Challenging Dogma - Fall 2007

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

Monday, December 10, 2007

Messaging Breakdown: Shanghai Contraceptive Program Fails to Enable Sexual Health Behavior Change - Mary Kate Allee

As long as there has been a history of civilization, so too has there been a history of abortion. Women have worked for millennia to control their ability to conceive (1). While the modern era has introduced an array of contraceptive options for both men and women, disseminating contraception has proven to be difficult due to the stigmatization of pleasurable sexual intercourse and the embarrassment surrounding sexual health. Over the last twenty years Chinese attitudes toward sex have been shifting due to many social and economic changes (2). Many positive public programs and governmental policies supporting gender equality led to Chinese women having more of a voice in their marriages and an improved leadership status within the household (3). Amidst these cultural changes in China, premarital sex has become more accepted among Chinese youth (2). In the Shanghai region there is a need for sexual and reproductive health education among the unmarried youth population. Sixty-nine percent of unmarried women have experienced sexual activity prior to marriage (4). Approximately 12% of males use condoms in Shanghai, while nationally intrauterine devices (IUDs) and female sterilization are the chosen forms of contraception (3). In order to increase contraception use among female factory workers in Shanghai, a pilot workplace-based intervention conducted sex education seminars based on information gathered in worker focus groups. Due to the flawed implementation of this program, the participants received insufficient information to successfully change their sexual health practices.
Assumptions, Assumptions, Assumptions
When implementing a public health program, it is imperative to utilize the members of the community because they know the habits, attitudes, social groups, and where things happen for their community as well as bring legitimacy to the intervention (5). An effective program is designed through a structured system of analysis for the purpose of understanding the type of intervention that would be most successful within the given population. The PRECEDE-PROCEED approach analyzes the social, situational, epidemiological, behavioral, environmental, educational, ecological, administrative, and policy elements prior to the implementation of a public health program. As a result, challenges and assets are identified, which allows public health professionals to address the specific community needs (5).
Granted, a workplace is a special type of community due to its very existence as a specific subset of the greater town or city. However, the analysis phase prior to program design is still crucial (5). There were many weaknesses with the basic analysis conducted by the researchers of the Shanghai contraceptive program. Prior to study implementation, the researchers did not fully utilize participant input for the design of the intervention and did not analyze the social networks within the factory. Impersonal sexual health interviews created a disconnected environment between the interviewers and the workers, which hindered the researchers’ data collection. With women in a different factory department from which the intervention took place, the researchers held three focus groups and conducted four individual interviews. General statistics on the target population were obtained from surveys and basic interviews. Because they primarily examined survey data, the researchers were unable to define social relationships within the factory and their impact on the participants’ decision making process.
Since this intervention took place within a defined group of participants (in a selected workplace), the utilization of Social Network Theory would have been an appropriate model for the program. In Social Network Theory, individuals are influenced and make decisions based on their relationships with others (5). A powerful mechanism for increasing safe sexual behavior among the factory workers would have been to identify the social leaders within the group and utilize them as either facilitators of sessions or as constant participants. If the social leaders within the factory consistently attended the voluntary sessions, other factory workers would have been more inclined to attend. However, this program failed to use factory relationships to benefit the final outcome of the overall program (5). Further, the researchers did not evaluate potential networking strengths within the factory, such as a break room for reinforcing their message on sex education. Additionally, the researchers were unaware of the administrative challenges to their intervention, such as a great number of the women being too busy with work to attend the lectures.
None of the participants assisted in developing the overarching message of the sex education program, and this message was disseminated without being tested on its target audience. Many public health programs work with their target population to develop an intervention because the message can be more successful if it is developed by the individuals that the campaign is trying to reach. One example of this is the Florida Truth Campaign. By effectively utilizing the wisdom of the target teenage audience, the program reduced youth tobacco use throughout Florida. Part of this campaigns strengths were due to the fact that youth opinions were not only valued, but they were also validated (6-7). In contrast, assumptions guided the Shanghai campaign for spreading contraceptive knowledge to the young female migrant workers.
One assumption was that the two existing factory doctors were the best individuals from whom participants could gain sexual health information and obtain contraception. Like many young people, young Chinese women exhibit a certain level of embarrassment when acquiring contraception. Being “too shy” to purchase contraceptives at a drug store or obtain contraceptive methods from a health care provider is common among Chinese youth (2). This program failed to give the participants an option with which they were comfortable for obtaining contraceptive resources. In this cultural group, a young woman’s mother and her friends are the most influential sources of information and support regarding sexual health (2). Utilizing these individuals as the contraception distributors may have effectively provided participants with contraceptives. Another option could have been to train the women in purchasing contraceptives or in broaching the subject of sexual health with their doctor. Assisting the participants in overcoming the barrier of embarrassment would have vastly improved their ability to obtain contraceptives.
Messaging and Context – Failed Format
The intervention’s ineffective frame was simplistic in nature and had an incomplete message. “Talk about sex at work when there is a facilitator nearby” was the message that the Shanghai migrant workers took away from this intervention. An unfortunate missed opportunity, one of the large programmatic flaws was the inability to give these women examples of how to apply this newfound comprehensive knowledge regarding female anatomy and contraception to their real lives. The participants gained knowledge, but were not given any instruction or resources for implementing it after the intervention’s conclusion. Prevention programs that encourage communication and sexual negotiation skills while promoting condom use are needed for Chinese youth (2). The program fell short in educating the women on how to make sexual health changes in their lives.
To make a real impact on how women behave sexually, we must first evaluate a woman’s perception of herself, particularly her vagina (8). It would have been empowering for the participants to discuss their perceptions and attitudes toward their vaginas because vaginal health is so closely tied to a woman’s sexual and physical health, while also creating a natural transition into a vaginal contraception dialogue. In order to change sexual behavior and contraception choices, women need not only the information about their bodies, but also a less stigmatized environment in which to discuss the vagina (8).
This intervention worked in a few different settings for the purpose of increasing contraception knowledge. Under the false assumption that the two factory doctors were the best resource for providing the participants with family planning and contraceptive resources, professional training was provided for both doctors to prepare them to give appropriate counseling and sexual health services. Experts from Shanghai Institute of Family Planning Technical Instruction gave two sets of lectures that were repeated several times in order to reach as many factory workers as possible. One lecture topic was reproductive physiology and barrier methods, while the second lecture topic was oral contraception, emergency contraception, and sexually transmitted infection (STI) prevention. Attending the lectures was optional and workers would have taken time away from work to attend. Booklets covering similar topics discussed in the lectures were developed by the Fudan University School of Public Health and were made available at lectures as well as through the workshop managers. Additionally, free condoms, counseling, oral contraception pills, and emergency contraception pills were provided.
Amidst all of the practical subjects that were omitted from the sexual health seminars, like overcoming the embarrassment of purchasing condoms and talking to your partner about contraception, this intervention also failed to explore the participants’ attitudes toward premarital sex. Many of the women in this study disapproved of sex before marriage and yet participated in this very behavior. The message of the intervention was not shaped with this knowledge nor was it shaped by the baseline survey fact that 83% of participants disapproved of colleagues who become pregnant before marriage. Clearly there were inconsistencies between how the participants perceived sexual behavior and their actions. Despite all the previously mentioned influences on sexual behavior, the intervention focused exclusively on disseminating information versus discussing the multitude of factors like culture, religion, family relationships, or education that may have impacted the participants’ attitudes toward sex and contraception.
In order to increase contraceptive use, men’s cooperation and participation are needed (3). Since the program’s goal was to change sexual behavior, it was imperative that both partners be involved. Discussing sex and contraception can be a difficult topic for many couples and these participants needed tools to discuss sexual health. Two important indicators of young Chinese women’s sexual behavior include: male partners approval of contraceptive use and contraceptive discussions among partners (10). By not coaching the young women on ways in which to discuss sex, the program crippled their ability to control their sexual future. While the sexual and reproductive health knowledge was comprehensive in this program, it failed to teach the participants how to truly implement this new knowledge.
Further, the information that was distributed was unbalanced as it focused primarily on condom and hormonal contraceptive use. By failing to explore many participants’ decision to use natural family planning as her primary contraceptive method, this program neglected to address certain cultural choices made by the participants. Some women of Korean descent are apprehensive about using hormonal contraception because there are false assumptions that hormones have negative long-term impacts on women that use them (11). Perhaps there was a similar phenomenon occurring with these migrant workers. Due to the incomplete pre-assessment of participants, we are unable to draw conclusions regarding the participants’ perceptions of various contraceptive methods. The exploration of the participants’ acceptance of various contraceptive methods prior to designing the intervention would have allowed the researchers to shape sessions specific to the cultural demands of the population. Due to the popularity of natural family planning, it may have been useful to discuss how to use it efficaciously and to discuss its limitations in protecting against STIs and preventing pregnancy as compared to other forms of contraception.
Many factors influence individual behavior
When attempting to change behavior, each individual is part of a complex social-ecological web. There are many factors impacting each of us and how we behave (5). For instance, sexual behavior is tied to multiple elements including an individual’s perception of herself, her belief that her behavior can be changed, her sexual partner, the media influence, the cultural influence, and her socioeconomic status. This program was flawed because it did not work with the participants as though there were other influences in their lives. Regardless of external work factors, there was discontinuity of the sexual health information within the work environment because it was only available during the seminars. There was no effort to increase the sexual health knowledge throughout the workday.
Moving Forward
Overall the Shanghai contraceptive program can be summarized as a series of missed opportunities. Although the information increased participants’ knowledge regarding sexual anatomy and contraception, this program was based on a flawed individual model of behavior change. It had the potential to change the sexual health behavior of participants. However, the researchers made the false assumption that by simply providing participants with information that their behavior would change. When information is used exclusively without integrating social support, family influences, and many other factors, knowledge alone will rarely lead to behavior change (5).
Social, economic, geographic, cultural, and many other factors must help shape public health interventions, but the researchers did not account for these other factors. While there are multiple aspects of an individual’s sexual health decision-making process, this program neglected to evaluate the reasons that women have unprotected sex. Many items inhibit one’s ability to get health care and the three frames of social, behavior, and disease are all linked (12). Because the frame of this intervention was on an individual level, it was unsuccessful in making a lasting impact on the participants’ sexual health behavior.
1. Paul M, et al. A Clinician’s Guide to Medical and Surgical Abortion. Washington, DC: Elsevier, 1999.
2. Wang B, et al. Sexual attitudes, pattern of communication, and sexual behavior among unmarried out-of-school youth in China. BMC Pubic Health 2007; 7:189-99.
3. National Population and Family Planning Commission of China. Project Initiatives. Beijing, China: National Population and Family Planning Commission of China.
4. Qian X, et al. Unintended pregnancy and induced abortion among unmarried women in China: A systematic review. BMC Health Services Research 2004; 4(1):1.
5. Edberg M. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett, 2007.
6. Hicks J. The strategy behind Florida’s “truth” campaign. Tobacco Control 2001; 10:3-5.
7. Bauer U, et al. Changes in youth cigarette use and intentions following implementation of a tobacco control program: Findings from the Florida Youth Tobacco Survey, 1998-2000. JAMA 2000; 284: 723-8.
8. Nappi R. et al. Attitudes, perceptions and knowledge about the vagina: The International Vagina Dialogue Survey Contraception 2006; 73(5):493-500
9. Wu J, et al. A survey on contraceptive knowledge, attitude and behavior among never-married young women who are seeking pregnancy termination in Beijing. Chung-Hua Liu Ping Hsueh Tsa Chih Chinese Journal of Epidemiology 2001; 22(3):219-22.
10. Wu J, et al. Contraceptive use behavior among never married young women who are seeking pregnancy termination in Beijing. Chinese Medical Journal 2002; 115(6):851-5.
11. Wiebe E, et al. Ethnic Korean women’s perceptions about birth control. Contraception 2007; 73:623-7.
12. Link B, Phelan J. Social conditions as fundamental causes of disease. Journal of Health and Social Behavior 1995; extra issue:80-94.

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