatively affected, lowering a feeling of self-efficacy and many individuals may not have the motivation to look elsewhere for more economical ways to donate.
Without providing the tools to increase the consumer’s confidence that their actions are actually making a difference, Product(RED) cannot hope to create a sustainable flow of aid to the Global Fund.
Buy(LESS), Give and Learn More
Despite all of the criticism surrounding the Product(RED) campaign, several alternatives have surfaced that highlight areas in which we can improve upon and make better cause-related marketing campaigns. The Buy(LESS) campaign, a parody of the Product(RED) campaign, along with the (RE) campaign encourage individuals to donate directly to charities instead of buying products from which only a small percentage of profits are sent to the recipient (11, 12).
On its website homepage, Buy(LESS) invites potential donors to join them in “rejecting the tired notion that shopping is a reasonable response to human suffering” (11). In addition to the mission of Buy(LESS), individuals can find links to hundreds of charities that deal with a wide range of public health problems ranging from HIV/AIDS to hunger, Alzheimer’s disease and services for refugees. The money donated on the website goes directly to these charities, and no products are sold. There is also an option to recommend a charity to be posted on the Buy(LESS) website.
The (RE) campaign is another alternative to the Product(RED) campaign that seeks to “raise awareness for AIDS in Africa, encourage conscious consumption, and provide a means of involvement for those unwilling or unable to buy Product(RED) products” (12). Three choices are presented to the individual donor: donate through the purchase of re-used thrift shop t-shirts, skip purchasing and donate directly to a charity what you would have paid for a product, or donate red items that can be auctioned off to raise money for charity (12). All three options encourage conscious consumption and reduce the prominence of a middle man in donating to a cause. One hundred percent of proceeds go directly to grassroots organizations at the community level, rather than a global organization, which may not use the funds to directly impact HIV/AIDS programs. This campaign engages consumers in evaluating their own lives and reusing the things they already own to make an impact on a public health problem.
The development of alternative programs such as these is only one solution. If Product(RED) is going to remain a major public health campaign, it must be improved upon. In the article, Building a Better (RED), Jonathan Greenblatt of WorldChanging Newsletter, outlines specific improvements that would help to make Product(RED) a more sustainable, more proactive choice for the consumer. His suggestions include providing a tool with which consumers could track the amount of dollars that each product is raising and a mechanism with which consumers could vote on products they think should join Product(RED) (13). Greenblatt heavily emphasizes his last suggestion in which he challenges Product(RED) to emphasize “education as much as fashion and create channels that allow its consumers to learn more about the issues and get engaged in addressing them” (13). In addition, he praises Product(RED) in that it is based on theory that could potentially greatly excite a young generation of potential donors to make a huge impact on their world.
A Shift in Focus
Perhaps instead of focusing the criticism on what Product(RED) does wrong, the attention should be on what Product(RED) can do right and has the potential to do right, Greenblatt suggests (13). By incorporating educational tools, such as informational brochures next to product displays, information about other HIV/AIDS fundraisers and charities and more information on the dynamic of the Global Fund and similar organizations, Product(RED) has the great potential to leverage capitalism to spark activism and leadership in the up and coming generation.
REFERENCES
1. The Global Fund. How the Fund Works.
http://www.theglobalfund.org/en/about/how/
2. Product(RED). What RED is. http://joinred.com/
3. Trimble CS, Rifon, NJ. "Consumer perceptions of compatibility in cause-
related marketing messages", International Journal of Nonprofit and Voluntary Sector Marketing, Vol.11, No. 1, 2006.
4. Rosenman M. Patina of Philanthropy. Staford Social Innovation Review, 2008.
5.Nixon R. Bottom Line for (RED). The New York Times.
http://www.nytimes.com/2008/02/06/business/06red.html?_r=1&oref=slogin.
6. Polonsky M. Linking sponsorship and cause related marketing: Complementaries and conflicts. European Journal of Marketing, 2000.
7. Edberg, Mark. Communications Theory. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Chapter 6, pg. 65-76. 2007.
8. Pajares F. Overview of social cognitive theory and of self-efficacy.
http://www.emory.edu/EDUCATION/mfp/eff.html
9. Lafferty BA, Goldsmith RE. Cause-brand alliances: does the cause help the brand of does the brand help the cause? Journal of Business Research, 2005.
10. Kim R. Shopping is Not Sharing. The Nation, CBSNews.com.
http://www.cbsnews.com/stories/2006/10/17/opinion/main2098633.shtml.
11. Buy(LESS). http://www.buylesscrap.org/
12. (RE). http://reinspired.blogspot.com
13. Greenblatt J. Building a Better (RED). WorldChanging Newsletter.
http://www.worldchanging.com/archives/005150.html.

TITLE: WHO'S ROLL BACK MALARIA: WHERE EXACTLY ARE WE ROLLING? SOME SAY NOWHERE – KATE DILLEY

Introduction
Malaria is the most common vector borne disease, meaning that malaria is transmitted through a bite from a mosquito. The most common vector for malaria is the anapholies mosquito. Malaria is an endemic disease, which means that there is a very distinct seasonal transmission or regular transmission of the disease. Malaria is the most common vector borne infectious disease impacting countries in Africa, Asia, South and Central America. Current estimates place the global burden between 350 to 650 million cases each year. In children under the age of five, malaria is one of the leading killers. Each year, approximately 1 million children die from malaria. Africa bears the greatest burden in the world, with 60-90% of all malaria illness and deaths occurring on the African continent, in Sub-Saharn Africa (1).
In 1998 the World Health Organization, UNICEF, the United Nations Development Programme (UNDP), and The World Bank came together to start the Roll Back Malaria (RBM) initiative. The goal of this partnership is to halve the global burden of malaria by 2010 (2).
The fight against malaria is a complicated one, with three major challenges facing the RBM initiative. The first and most important challenge is that of poverty. Malaria is an inexpensive disease to treat and prevent, but many of the countries with the greatest burden of disease lack the infrastructure to implement prevention and treatment programs without major subsidies or donations from governmental and non-governmental organizations. Additionally, citizens of these countries often lack the resources to protect and treat themselves on an individual level (3). The second challenge is that of resistance development among mosquitoes. Resistance has been developing to both the insecticides used to kill the mosquitoes as well as to the drugs to treat malaria (3). This developing resistance is changing the landscape in which the RBM initiative is working. Finally, conflicts and natural disasters often displace large numbers of people into areas with high malaria transmission.
These complex humanitarian emergencies are problematic for a number of reasons. By pushing people out of their homes and into refugee camps or other temporary living situations a variety of things can heighten the transmission of malaria. People who have not been living in malaria endemic areas (where malaria is present or heavily transmitted) can be pushed into malaria endemic areas and they have little or no immunity so are susceptible to malaria infection. Additionally, further breakdown in infrastructure and loss in wealth means that malaria falls lower on the priority scale for many affected populations. Any personal preventative or treatment measures that were being undertaken are no longer in place so individuals are now more susceptible to malaria infection.
The RBM initiative is a three tiered program, including personal protection, mosquito control, and appropriate use of medication. Insecticide treated mosquito nets (ITNs) are a simple and cost-effective way to prevent a bite from an infected mosquito, therefore are the first line of defense against malaria. The use of ITNs has been targeted mostly at children, pregnant women, and those with HIV/AIDS. RBM has used social marketing and educational campaigns in order to raise awareness about malaria prevention (4). The second component of the intervention is mosquito control. The insides of peoples homes are sprayed with insecticides to kill mosquitoes. This type of indoor residual spraying has been an effective measure to control mosquitoes in Central and South America, Asia, and southern Africa. However, indoor residual spraying is not a very widespread component of the initiative; instead it is used only in specific and targeted situations (4). The final component of the RBM initiative is access to appropriate medical care. The goals of this component of the intervention are for all persons to have immediate diagnosis followed by treatment with correct and effective medications. Persons ill with malaria must be diagnosed immediately and promptly treated with the appropriate medications. However, the increasing development of drug resistance is causing a range of problems from ineffective treatment in some cases to the inability to treat malaria at all (4).
Two years away from the culmination of this initiative there has been little or no substantial progress. The annual number of deaths from malaria in 2004, was higher than in 1998 (Yamey 2004). Many are saying that this initiative is clearly failing, and dealing ineffectively with an increasingly complex battle of reducing the global burden of malaria. One critic of the RBM initiative asserts that the campaign currently has all of the necessary tools to combat the growing malaria burden, but that those tools are not widely available due to geographic or economic barriers. He goes on to say that the last thing that the campaign needs is a lack of donors. There is still great work to be done, and the goals of the campaign are within reach, however, continued donor support will prove to be vital (5)
The Roll Back Malaria Initiative started by the WHO and UNICEF is failing to address the basic needs of malaria prevention and treatment by ignoring basic social and behavioral factors associated with the disease; socioeconomic and geographical barriers, as well as access to the resources that communities need in order to have success with the various components of the intervention.
Poor implementation of a promising tool: Insecticide Treated Bednets
While the campaign has been somewhat successful in communicating the importance of using ITNs, it is failing to increase the proper use of nets, because it ignores important socioeconomic factors of its target population such as family income, priority of disposable income, and willingness to pay.
Populations that suffer through endemic and seasonal malaria are well aware of its dangers as a disease. People know how serious of an illness that it is and that it is an illness that can have potentially devastating affects on a family and a community. That knowledge combined with the knowledge of ITNs has the potential to be a powerful tool in combating malaria around the world. ITNs can reduce malaria transmission in the general population as well as all cause mortality in children under the age of five by 15-33% in areas with low to high, although seasonal transmission (6). However, there are reasons why communities are not utilizing the ITNs at the rates the RBM initiative was hoping for. It is now necessary to understand and examine adherence and use of ITNs in malaria endemic areas. A major focus of these studies must be how community and individual level factors are impacting adherence.
Overall, uptake of ITNs in the general population is high, and often the result of successful social marketing and educational campaigns. These campaigns combine free distribution of ITNs and other active community education, and can result in bed net uptake as high as 83% (7). The high use of ITNs illustrated very clearly by the fact that families who participated in randomized control trials are more likely to have bed nets in their homes. When enrolled in a trial, families or heads of households receive extensive education regarding the proper use of bed nets, their advantages, and ways to make them more effective, including the use of insecticide treatment (8).
When community members talk about the ITN uptake and use in their villages, many cite the strengths of the educational campaigns and the social marketing. However, there are a number of barriers associated with not using ITNs, mostly focusing on issues of access and affordability. Bed nets are not always for sale in convenient locations, and if they are they are far too costly for families to purchase them. These access and financial barriers lead to people having to travel great distances to find a bed net at a cost they can afford. The same barriers exist when examining the failure to treat or retreat nets with the insecticide treatments. While the communities understand the importance of and have the skills to mix the insecticides and treat the nets, the chemicals are often not available for reasonable prices or within close proximity (8, 9, 10).
These various studies highlight one of the major problems with the Roll Back Malaria initiative. It is based on the Health Belief Model, assuming that when the target population is armed with all of the appropriate information, aware that they are at risk for something, and have the intent to make a change, that change will occur. The RBM partners are ignoring glaring limitations and barriers to actually achieving the behavior; the economic barriers and infrastructure limitations are preventing a large number of people from using ITNs.
Various problems with pharmaceutical access and administration
The second goal of RBM is that all people will get the right drugs, from the right place, at the right time. Currently, this appropriate medical treatment is not happening. The inappropriate medication of patients is creating complicated problems, including increasing drug and insecticide resistance. All of these factors are combining to make malaria control, let alone malaria eradication, difficult to achieve because the disease keeps changing. By ignoring key socioeconomic and geographic barriers to health care, the RBM initiative is failing to ensure that all individuals in malaria endemic countries receive fast and effective treatment (11).
Although baseline access to good and effective malaria treatment was low, in 2000 little progress had been made. In 2000 The African Summit on Malaria was held to address the current progress against malaria, what challenges remained, and what could be done to make progress against those challenges. This meeting included community and political leaders, WHO representatives, and public health officials from around the world (12). By 2008, treatment improvement was a major cornerstone of the Abuja Declaration made at the African Summit on Roll Back Malaria in 2000. The goal following the conclusion of the Summit was that by 2005, at least 60% of those suffering from malaria have access to affordable, appropriate and timely treatment (12).
The definition of appropriate treatment is complex. The factors that go into treatment include receiving a correct diagnosis of malaria, administration of an appropriate medication, in the correct dose, and taking that medication for the defined amount of time. Some estimates suggest that only 7% of children under the age of 5 years are being treated in compliance with the RBM initiatves goals and recommendations (13).
The most common anti-malarials given to patients in sub-Saharan Africa are chloroquine and pyrimethamine plus sulfadoxine. While chloroquine is currently almost completely ineffective in treating malaria in Africa, medical professionals are moving towards a more effective, but more expensive, treatment. That treatment is artemisinin-based combination therapies (ACTs) which are available for $0.75-$2.75 per treatment. Although this cost seems inexpensive, it is a much higher price to pay than individuals have been previously paying (2). Individuals’ willingness to pay for treatment of malaria decreases with decreasing socioeconomic status, meaning that the poorest people do not want to pay for treatment, or are less willing to pay, and when that transpires, it means that people with fewer resources are not accessing the care that they need when they are ill (14).
Other factors related to childrens’ access to medical care include the age of the child, perceived severity of illness, education level of the head of household, and socioeconomic status. Adults do not receive appropriate care for similar reasons, including availability of care in close proximity to the home, care must be given at a fair or reasonable price, and those administering the care must be capable of fostering a polite and enjoyable relationship with the patient (14, 15, 16).
Another issue related to inappropriate care is the dependence of many African communities on private sector drug distributors. This includes formal sources of drugs, like small pharmacies or merchandisers, but also informal drug dealers at small kiosks or nomadic dealers who move around from village to village. The reliance upon these distribution schemes is understandable when they are more numerous, closer to home, offer variable payment plans, are stocked with the desired drugs, and a friendlier atmosphere. They possess all of the qualities that the public sector venues lack (17). However, these drug outlets are increasingly problematic due to the fact that it is well known that they are poor care providers. They often do not provide proper advice, complete or correct doses, and in too many cases, they do not provide the correct drug for the illness. These factors are all directly related to diagnosis of malaria, which is the crux of the problem. Because there is such poor infrastructure, diagnosis is generally made using only symptomatic criteria. This leads to all fevers being diagnosed, and treated, as malaria (17).
Poor implementation strategies of the major initiative components
Despite having realistic goals and sound strategies, the RBM initiative fails in its implementation. By employing traditional, or western, implementation techniques, the campaign fails to account for the unique needs of it's target population. The traditional, or western, mechanisms for employing the use of insecticide treated bed nets and appropriate treatment are clearly not working in these African communities. The success of this intervention rests on considering novel implementation techniques both for ITNs and medication.
The World Health Organization and other non-governmental organizations suggested that novel distribution techniques for bed nets and new ways to administer medical care may be part of the solution for malaria treatment and prevention. Some of these suggestions include using community health workers to distribute malaria treatment, training private sector drug distributors in the knowledge that they need to prescribe malaria medications, and distributing ITNs during the measles vaccination campaigns (18).
A study published in 2006, examined the preferences of community members for having community health workers (CHWs) provide malaria treatment. It is clear that one of the major obstacles in the treatment of malaria is distance that individuals must travel in order to receive care. CHWs work in local communities and are trained in the health problems of the community they are working in, which means that they have the medical knowledge to provide appropriate and effective treatment and are conveniently located. The study clearly demonstrated that CHWs can be used to effectively get appropriate treatment to the individuals who need it. Furthermore, using CHWs is a sustainable strategy, since community members preferred being treated by the CHWs (19).
A similar study conducted in 2007 found the same results, but also examined the costs associated with establishing such a program and some community factors that contribute to, or detract from, the success of these CHW programs. Start up costs were low, which means that these programs are these programs can be easily implemented in communities where financial resources are lacking. Other conditions that led to the success of the CHW model in this population included CHWs behaving as a bridge between the community and the formal health care system, bringing all of the appropriate medical care to the community because the CHWs were so well trained (20).
Novel distribution techniques have been suggested for the increased implementation of ITNs. Combining the distribution of free ITNs with national vaccine days has proven to be a successful and equitable way to distribute ITNs. A week long measles vaccination campaign in Ghana was utilized to target children aged 1 – 5 years to receive free ITNs. Baseline data were collected and indicated that only 4.1% of the children under the age of five were sleeping under bednets. After the campaign, that number increased to 60.2%. Additionally, 68.3% of people had a net hanging over beds in the home and 94.4% had an ITN in the home. The second major finding of this study was that taking out the cost of the net, it is a way to target all levels of socioeconomic status equally. Following the campaign, the coverage of ITNs in the poorest homes was ten times that of the wealthiest homes at baseline. This study suggests that linking bed net coverage and vaccination campaigns could be a successful way to ensure that all people have exposure to ITNs (17).
Conclusions – Steps we must take to roll forward
Collecting data in the places where the RBM initiative is working presents a series of challenges. This makes it difficult to determine what of the initiatives targets have been met. However, there is a clear indication that steps have been taken in the right direction. These steps include making treatment more widely available and changing national drug policies, forcing the effective ACT’s as the first line of treatment, instead of the traditional chloroquines. Organizations are also stepping up and subsidizing the cost of the treatments, helping to make it more available (2).

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