Challenging Dogma - Spring 2009

Thursday, May 7, 2009

Successful Miscommunication: A Critical Review of the Peace of Mind Campaign -Matthew Hanlon

In an effort to combat high rates of unhealthy sexual behaviors and negative outcomes of those behaviors the Health Promotion Agency, a public health organization in Ireland, launched a campaign in Northern Ireland. This initiative named "The Peace of Mind Campaign," focused on increasing knowledge of existing sexual health issues facing the Northern Ireland population aged between eighteen and thirty years. The campaign began its efforts in 1993, with a poster campaign that was received very well, but not directly followed up upon. It was not until 1997 that a new poster campaign was launched. These posters were targeted primarily university students at first, as they were used as a test group. Advertisements addressing transmission of chlamydia, getting regular STD tests and to a lesser extent condom use were placed in and around university campuses and surrounding pubs. Studies were then conducted in order to measure awareness of the poster advertisements in the target population. It was found that approximately two thirds of the population was aware of the advertisements and their message.
Based on the findings of the awareness study the in December of 2000 the intervention was expanded to include information leaflets, fact sheets and other forms of print media as well as other locations not directly associated with university students. However, it is important to note that the target age group was not expanded at this time. As the campaign progressed posters were changed regularly with about one year between new iterations. By 2004 fourteen different posters had been created and used in the campaign. Keeping in line with the strategy of varying how the safe sex message was delivered in April of 2007 the Health Promotion Agency began launching radio and television advertisements in Northern Ireland as well (10).
HBM and the Peace of Mind Campaign
This intervention, as has been stated previously, is an educational campaign based on the dissemination of information and subsequent awareness of sexual health issues faced by the population being targeted. It is worth noting that content of the print media contained within this campaign can be divide into two main classes. The first class is information aimed at increasing the population's view of benefits derived from safe sex behaviors. This is achieved by enlarging the population's view of its susceptibility to and the severity of the negative health outcomes associated with sexual behaviors, such as unwanted pregnancy, chlamydia, HIV or other STDs. The second class of information deals with providing specific knowledge about sexual health clinics or where to get further information on sexual health issues. This type of information can be seen as material aimed at reducing the perceived barriers to gaining information about and practicing health conscious sexual behaviors. These two factors, perceived susceptibility and perceived barriers are major components of a popular model for public health interventions known as the Health Belief Model (HBM). The HBM asserts that perceived benefits and perceived barriers are in opposition of each other, and that in order for someone to develop an intention to perform a health behavior the perceived benefits must overcome the perceived barriers (3).
The HBM can be very useful at the beginning stages of a public health intervention. It provides direction and focal points for disseminating information to the target population. There are a number of people that do and will respond to the strategy outlined by the HBM early on in the intervention. Often times there can be a change in a significant portion of the population when a campaign based on the HBM is instituted. However, it is important to note that the entire population does not respond the same way as this smaller group that is fast to develop safe sex habits. There are a few explanations for this occurrence. One is that the people who are fast to pick up condom use and other safe sex habits are different from the rest of the population regarding health conscious behaviors. Due to variables not shared by the rest of the population this group of people readily makes behavior changes when they are given health information they did not previously have. The second explanation is that the educational information presented in the intervention are more salient with the first group and have simply not reached the others who have yet to develop the safe sex habits being promoted. Each of these explanations results in a very different view of the HBM's impact as an intervention model.
Failure of the HBM
When viewing "The Peace of Mind Campaign" through the lens of the HBM it seems to be a rousing success when 67% of subjects in the study evaluating awareness of the campaign responded they knew of the posters and that they recalled the message(10). This is especially true if it is believed that the reason the HBM may be unsuccessful is not because of different groups' response to health information, but whether or not they retained the information given to them. However, this is also based on the assumption that health behaviors in general and, more specifically, sexual health behaviors do follow the HBM, which has been shown to not be the case. In a study where the predictive powers of the HBM was compared to other health behavior models it was shown that the HBM accounted for less variance in diet, exercise and smoking behaviors than did the theory of reasoned action or theory or planned behavior (5). In addition, a later study based on a quantitative review of many preexisting studies it was shown that the HBM was lacking in predictive powers, which was then attributed to its focusing only on factors predisposing people to a behavior (4). Because of these studies it can then be concluded that the HBM functions through the first explanation given for why the HBM does not reach an entire population: there are different groups within a population with different dispositions towards adopting a health behavior. As such this entire campaign is fundamentally flawed because it is based on faulty assumptions made by the HBM and how it is applied to target populations.
Lack of Aim in Addressing Relevant Populations
Another major flaw with this campaign is the target population for the intervention. This intervention was an educational campaign focused on creating awareness of sexual health so that people would then subsequently change their behaviors to conform with their new knowledge. In addition, as stated earlier "The Peace of Mind Campaign" targeted adults of ages eighteen to thirty years. Although there is nothing inherently wrong with targeting a safe sex intervention to that age group, it was a mistake in this particular intervention to place that specific age restriction on the campaign. There is reasoning based on both psychological theories and empirical data collected directly in relation to this campaign that gives credence to an age restriction of eighteen to thirty years being a mistake.
As stated earlier, interventions of this type do have an effect on some members of the population, but there still remains a large proportion that does not change their preexisting behaviors. One possible explanation for this occurrence comes from an extension of the endowment effect. The endowment effect states that people will place higher value upon an item that they have ownership of in comparison to a similar item that they do not own (7). This can be interpreted to mean that owning something has an inherent value to a person and that value is substantially higher than the innate value of that item. It is therefore very easy to infer that people who do not readily change their behaviors to safe sex practices as prescribed by "The Peace of Mind Campaign" feel ownership of their preexisting behaviors. Also, the value members of the target population place on that sense of ownership is substantially higher than what they feel the will receive in return for ceasing their current behaviors.
In order to effectively change the sexual behaviors of those living in Northern Ireland the sense of ownership stemming from the endowment effect must be circumvented. Classical conditioning theory shows that behaviors become more ingrained over time and repetition. The more often, longer duration and amount of reinforcement received from a behavior performed the more ingrained that behavior becomes (6). Thus in order to circumvent that sense of ownership that develops from an ingrained behavior it would be ideal to create a change before or in the early stages of behavior conditioning. Research done by the Health Promotion Agency, the same organization responsible for "The Peace of Mind Campaign," shows that approximately 90% of females and 80% of males between the ages of twelve and fifteen years old are sexually active. Based on this research the target audience of the intervention should have used age twelve as the lower bound for the target population. By educating the population early on it is easier to effect change as behaviors are not yet ingrained and individuals do not possess a sense of ownership yet. Also, it is considerably more likely that by targeting a younger population that early sexual behaviors will be health conscious and will continue into the future due to the processes described by conditioning theory and the endowment effect.
Breakdown in Communication
Borrowing from the endowment effect again another issue can be raised with "The Peace of Mind Campaign." In this instance the issue is not with the delivery of the message, but rather the message itself. The posters used in the promotion of health information this intervention is based around may actually be counterproductive to the end goal. A specific example is one poster used in May of 2004 to educate that chlamydia may not present with any noticeable symptoms. The poster reads "You could be looking at someone with chlamydia." This message is written upon a mirrored background so that whoever is reading it should see their own reflection. This one poster is sending the wrong message, according to three different theories explaining behavior. The first, as was mentioned, is the endowment effect. This poster goes against what you would expect to see if the endowment effect was considered because the poster is threatening a person's sense of ownership of health. People place value on being healthy and this poster in a sense attempts to purchase that belief in exchange for either proof of health or proof of illness. This is not an exchange that would seem worthwhile to a person who believes that he is in fact healthy.
The second theory this poster seems counter to is psychological reactance theory. The basics of reactance theory can be explained as follows. When people perceive a threat to their freedom they will often overexercise that freedom in order to prove that they still hold control over the situation. This can manifest in one or both of two possible ways: behavior or attitude. When a person perceives a behavioral freedom is threatened reactance to threat will motivate the person to further participate in that behavior. Also, if a person feels a particular attitude is being forcible impressed upon them he will most likely take up the opposite attitude in order to assert his freedom (2). This outcome can occur in this situation, as there is a threat being made to a person's freedom from illness and his sexual freedom. A behavioral reaction predicted by this theory would be that a person would not get tested. By making a conscious choice not to get tested a person can reassert their control over being healthy or sick and maintain their sexual freedom. Having an asymptomatic illness allows this choice as the only way to "become" ill is to actually get tested, thus allowing a person to create their own state of health or illness.
Creation of categories based on the physical status of a person leads to the third theory that this poster opposes: labeling theory. This theory asserts that when an individual is labeled as part of a group they will begin to conform to what that label would expect of them (1). There are two different ways under labeling theory that this poster is counterproductive to the goal of promoting safe sex. The first is that poster labels all people, regardless of their true situation, as being at risk for chlamydia. This is a dangerous label to apply to both those at risk and those not at risk as for either group it promotes sexual risk taking in regards for chlamydia. As per labeling theory people or either risk group may be given motivation, they would not have had otherwise, to attempt to live up to the label of being at risk for chlamydia by participating in risky sexual behaviors such as intercourse without condoms. This increases the the level of risk for those already at risk for chlamydia or other negative outcomes of unsafe sexual behavior, and creates risk for those that had a minimal amount beforehand.
The second aspect of labeling theory this poster is set against has to do with stigmatization. Because chlamydia can be asymptomatic the only way to be certain of a person's infection status would by medical testing. However, those who get tested can be labeled quite negatively as being at high risk or even worse actually having the disease. This creates a stigma that is associated with the act of being tested(8). People, regardless of their actual risk or infection status, fear being labeled as having the disease simply because they do get tested. This stigma in turn discourages people from seeking medical tests to determine their infection status. A public health intervention should seed to discourage stigmas around being tested instead of promoting them. This poster unfortunately promotes stigmatization of those seeking medical tests and in fact goes against its own goal.
Evaluation of The Peace of Mind Campaign's Effectiveness
Although as stated earlier the Health Promotion Agency cited a study in which 67% of respondents were aware of their campaign, it was by no means a massive success. What this study of the effects of the intervention showed was that people were aware of the intervention's message. In terms of getting the message and information "The Peace of Mind Campaign" was presenting to the public the intervention was moderately successful. Reaching two thirds of the target population is a very large step in the correct direction for a public health intervention. However, reaching the target population in itself does not mean that the message received was effective.
There may have been a portion of the population, as earlier stated, that responded to the health education approach used by this intervention. However, it is highly unlikely that this intervention had any appreciable effect on increasing sexual health behaviors and subsequently decreasing infection rates of sexually transmitted disease beyond those that were reached easily and early on in the intervention. Incidence data for sexually transmitted disease collected by genitourinary medicine clinics in the United Kingdom support this claim. Between the years of 1998 and 2007 chlamydia rates have increased 2.5 times and total diagnoses of any sexually transmitted disease has increased 1.63 times. This data shows it is absolutely vital that public health interventions be rethought. There is a vast body of research that exists and can be applied to campaigns promoting any number of health behaviors, that is not being used to its fullest potential. By tapping into resources not traditionally used by public health agencies interventions can become massively more effective. If new approaches are not used there will just be more interventions like "The Peace of Mind Campaign" that span decades, but only accomplish wasting funding and effort.
Possibilities for Future Interventions
The "Peace of Mind Campaign" instituted in Northern Ireland by the Health Promotion Agency in order to improve the rate of safe sex behaviors was not nearly as effective as it could have been, due to a number of flaws in its design (10). Some flaws existed in the very foundation of the intervention others came about later on and were introduced at a later stage. Regardless of where these flaws were found they detracted from the overall effectiveness of the "Peace of Mind Campaign," which is an unfortunate occurrence as promotion of safe sex behaviors is an important public health goal. However, the "Peace of Mind Campaign" was not a total loss as in addition to its flaws it had some effective strategies as well and because of this can be used as a comparison point for future plans for safe sex interventions. By judging what was effective and what was not about the "Peace of Mind Campaign" an intervention that is significantly more effective as a whole can be designed.
Choosing the Proper Model
The first flaw with the "Peace of Mind Campaign" that was discussed was its reliance on an ineffective behavior model, the Health Belief Model. Therefore, a new intervention would have to diverge from using this model as a basis for planning the intervention. One possible approach would be to create an intervention based on a combination of social expectations theory (SET) and social network theory (SNT). Social Expectations Theory explains behavior which may at first seem to be an individual choice, like condom use, is in fact a social behavior (11). As such, safe sex practices are largely a result of conformity to the expectations of the larger group of which a person is a member. Social network theory also deals with people as being influenced largely by their peers. Under SNT people do not exist as individuals but rather as part of a great social amalgam. Because of this view SNT asserts that behavior change does not occur on the individual level, but rather on the group level and that in order to affect behavior change it must be group focused rather than individually focused (12).
By using group level models instead of the HBM the issue of individual differences between people influencing the effectiveness of the intervention is decreased. Whereas there may exist a strong degree of heterogeneity between individuals, there is much higher degree of homogeneity between groups. This is an important concept for a number of reasons. The first reason, it allows a more focused campaign in terms of how the intervention appeals to an individual. Rather than making hundreds of posters that are designed to appeal individually to people, only a few posters need to be made provided they are designed to appeal on a group level. Another reason is that within a population there are those with different levels of safe sex behaviors. By using a group centric approach this difference does not matter, as changing the group dynamic will reinforce behaviors in people that already practice safe sex, and cause a shift towards safe sex behaviors for people that are not yet there. Therefore, by targeting groups, instead of individuals, it is much more likely that an intervention will be effective for a large proportion of the population rather than a small subsection.
Individual Behaviors Change on a Group Level
Also, using a group centric model as the base for this intervention helps in addressing the second major flaw of the original "Peace of Mind Campaign": its failure to address problems facing the intervention stemming from endowment theory and classical conditioning. As stated earlier, when these two theories are applied to sexual behaviors they show that people are unwilling to make changes because of the intrinsic value of ownership and the level of conditioning they have with respect to that behavior. By using a model that promotes group change for the basis of the intervention it helps alleviate both of these issues. People are more likely to change a behavior they value if they believe they will gain something of equal or greater value. A group level model directly effects this exchange. As the social group a person belongs to shifts, they will be forced to alter their behavior in order to maintain their place in the social hierarchy. In a sense people are exchanging individual behaviors for a sense of social belonging (7). Also, affecting a change in a social network helps to lessen conditioning people have towards sexual behaviors. Changes in social networks result in a break down of cues for the conditioned response a person has towards a behavior (6). If a large enough change can be created then there will be removal of many, if not all, of the social cues that trigger unsafe sexual behavior.
Focusing on the Message
The issues addressed so far have only dealt with the general concepts of a public health intervention without going into the specifics, such as the method of interacting with the public. The "Peace of Mind Campaign" used mainly print media, such as posters and leaflets to reach the target population. This proved to be effective in just terms of exposure in that 60% of people interviewed in a study by the HPA recalled the content of the posters (10). Therefore it seems print was a good media for gaining exposure in the target population. However, the "Peace of Mind Campaign" had problems, not in exposure, but rather in terms of the content of the posters it presented.
One such poster with lackluster content was already discussed in great detail. The major issues with this poster being that it went against what would be expected from an intervention that consulted endowment theory, psychological reactance theory or labeling theory. Therefore it would make sense to design a poster that incorporated the major tenets of these theories rather than disregarding them. The first concept to be included in this poster would come from endowment theory: the poster should somehow offer something of equal or greater value than the behavior being targeted. Psychological reactance theory states that the poster should not threaten the sense of freedom a person possesses, otherwise they will rebel against the message presented (2). Labeling theory states people will conform to a label placed upon them, so the poster should place a positive label on people.
One example of a poster that meets these requirements is as follows: The main picture on the poster is of a couple sitting at the bar talking. The people in the poster are fairly representative of the target population. There is a main caption that reads "It's not about getting lucky tonight, it's about being prepared for the night. Know where you're going, and bring a condom with you." In this poster an exchange is being offered, for a change in sexual behaviors. The message implies that by using a condom it will make a person more sexually attractive because it's "not about getting lucky." This is an exchange that gives a person something of value for giving up their previous behavior. Also, by using a couple representative of the target population it creates a sense of identification for the recipient of the message which limits psychological reactance to threatened freedoms (2). Finally this poster creates a positive label for condom users, without the co-creation of a negative one for non-condom users. "Know where you're going" implies a sense of purpose, direction and confidence. These are all positive traits that people will aspire to have that according the poster condom users have. Therefore if the poster is salient enough people will attempt to take on the label of being a condom user in order to gain these traits that come with it (1).
Synthesizing an Effective Approach
After analysis of the shortcomings of "Peace of Mind Campaign" and their comparison to other approaches described a general understanding of what an effective public health intervention would require can be reached. The first step in an effective intervention is to choose a model that works to base the intervention upon. Group level models have distinct advantages over individual level ones that make them much more useful in this setting. By using a group level model it allows interventions to focus on the issue at hand in a homogeneous population rather than getting bogged down by trying to determine how best to influence a conglomeration of heterogeneous individuals. Also, group level models confer the added advantage of creating a new set of social norms. This is aids in the second step of creating a successful intervention: people must feel they are benefiting from making the behavior change proscribed by the intervention. Changing social norms is an advantage in reaching this second step. People will exchange their negative behavior for these new norms because they gain a sense of group belonging as replacement for their lost behavior. The third step is to make sure the message of the intervention is salient and coercive to the public. Three cognitive theories were used in creating the poster in described as a replacement for the one that came from the "Peace of Mind Campaign." However, there are countless useful cognitive theories that can be applied as well. It falls to public health officials to carefully design interventions so that they meet these criteria. If this is done, there will be more successful interventions that occur.

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