The
White House and Centers for Disease Control and Prevention spearheaded the Act
Against AIDS (AAA) initiative in 2009 in the Unit States. The rapid spread of HIV over the past two decades
raises concerns for both government organizations. The initiative hopes to fight complacency with
HIV/AIDS amongst Americans by increasing awareness and reducing the incidence
of infection in high-risk populations.
These populations include men who have sex with men (MSM), African
Americans, and Latinos (1).
The AAA initiative consists of eight
different programs. Four of these
programs target patients while four target healthcare providers. Three of the four patient programs target a
specific subgroup in the United States.
“Let’s Stop HIV Together” targets the stigma of HIV amongst Americans is
the only generalized campaign in the organization. “Reasons/Razones” encourages the Latino MSM
community to get tested while the other two, “Take Charge. Take the Test” and
“Testing Makes Us Stronger” aims to empower members of the African American
community to get tested for HIV. The
former targets African American women while the latter targets African American
MSM (1). All of these programs help to raise
awareness about the complications and consequences of HIV but have very
different methods of conveying this information.
The four physician programs target
specific subgroups amongst healthcare providers. “One Test. Two Lives” targets obstetricians
and encourages them to test any pregnant woman in their clinic for HIV. “Prevention is care” aims to ensure
clinicians council patients on reducing risky sexual behaviors. “HIV Screening. Standard Care” encourages all
primary care providers to screen all patients for HIV while “Testing and
Linking Minority Patients to Care” aims to help providers support the minority
African American and Latino communities screen for HIV (1). As with the patient programs, all of these
target specific subgroups within the medical field. Unlike the patient program, they tend to have
the same overall prevention and screening messages.
Though two powerful organizations back
this important initiative, their method of conveying the information may not
maximize the full potential of these programs. The initiative’s overall presentation, use of
statistical facts, and lack of people recognition could lead to unsatisfactory
results. The leadership should consider
adjusting some of its campaign strategies to effectively reach more people. If executed differently, this initiative
could have a substantial impact on the number of HIV tests as well as raise
awareness about the disease.
Overall Presentation
Many public health programs base
their campaigns on individual level models.
These models suggest an individual’s will power alone will help them
overcome a perception of a problem. Unfortunately,
these programs do not account for other external factors, such as someone’s
environment, social support, or education.
The AAA initiative is another example of a public health program using
individual level models. For example, if
an AAA advocate were to ask people on the street whether they should get tested
for HIV, the overwhelming majority would likely say they should. However, there is a substantial disconnect
between HIV testing awareness and utilization.
Multiple studies show an association between lack of HIV status
awareness and HIV transmission (2-3). This implies these people do not get the annual
screening the CDC recommends and unknowingly pass HIV on to intimate partners (2).
Though studies repeatedly show a
lack of utilization, the AAA initiative never shows a specific community how or
where to get tested. Instead, they
simply state facts, statistics, and reasons to go get tested. This suggests this initiative follows the
Health Belief model. In this model, an
individual will weigh their perceived susceptibility to and severity of the
illness against the cost-benefit analysis of getting tested (4). This model does not take into account the
many external factors that affect the potential audience’s ability to get HIV
testing. For example, an individual may
realize the importance of getting HIV tests but are unavailable when their
local testing center is open due to other commitments. Even worse, this individual may be unaware of
where they could get tested. This is one
of many factors the leadership did not take into account while developing this
program.
Additionally, the core values the
organization use, as arguments throughout the campaign are insufficient. The organization uses health and love as core
values to support their goals. Most of
the current campaign emphasizes the need to protect loved ones from HIV or
getting family support after a HIV positive diagnosis. For instance, one campaign suggests it will
be good for you and your partner to be aware of your status to protect each
other. Also, the “Testing Makes Me
Stronger” campaign suggests you will be healthier and a stronger unit if you
get tested (5). While it is helpful for
couples, this type of initiative will likely not be helpful for singles who
fall into these at-risk communities.
This will not speak to them as much as it will to partners. Additionally, the “Reasons” campaign suggests
reasons the Latino MSM community should get tested. One of the reasons proposed is getting tested
for the person’s family. Because the diagnosis
goes to the individual and not their family, this argument might be
flawed. Furthermore, given the stigma
associated with the disease, this individual’s family might abandon and no
longer speak to them. Ultimately, health
and love may be insufficient to get people motivated to get tested.
Finally, each program created by the
organizers targets each of the high-risk communities using different
messages. These messages utilize
different core values that are important to the community it targets. For example, Latinos tend to value family
more than other groups. This is
evidenced through increased family cohesion as compared to other ethnicities (6). However, these values might not be congruent
with certain groups within that ethnicity.
For example, the lesbian, gay, bisexual, and transgender (LGBT)
community might not have these same values they associate with these groups. Some LGBT individuals’ families meet them
with hostility after their children reveal their feelings (7). Thus, family
might not be as important to them as the initiative’s organizers believe,
especially if they are heavily religious.
It is important to consider the beliefs of a few in the high-risk
population might not be congruent with that ethnicity’s stereotype.
Statistics and Bias
This initiative provides facts,
statistics, and information about HIV infection in one of the first portions of
its website (8). Statistics are important
for scientists to understand the current problem and its potential impact. However, it will not help convey the
importance or an individual’s risk of getting the disease. People tend to believe a disease with a relatively
small incidence rate in the overall population will never affect them
personally. If they are less likely to
believe it will occur to them, they will not take the necessary precautions to
prevent it. This is an example of the
Law of Small Numbers.
The Law of Small Numbers states an
individual will believe a small sample’s outcomes accurately reflect the
overall probability of that event occurring to them (9). However, the outcomes in that small sample of
the population could convey they have a significantly smaller risk than the
standard incidence rate. Consider an
individual who practices a risky behavior (i.e. unsafe sex) multiple times with
multiple partners. If this individual
experiences no adverse outcomes over a period of time, they are less likely to
believe these outcomes will occur to them.
Similarly, if adverse outcomes do not occur to friends, this individual is
less likely to take the necessary precautions to prevent any diseases. It is not until after the disease occurs when
they realize their error. This is one of
the many reasons HIV spreads through humans.
Compounding this problem is issues raised
as a result of the Theory of Optimistic Bias.
This theory states that people tend to underestimate the probability of
bad things happening to them (10). The
AAA campaign features an individual who felt she was protected against HIV. She did not believe HIV would happen to her
since the risk was so small and none of her friends had it. It was not until after she got infected that
she realized she should protect herself from this disease (11). This
irrational thinking emphasizes the need to provide a different perspective on
HIV testing. Eldrige et al. (1995)
discussed the Theory of Optimistic Bias in a study on low-income African
American women’s barriers to condom and protection methods in sex. The study did not show that African American
women believed others were more at risk of getting HIV than themselves. However, this study did show women believed
the barriers to condom use for other African American women were worse than
their personal barriers (12). These
women believed they would personally be able to use a condom when they wanted
to while their counterparts would be unable.
It is important to note a woman’s’ ability to use condoms does not necessarily
mean they will utilize them to protect themselves against sexually transmitted
infections (STI). Regardless of access,
these women will be less likely to use condom if they perceive their risk of
getting infected with HIV as low. The
leadership should consider changing their framing of the issue to eliminate these
population-based biases.
People Recognition
Some campaigns choose to use celebrities
or well-known names to help convince people their ideas are worthwhile. Others choose to use everyday people to push
their support for a certain campaign.
Utilizing either can be an effective method to bring people to a
consensus. However, an organization’s
leadership must choose their spokesmen carefully. The spokesman’s message might not get through
to their audience as intended for any number of reasons. Furthermore, the spokesman’s message might
backfire and push people away from their overall message. While the AAA initiative obtains both
everyday individuals and a celebrity spokesperson, further changes could be
made to ensure people are receptive to their message.
The AAA initiative uses every day people
either infected with HIV or affected by a HIV diagnosis. These individuals are either a person living
with HIV or a family member of an HIV-infected person. In addition to changing the core values, the
organizers could change the people delivering the message as well. Currently, a middle-aged mother, an African
American man, and middle-aged Caucasian male are featured in the campaign’s videos. There are several important groups not
included in any of these videos. A
Latino, young teenager or early adult, or LGBT individual (either individually
or with a partner) are all not included.
Not only does the organization try to target these groups, but people
who are part of these groups need to hear this message coming from them without
a family member next to them. Their
current every day spokespeople could promote the Psychological Reactance
Theory.
The Psychological Reactance Theory says
an individual will either ignore or respond negatively to someone’s requests if
they do not identify with them (13). Some
studies show if information disseminators are unlike the target audience, it
will likely not affect their perceptions or attitudes. For instance, Driscoll et al. showed that
teenage lovers were more likely to stay together if their parents attempted to
interfere with their relationship (14).
Similarly, drug abuse campaigns demonstrate the effects of doing various
drugs (e.g. marijuana) for an extended period of time (15). Since its creation, there are a number of
parodies of that campaign floating around on the Internet. This is an opportunity for the AAA campaign
to learn from the mistakes of previous campaigns and change certain aspects to
promote a more effective campaign.
In addition to everyday individuals, the
AAA initiative uses one celebrity, Jaime Gomez.
He presents the importance of getting tested for HIV and suggests it is
critical to do so. He mentions some
statistics and discusses his first cousin’s recent HIV diagnosis (16). There are several issues associated with the
AAA strategy with this video. He is a lesser-known celebrity, which might
not make him as effective at changing people’s attitudes. Thus, people might be less likely to listen
to him, as he is not an authoritative figure in pop culture. Additionally, he might provoke the
aforementioned psychological reactance in some since people may not be able to
relate to or know of him. Finally, he
references some statistics, which might not promote his cause. Mentioning these statistics violates the Law
of Small Numbers (9). Combine all three
of these issues and there is a recipe for resistance from the targeted
audience. The leadership team should
consider developing a new type of intervention that will effectively bring this
audience on board.
Proposed Intervention
The proposed intervention blends all
aspects of the current intervention together.
The initiative will no longer have four programs for both patients and
caregivers. Instead, one program will
target all patients while another will target all healthcare providers. Because the intervention amongst healthcare
providers is fairly consistent, most of the changes below will apply to the
patient programs. The new patient
initiative may contain videos, posters, and brochures that discuss the
importance of getting tested for HIV.
These materials could use a wide variety of people or celebrities and
contain emotional stories in different regions of the United States and will
contain no statistics. These stories could
have justice and freedom as core values and will have a listing of prominent
local testing centers in the area along with contact information and
hours.
Stories Tailored to
Targeted Population
The organization could tailor these
stories to multiple populations to try to ensure they react a certain way. The organization could create multiple
versions of brochures, flyers, and advertisements that show multiple people
within a specific target population. These
materials would focus on the Latino, African American, and LGBT communities. They could also have several materials
tailored to those communities less at risk, such as middle-aged females. The organizers could disseminate these
materials through primary care offices, local health departments, and local
supermarkets. Since people frequent all
of these places, they will likely be exposed to the campaign’s message. If the message is effective, the organizers
will encourage the target audience to go to their local testing site for a HIV
test.
For example, the organizers could tailor
a brochure towards the Latino MSM community.
The brochure should have one or more LGBT Latino/a(s) discuss his or her
experience with HIV. They should tell
some type of emotional, personal story that has justice or freedom core value. For instance, this story could talk about
their family rejecting them after being diagnosed with HIV, moving out of the
house after a rough breakup with a cheating partner, or something similar. Tailoring these HIV testing campaigns to
specific communities with strong core values could create a lasting
impression. More people will likely have
some type of reaction, which will encourage them to act.
Furthermore, messages coming from similar
people will lessen the psychological reactance from these target populations. Because many fear getting tested for HIV,
they need a strong enough reason to do so.
If the spokesperson is similar to them in many respects, the person will
be able to identify with individual telling the story. It will likely encourage them to pay
attention to the campaign’s message, and they will be less likely to have a
negative reaction. This might encourage
people to go get tested as soon as they can, which is the ultimate goal of the
campaign.
Distribute Organization
into Regions
Some current materials offered by the
AAA initiative website provide some general contacts for support and testing. While one website has a zip code search of
local testing sites, none of the other websites offer this tool. None of their print materials have much
contact information listed, if any. Their
print material also assumes their audience has Internet access, which is not
always true. It would be worthwhile for
the organization to offer specific contact information for testing sites in
someone’s area. The organization should
consider breaking up into regions to better serve their target population and
their specific communities.
To accomplish this, the organization
could split the United States into regions much like the Veterans Health
Administration (VHA) (17). This will
give distinct, pre-defined zones that give guidance on how and where to define
the program boundaries. Within each of
these zones, the organization could identify major metropolitan areas as well
as key towns in rural areas that offer testing services. To simplify this process, they could simply
target areas currently with VHA outpatient and medical centers. While the actual VHA centers themselves would
not provide the testing, this could inform organizers as to where they should
look for potential testing centers. It
could make it easier for individuals to obtain HIV testing.
Moreover, distributing this organization
into zones will help to efficiently manage this organization. Currently, it appears the organization
operates on a national scale with little to no regional offices anywhere. Operating in a regional system will allow for
more unique, tailored approaches to reaching the target populations. For instance, the beliefs and challenges for
the LGBT community might be different in Mississippi as compared to
Massachusetts. In addition to listing
the contact information for local testing centers, the organization could
tailor their messages to directly match the issues affecting these communities
most. This could help increase HIV testing in the communities hardest hit and prevent
the spread of HIV.
Utilize Theory of Reasoned
Action
Although it is an individual level
theory, organizers should consider incorporating the Theory of Reasoned Action for
this campaign development. This theory
suggests an individual has certain outcome expectancies related to an
event. All individuals getting tested
have an attitude about what will happen if they get tested and assign it a
weight. Societal social norms will play
a factor in any decision they make, and they will consider who might not
approve of it and to what degree (18).
For example, a patient might not get tested due to the stigma of being
HIV positive. This stigma, rooted in
social norms, will be weighed against the outcome expectancies of tested for
HIV. An individual’s attitudes about
their perceived outcome expectancy and the weight given to that attitude will
help determine whether the individual will get tested at all. If organizers emphasize support services
offered to HIV positive patients, this might encourage more people get
tested.
Organizers
could also ask people to give stories that describe their reaction when they
received a negative result. It seems
most stories people hear about are those that test HIV positive. However, there are substantially more patients
who test negative for this condition. This
might encourage more people to get tested to just know their status. Studies show that the stigma surrounding HIV
is the biggest reason people do not get tested (2-3). Using this method, the organization could
show not all who get tested end up HIV positive. Also, they could show that someone should
simply know their status for their own peace of mind as well as for others.
Finally, the
organization could emphasize there are support services out there for those who
test positive for HIV. This could show
there are people with this diagnosis who support others. This campaign could emphasize a nurturing,
caring environment where people support each other through their recent
diagnoses and learn how to cope. They
could also emphasize that people live with HIV daily, and it is no longer a
death sentence. All are methods to get
people to change people’s perceptions of the standing social norms. It might also encourage people to think more
about who would approve and by how much.
Conclusion
HIV testing is vital to HIV
prevention and treatment. Initiatives,
such as AAA, attempt to get patients and healthcare providers alike to
understand the importance of HIV testing.
These organizations specifically target high-risk communities to ensure
they are not prone to getting infected.
While the CDC and White House established a very important and
worthwhile organization, these organizations could take steps to improve the
organization’s overall effectiveness. They
could tailor the organization’s messages further, regionalize the organization,
and approach social norms from a different angle.
This organization will continue to grow
as word continues to spread and is one of many trying to fight the spread of
HIV. More should be done to fight the
war against HIV. Scientific advancements
continue to push towards a cure. Until
scientists find a cure, this war will not stop.
Prevention through HIV awareness, safe sexual practices, and HIV testing
are the best methods of protecting the population from this disease. This organization promotes all of these, but
it can do all more effectively.
Incorporating these changes could have an impact on the efficacy of the
organization, and it could reach more people than it thought possible.
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