Tuesday, May 13, 2014

A Critique of the Boston Public Health Commission’s “It Could Be Hiding in You” Campaign – Alexander de Groot

            According to the Centers for Disease Control and Prevention (CDC), Chlamydia is the most commonly reported notifiable disease in the United States (1). In 2012 alone, over 1.4 million cases of chlamydia were reported, with 69 percent of the burden coming from the 15 to 29 year age group (2). The city of Boston currently faces a similar problem with chlamydia. There were 4,823 cases in Boston in 2012, and 64 percent of these cases were in 15 to 24 year olds (3). Although chlamydia is easily treatable with antibiotics, it tends to go undetected as it often has no symptoms, making it a difficult public health issue to manage (1). If left untreated, chlamydia can cause serious health problems, such as infertility in women.
            In an attempt address the issue of chlamydia in Boston, in February 2014 the Boston Public Health Commission (BPHC) announced in a press release the launch of its “It Could Be Hiding In You” awareness campaign (4). According to the press release, the campaign is aimed at educating youth about preventing and reducing the risk of chlamydia and also providing resources for youth to get tested (4). The “It Could Be Hiding In You” campaign is multi-faceted in its approach, utilizing social media, posters, and other promotional materials to spread its message. A key component of the campaign is its posters. The top half of the posters depicts a man or woman from the neck down wearing camouflage cargo pants. The words “It Could Be Hiding In Him” or “It Could be Hiding In Her” are strategically placed over the crotch of the person in the poster. The bottom half of the posters explains that chlamydia often has no symptoms and can cause serious consequences, and it also provides links to the campaign’s website, Twitter, and Facebook pages. To ensure that these posters reach the target youth audience, they were placed in Boston public schools and on Massachusetts Bay Transit Authority (MBTA) trains (5).
            While the campaign does a decent job of spreading its message through social media and strategically placed advertising, it has several weaknesses that ultimately render it ineffective. First, the campaign’s use of the Health Belief Model is flawed in that it inadequately addresses perceived susceptibility and perceived barriers and also focuses too much on individual level behavior change. Second, the campaign’s lack of peer messengers and utilization of fear tactics induces psychological reactance among the target audience of high school students. Finally, the campaign is framed ineffectively in that it addresses health as a core value, which does not resonate deeply with youth. These weaknesses will be discussed in greater detail throughout the rest of the paper.
Critique 1: Focuses on Individual Through Health Belief Model
            First and foremost, the campaign’s attempt at utilization of the Health Belief Model ultimately weakens the campaign’s goal of increasing chlamydia testing among youth. The Health Belief Model is based on two components of health behavior theory: 1) that people want to avoid illness or they want to get better if they are already ill, and 2) the belief that a specific health action will prevent or cure the illness (6). The Health Belief Model addresses these components through six constructs: perceived susceptibility, perceived severity, perceived benefits, perceived barriers, cue to action, and self-efficacy (6). The campaign structures itself around these core constructs by telling people there are serious consequences to not treating chlamydia (perceived severity), insinuating through slogans that anyone could have chlamydia (perceived susceptibility), telling people that treatment will cure those symptoms (perceived benefits), providing information on free testing sites (perceived barriers), telling people to get tested if they are having sex (cue to action), and insinuating that testing is easy (self efficacy) (4). While all these constructs are supported weakly by the campaign, perceived susceptibility and perceived barriers are addressed the worst because of the Health Belief Model’s limitations as an individual model of behavior change. Because the Health Belief Model is an individual model, it does not allow the campaign to address differences in perceptions toward sexually transmitted infection testing amongst males and females.
            First, for perceived susceptibility, the campaign assumes that men and women have an equal opinion of their risk for contracting chlamydia as well as an equal knowledge of the health care system’s resources for sexual health services. This is not the case. According to Marcell et al., women use health services more often than men, and reproductive health services are more readily available for females than they are for males (7). The study performed an analysis of three national data sets and found that men 16 to 20 years of age use less primary care services than women of the same age group (15.8% versus 34.7%, respectively) (7). Furthermore, when OB/Gyn services are eliminated, the difference in primary care use becomes narrower (18.6% for men versus 23.9% for women) (7). This narrowing suggests that men and women do not have equal access to reproductive services, which is essential to understand in order to effectively tackle perceived susceptibility in men.
            Second, the campaign assumes that men and women perceive the same barriers to sexually transmitted infection testing. Specifically, they assume the cost of getting a sexually transmitted infection test is the only barrier. This is partially true, but the campaign overlooks psychological barriers to testing among men. Women tend to be more accustomed than men to addressing reproductive health services with their doctors, as the health care system places more of an emphasis on women’s reproductive health than on men’s reproductive health. A qualitative study by Shoveller et al. on young men’s experiences with sexually transmitted infection testing reveals that many men view it as a potentially sexualized experience, where they feel they are vulnerable in compromising their dominant ideals of masculinity, such as by getting an erection during the procedure (8). The “It Could Be Hiding In You” campaign’s flaw in addressing perceived barriers among men arises from the fact that the Health Belief Model is an individual model of behavior change. The Health Belief Model does not address the social norm of masculinity that many men consider and important part of their identity.
Critique 2: Failure to Recognize the Effects of Psychological Reactance
            In addition to the campaign’s use of an individual model of behavior change, a second critique of the campaign is that it fails to recognize the effects of psychological reactance theory. The main premise of psychological reactance theory is that the elimination or threat of elimination of a freedom causes individuals to react in a manner that is opposite from what is expected (9). In a study by Dillard and Shen, it was found that psychological reactance is influenced by three factors when used in health campaigns: dominance, explicitness, and reason (10). Dominance refers to the extent to which the message reveals the source’s intention of controlling the recipient of the message (10). Explicitness refers to the degree to which the source of the message makes the message’s intent obvious (10). Reasoning refers to the amount of support that is given to persuade the receiver of the message to change his or her actions. The study by Dillard and Shen found that messages with greater amounts of dominance tend to induce greater amounts of psychological reactance (10).
            The “It Could Be Hiding In You” campaign incorporates dominance too much through the use of fear tactics, thereby weakening its effectiveness. One fear tactic the campaign uses is its slogans coupled with explicit messages that chlamydia causes severe consequences. Slogans such as “It Could Be Hiding In Him,” “It Could Be Hiding In Her,” and “It Could Be Hiding In Them,” and messages about the seriousness of chlamydia, create a feeling of uncertainty and fear among the young target audience of the campaign. This uncertainty could ultimately scare away youth from getting tested. In one study, Grandpre et al. looked at the effects of message type (explicit or implicit) on reactance to different anti-smoking public service announcements, and found that explicit messages tended to induce more negative reactions than positive emotions (11). In fact, study subjects associated the explicit messages with a threat to their freedoms (11). In sum, the message of the “It Could Be Hiding In You” campaign uses too much dominance, and thereby triggers psychological reactance.
            However, in addition to dominance, the campaign further induces negative psychological reactance because it lacks a messenger that is similar to the target audience. The campaign posters show men and women from the neck down, making the age of the person on the poster less obvious. This makes the messenger of the campaign ambiguous, and so it seem like the message of the campaign is coming from the Boston Public Health Commission rather than from a peer. Having a messenger that is similar to the target audience is imperative in reducing psychological reactance. In a series of experiments looking at interpersonal similarity and reactance, Silvia found that “similarity increased the force toward persuasion by increasing liking, and it decreased the force toward resistance by making the message seem less threatening” (12). The campaign is thereby weakened by its lack of a relatable messenger.
Critique 3: Ineffective Framing of Core Values
            A third, and final, critique of the “It Could Be Hiding In You” campaign is that it uses framing theory ineffectively. Framing theory posits that in order to convey a message in a way that meets one’s intentions, it needs to be presented in a manner that incorporates the facts of the issue into a story that resonates with the message recipient’s core values (13). The “It Could Be Hiding In You” campaign attempts to spread the message that if an individual is sexually active, he or she should get tested for chlamydia. However, it does this unsuccessfully by attributing testing to the potential for better health, a core value that does not resonate effectively with most people. According to Maslow’s Hierarchy of Needs, health is considered a higher level need (14). As the name implies, Maslow’s Hierarchy of Needs organizes human necessities into an ordered system that requires an individual to acquire certain basic needs before he or she can attain higher needs (14). From most needed to least needed, the order of the hierarchy goes physiological needs, safety needs, needs for love and belonging, a need for self-esteem, and finally self-actualization as the highest need (14). Because health is a higher need, youth, who are likely to be healthier than the general population, do not recognize their need for better health. Thereby, trying to frame a campaign around the core value of health is ineffective.
Articulation of Proposed Intervention
            The current form of the “It Could Be Hiding In You” campaign is currently modeled in a way that will make it unsuccessful at persuading youth to get tested for chlamydia if they are having sex. Its use of the Health Belief Model is incomplete in that it focuses too much on individual-level behavior change rather than group-level behavior change. Additionally, the campaign induces psychological reactance through the use of fear tactics and lack of peer messengers. Lastly, the campaign is framed around the core value of health, which does not resonate with students in the targeted age group.
            In order to improve the campaign, each of the three critiques needs to be addressed separately. First, I recommend abandoning the Health Belief Model, and using Social Expectations Theory to re-design the campaign. Second, I would reduce psychological reactance by removing fear tactics, such as the slogans the campaign uses, and including peer messengers as part of the educational component of the campaign. Finally, I would reframe the campaign so that it focuses less on the core value of health and more on the core value of freedom. The rest of this paper will address each of these recommendations in more detail.
Defense of Intervention 1: Use Social Expectations Theory
            The first recommendation I have for the “It Could Be Hiding In You” campaign is to re-model itself based on Social Expectations Theory. The present campaign follows the Health Belief Model and assumes that if an individual perceives they are susceptible to a disease and that there are benefits to addressing the disease, he or she will do something about it (6). This is not always the case because humans are extremely social in nature. According to Social Expectations Theory, people’s actions are greatly influenced by their interactions with others (15). Therefore, the “It Could Be Hiding In You” campaign should consider removing messages telling youth what to do (get tested for chlamydia), and instead attempt to start a conversation among youth about what it means to lead a healthy sexual life. To address social interactions, Social Expectations Theory can be broken down into four constructs: norms, roles, rankings, and sanctions (15). The first three of these constructs can be used by the “It Could Be Hiding In You” campaign to create a community conversation about safe sex practices, and ultimately get students tested for chlamydia if they are sexually active.
            First, social norms around sexually transmitted infection testing need to be addressed. In Social Expectations Theory, norms are rules, traditions, or rituals that are followed by a society, whether they are implicit or explicit (15). One of the issues with sexually transmitted infection testing is that there is stigma associated with it, especially among men. Men tend to feel that that sexually transmitted infection testing procedures have the potential to be sexualized, and they fear accidentally compromising their masculinity (8). Masculinity is an important attribute to most young men; it is a social norm. The potential for compromising it might prevent men from getting tested in the first place. To address this social norm, the “It Could Be Hiding In You” campaign should emphasize to men that there are non-invasive procedures to test for chlamydia, such as a urine test (8).
            Second, roles and ranking should be addressed in the campaign. In Social Expectations Theory, roles are the application of norms to individual people who play a specific part in society, and ranking refers to the hierarchy of power that is given to people in a society, where some people have more power and some people have less (15). The youth target audience should have a distinct role in the campaign that is placed at a ranking close to that of the Boston Public Health Commission. As the target population, young men and women can relate better to youth and teach them the importance of STI testing while also being seen as a peer. The Boston Public Health Commission should invest its time in educating youth in matters related to sexual health, chlamydia, and sexually transmitted infection testing, and use them to spread the message about the campaign. Furthermore, the campaign could create a youth advisory committee to learn more about what aspects of the campaign are resonating with youth and what aspects are not. In this way, the target audience will feel as if they are part of the solution to ending chlamydia and they will also feel like they have an important role. In sum, addressing the constructs of role, ranking, and hierarchy will make the campaign more group-based rather than individual based, ultimately improving the campaign as a whole.
Defense of Intervention 2: Remove Fear Tactics and Involve Peers
            My second recommendation is that the campaign addresses Psychological Reactance Theory by removing fear tactics and involving peers in the educational component of the awareness campaign. To remove fear tactics, the campaign needs to change its slogans on its posters: “It Could Be Hiding In You,” “It Could Be Hiding In Him”, “It Could be Hiding In Her,” and “It Could Be Hiding In Them.” The current slogans utilize fear tactic strategies in an attempt to shock recipients of the message into doing something about potentially having chlamydia. For most people, finding out they have a sexually transmitted infection is frightening and can create confusion. If tested positive for a sexually transmitted infection, there might be anxiety regarding what to do next. Who does one tell they have a sexually transmitted infection? What does one do to treat it? All of this questioning can create a significant amount of stress. In fact, studies have shown that fear tactics are less successful at creating behavior change than positive messages, because rather than promoting behavior change, fear tactics tend to induce negative reactance (16). To avoid this, the campaign should change its slogans to ones that have a more positive message, such as “It Takes One Pill to Cure” or “You Deserve a Healthy Sex Life”. More positive messages might reduce reactance in that they are associated with feelings of self-control and empowerment.
            Beyond just changing its slogans to reduce the use of fear tactics, and ultimately negative psychological reactance, the campaign should reconsider how it addresses the seriousness of chlamydia. In addition to the slogans, the posters currently include short paragraphs on them that state chlamydia is a disease with serious consequences. This only creates additional fear and negative emotion. Instead of utilizing such a tactic, the campaign should consider using personal anecdotes of students talking about how easy it is to get tested and how the test is non-invasive. This would address fears men have of accidentally compromising their masculinity while reducing negative reactance. A study by Dunlop et al. found that narratives tend to elicit emotional responses that encourage people to change their behaviors (17).
            Finally, the campaign should also include peer mentors. Studies have shown that peer education groups can be effective at teaching about sexual health issues (18). Having peer educators to talk about chlamydia and sexually transmitted infection testing would reduce reactance by increasing similarity between the messenger and the target audience (12). Peer mentors have the ability to address concerns related to social norms more effectively, as they are part of the group that is targeted by the campaign.
Defense of Intervention 3: Reframe the Campaign
            My final recommendation is that the “It Could Be Hiding In You” campaign reframes itself around the core value of freedom rather than health. As was explained earlier in the paper, Maslow’s Hierarchy of Needs classifies health as a higher order need, and so it is less relevant to youth (14). Youth tend to see health as something they will always have and never lose. This is explained by a phenomenon known as optimistic bias. Optimistic bias is when an individual feels good events are more likely to happen to himself or herself than to his or her peers (19). One example of a way to frame the campaign around the core value of freedom is to focus less on the potential negative consequences of chlamydia, and more on the fact that safe sex practices and getting tested leads to a more free and fulfilling sexual life.
            In conclusion, the “It Could Be Hiding In You” campaign is ineffective at encouraging youth to get tested for chlamydia. It focuses too much on the individual through use of the Health Belief Model, and the use of fear tactics induces psychological reactance. Furthermore, the campaign’s framing of the issue around the core value of health is weak in that most people do not view health as an immediate need in their life. With the increasing prevalence of chlamydia in Boston, it is imperative that the Boston Public Health Commission changes its campaign in a way that is more group-focused, minimizes the use of fear tactics, involves the youth target audience, and frames the issue around a core value that resonates more strongly with young people. Otherwise, the campaign risks being ineffective at curbing the spread of chlamydia.
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