Advance Provision of Emergency Contraception and its effects on Prevention of Unintended Pregnancies- Diego Martinez-Vasquez,M.D

Modern contraceptive methods represent more than a technical advance: they are the instrument of a true social revolution—the "first reproductive revolution" in the history of humanity, an achievement of the second part of the 20th century, when modern, effective methods became available. Today a great diversity of techniques have been made available and—thanks to them, fertility rates have decreased from 5.1 in 1950 to 3.7 in 1990. As a consequence, the growth of human population that had more than tripled, from 1.8 to more than 6 billion in just one century, is today being brought under control (1).

The most recent cycle of the National Survey of Family Growth demonstrates that, despite a reduction in unintended pregnancies among adolescents, college-educated, and higher-income women, 49% of all pregnancies in 2001 (3.1 million) were unintended. Of these unintended pregnancies, 42% ended in abortion. Furthermore, 48% of unintended pregnancies occurred in women who were using contraception during the month of conception (2, 3).

Unintended and teenage pregnancies (49%) are major public health concerns in the United States (see above). Emergency contraception (EC) is used to prevent pregnancy after failure of a contraceptive method or after unprotected intercourse. EC can prevent pregnancy when taken within 120 hours of unprotected intercourse (4). Several types of EC regimens exist, including an estrogen-progestin combination (sometimes called "combined regimen" or "Yuzpe regimen"), levonorgestrel alone (plan B), and mifepristone.

Some clinical trials have been studied the benefits of providing EC in and advance manner (AEC) to facilitate females in their use (4). The idea begin was to determine if when giving AEC can reduce the rates of unintended pregnancy when compared to regular EC. These clinical trials did not showed any benefit in reducing unintended pregnancies in females who received AEC compared to EC.

Contraceptive counseling. A Healthy People 2010 objective is to increase the rate of intended pregnancy to at least 70% of all pregnancies (5). One approach to reducing rates of unintended pregnancy is providing contraceptive counseling during primary care visits. The National Survey of Family Growth defines birth control counseling as “counseling about whether to use birth control methods, how to get them, information about different methods, and how they are used.

EC for a woman, who has unprotected intercourse, requires several steps to reduce the risk of unintended pregnancy. She must perceive that her risk of pregnancy is real and must be motivated to prevent it. She must be aware that a post-coital contraceptive method exists that could reduce her risk of conception. She also must have specific knowledge about how to obtain it and time its administration. She must have access to it, including a place to get it, a way to pay for it, and the time to invest in getting it. Any of those steps can be barriers to actually using emergency contraception after unprotected sex.

One of the current and likely been a very significant barrier to making EC part of routine contraceptive counseling is that providers are unlikely to initiate discussions regarding EC or offer an advance prescription (AEC). One particular barrier to the provision of EC information may be lack of a standardized manner in which to deliver information and the option for EC. Major health organizations and groups, such as the World Health Organization, American College of Obstetrics and Gynecology and the International Consortium for Emergency Contraception, have guidelines regarding key points to be included in EC counseling. However, despite increases, knowledge is still limited and EC provision does not occur in a majority of visits(6).

Contraceptive counseling is defined as a form of interpersonal (as opposed to public) communication. It includes information-giving as well as opportunities for clients (patients) to express their concerns, values, and preferences and to ask questions. Information may be provided through multiple communication channels, and using multiple channels may have a synergistic impact, with written or video material reinforcing oral communication. In health care settings, counseling may include face-to-face discussions between the patient and her provider; group discussions; peer counseling; telephone hot lines or information resource lines; print or video materials made available in information kiosks or resource centers; and telephone or mail follow-ups or reminders. In the case of contraceptive counseling, the goal is to empower women to prevent unintended pregnancy (1, 2, 6).

Counseling is conceived as having three dimensions: 1) exposure refers to whether or not any counseling occurs through any communication channels; 2) content refers to the information imparted during counseling; and 3) personalization refers to the degree to which women’s needs and preferences are addressed. Little research on U.S. populations has addressed the relationship between counseling and contraceptive adoption or continued use (7).

The plausibility of the hypothesis that counseling is associated with contraceptive use is supported by evidence that provider counseling influences women’s use of other preventive tests and interventions. Studies of mammography screening find that one of the most common reasons reported by older women for not obtaining mammograms is that their physicians did not recommend it.

Theories of health behavior attempt to explain how individuals adopt or fail to adopt health-promoting behaviors (e.g., exercise, smoking cessation, use of screening mammography) or maintain those behaviors over time. Theories such as the health belief model, the theory of planned behavior, and the transtheoretical model provide a basis for examining the relationship between contraceptive counseling in the health care setting and contraceptive behavior. These theories recognize that knowledge alone is not sufficient to motivate individuals to adopt health-promoting behaviors and that factors such as values, expectations, and social influences also are important determinants of health behaviors. In addition, these theories draw attention to intervening steps between the acquisition of information and health-promoting behavior, such as building self-efficacy and forming behavioral intent.

The function of counseling in the health care setting can provide information and help clarify the options available to the individual, thus empowering individuals to make informed decisions with respect to their health. Counseling can help alleviate fears about specific options or reduce anxiety about social consequences of options, thus addressing some of the nonrational components of health decision making. Providing information and enabling individuals to cope with their concerns help build self-efficacy for behavior change. Counseling also can help individuals move from one stage of behavior change to another—for example, from the precontemplation stage, in which there is no intent to take action, to the contemplation stage, when an intent is formed to change behavior in the near future—or to maintain a health behavior once adopted.

Increase risky sexual behavior, increasing the risk of pregnancy or sexually transmitted diseases. Several studies have looked into AEC in effort to circumvent some of these obstacles. (8, 9). The studies showed that there is no evidence that suggests that providing AEC causes adolescents to have more unprotected intercourse or less consistent contraceptive use. Indeed, contrary to many health care providers and the public's views, the AEC group participants reported significantly higher condom use. The problem with this studies is that these studies failed to showed reduction in unintended pregnancies when compared to standard access situations (defined as routine contraceptive counseling, provision of information on emergency contraception, or emergency contraception on request) (4).

These trials share a common weakness. Reported information on use of emergency contraception, frequency of unprotected intercourse, and changes in contraceptive patterns was of unknown validity. Since these self reports lacked objective verification, this information should be viewed with caution. Objective evidence indicates that self reports on use of contraceptives other medications are inaccurate, and that self-report of unprotected intercourse is inferior to other ascertainment methods. Some degree of underreporting of pregnancies may have occurred in both the advance provision and control groups in these trials, particularly those trials using only self-reported data. Unintended pregnancies terminated by induced abortion are routinely underreported. However, results from the trials relying on pregnancy testing were consistent with results from the trials using self-reports of pregnancy(4).

None of the adequately powered trials showed difference in pregnancy rates, despite increased use, multiple use and faster use of AEC (4).

This conclusion conflicts with earlier optimistic projections of the potential public health impact of improved access. This intervention could have failed because the way women perceives pregnancy risk or because concerns about side effects, and inconvenience(10, 11).

Health care coverage or insurance. Although men and women have some similar challenges with regard to health insurance, women face unique barriers to becoming insured. More significantly, women have greater difficulty affording health care services even once they are insured. On average, women have lower incomes than men and therefore have greater difficulty paying premiums. Women also are less likely than men to have coverage through their own employer and more likely to obtain coverage through their spouses; are more likely than men to have higher out-of-pocket health care expenses; and use more healthcare services than men and consequently are in greater need of comprehensive coverage. Moreover some females don’t have coverage of prescription contraceptives. The direct medical costs of unintended pregnancies were US$5 billion in 2002 and direct medical cost savings due to contraceptive use were US$19 billion (12, 13).

In summary, advance provision of emergency contraception does not decrease unintended pregnancies nor increase sexual risking behaviors or sexual transmitted diseases. In order to decrease unintended pregnancies using advance provision of emergency contraception, routine and consistent counseling by health providers (physicians, pharmacists, nurse practitioners and physician assistant) in emergency contraception has to be provide to any female who is sexually active. Health behavior models like the health belief model, the theory of planned behavior, the transtheoretical have to be use in combination to assess the specific needs of each patient. Health coverage and insurance has to be taken in account when prescribing or recommending AEC. Overall not having access to medical coverage directly impacts the availability of physicians and health care providers. Moreover new programs have to be implemented to increase access of this population to health care.

Finally more studies need to be performed to asses the use of advance provision of emergency contraception. These studies need to be conducted looking at counseling and behavior model as described above. Nevertheless new programs that facilitated easy access to AEC for uninsured sexually active females have to be implemented through out the federal or state level.

References:

1. Benagiano G, Bastianelli C, Farris M. Contraception today. Ann N Y Acad Sci 2006;1092:1-32.

2. Chandra A, Martinez GM, Mosher WD, Abma JC, Jones J. Fertility, family planning, and reproductive health of U.S. women: data from the 2002 National Survey of Family Growth. Vital Health Stat 23 2005(25):1-160.

3. Martinez GM, Chandra A, Abma JC, Jones J, Mosher WD. Fertility, contraception, and fatherhood: data on men and women from cycle 6 (2002) of the 2002 National Survey of Family Growth. Vital Health Stat 23 2006(26):1-142.

4. Polis CB, Schaffer K, Blanchard K, Glasier A, Harper CC, Grimes DA. Advance provision of emergency contraception for pregnancy prevention (full review). Cochrane Database Syst Rev 2007(2):CD005497.

5. Services DoHAH. Healthy People 2010; 2007 October.

6. Petersen R, Albright JB, Garrett JM, Curtis KM. Acceptance and use of emergency contraception with standardized counseling intervention: results of a randomized controlled trial. Contraception 2007;75(2):119-25.

7. Pisaniello ML. Importance of counseling patients about contraception. Am Fam Physician 2007;75(5):624; author reply 624.

8. Gold MA, Wolford JE, Smith KA, Parker AM. The effects of advance provision of emergency contraception on adolescent women's sexual and contraceptive behaviors. J Pediatr Adolesc Gynecol 2004;17(2):87-96.

9. Raymond EG, Stewart F, Weaver M, Monteith C, Van Der Pol B. Impact of increased access to emergency contraceptive pills: a randomized controlled trial. Obstet Gynecol 2006;108(5):1098-106.

10. Adler NE. Contraception and unwanted pregnancy. Behav Med Update 1984;5(4):28-34.

11. Moreau C, Bouyer J, Goulard H, Bajos N. The remaining barriers to the use of emergency contraception: perception of pregnancy risk by women undergoing induced abortions. Contraception 2005;71(3):202-7.

12. Lindrooth RC, McCullough JS. The effect of Medicaid family planning expansions on unplanned births. Womens Health Issues 2007;17(2):66-74.

13. Trussell J. The cost of unintended pregnancy in the United States. Contraception 2007;75(3):168-70.

The Failure of PEPFAR and its ABC Campaign - Erin Lee

The World Health Organization (WHO) defines health as a “state of complete physical, mental and social well-being and not merely the absence of disease or infirmity… is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition.” HIV, also known as the human immunodeficiency virus, has played a major role in preventing thousands of people from obtaining this definition of health. In response to this growing crisis, the United States of America proposed an initiative to fight HIV/AIDS in some of the world’s most vulnerable countries. Known widely as the President’s Emergency Plan for AIDS Relief (PEPFAR), this initiative was created in 2003 with the goal of preventing 7 million new infections, treating 2 million people living with AIDS related illnesses, and providing care and support for 10 millions person affected by AIDS. One of the largest sources of international funding for HIV/AIDS, PEPFAR requires its beneficiaries to use one-third of the fund to promote its ABC (Abstinence, Be Faithful, Condom Use) campaign (8). However, the ABC campaign is an inefficient public health initiative because it does not incorporate the theories behind social and behavioral sciences in its implementation of programs to tackle HIV/AIDS in developing countries.

PEPFAR and Cultural Anthropology

Cultural anthropology is defined as an approach that strives to “understand and explain health behavior as part of a pattern of living that integrates action with meanings, symbols, and values, as these are connected to a larger social structure” (1). In order to create an effective public health intervention, one needs to incorporate the community and its perception of the health condition. In other words, the “behavior cannot be separated from its larger context” (1). For example, before implementing a child vaccination program, one needs to understand the local practices and their views toward vaccinating their children.

One reason why the ABC campaign is ineffective in its approach to tackle HIV/AIDS is because it fails to incorporate the ideas behind cultural anthropology. PEPFAR uses the principles behind “A” found in the ABC approach as a preventive measure to fight HIV/AIDS. It assumes that “Abstinence” can reduce the HIV transmission rates in many of these developing countries. However, this idea of abstinence is culturally ignorant because it does not acknowledge that sex may be used for different reasons (i.e. other than sexual pleasure) around the world. “Many sexual relationships include transactional or commercial sex, in order to pay for post-secondary schooling, to gain financial independence from family obligations, or to provide adequate resources for those contained in IDP camps” (2). Sex in these situations is used as a tool for survival and as a result abstinence is not an option.

In addition to being culturally ignorant, the promotion of abstinence assumes that other cultures also have a negative view towards premarital sex. As a result, this contributes to the stigmatization and demoralization of people who become infected with HIV. “Promoted evangelically, even in the context of generalized epidemics… the A/B-only message suggests that HIV negative people can prevent infection by moral fortitude” (7). This view not only stigmatizes HIV patients, but also reduces the general population’s self-efficacy to reduce HIV transmission. For example, if one cannot live a life of abstinence, one might assume that HIV infection is inevitable. Thus, this might discourage someone to have the self-efficacy to practice safe sex. By mandating its beneficiaries to promote abstinence, PEPFAR is essentially forcing U.S. based Christian ideals that premarital sex should be avoided.

The way sex is used is different depending on the culture and attitudes of its people. It is difficult to use abstinence as a preventive measure when sex is used as a tool for survival. As a result, PEPFAR and its promotion of abstinence fail to acknowledge the cultural issues surrounding HIV transmission. One way to remedy this problem is to do an anthropological study to determine the values and perception of sex found in these different countries, instead of forcing them to use abstinence as a form of prevention.

PEPFAR and Self-Efficacy

Self-efficacy is defined as a “person’s belief in his or her ability to take action” (1). It is considered as “one of the keys to change” and is needed for an individual to adopt a new behavior (1). For example, it is very difficult for an individual with the intention to quit smoking to actually change behavior if he/she lacks the self-efficacy to overcome his/her addiction to tobacco. The low level of confidence in his/her ability to fight the addiction hinders one’s ability to change the negative behavior. As a result, intention alone is insufficient to alter behavior if one lacks self-efficacy.

The ABC campaign is limited in its effectiveness in developing countries because of its failure to take into account the concept of self-efficacy. PEPFAR uses the principles behind the “B” found in the ABC approach as a preventive measure to fight HIV/AIDS. It assumes that if an individual has the intention to “Be Faithful” and is married, one has the ability to prevent the transmission of HIV. Ironically, by “promoting marriage as a prevention measure, this campaign negates one of the highest risk groups in Africa: monogamous, married women” (2). Despite their intention and commitment to marriage/being faithful, many of these women are vulnerable to HIV because of their sexually active husbands. Married men in many of these developing countries participate in extramarital sexual activity, which makes them susceptible to HIV transmission (4). Women in these countries lack the self-efficacy to protect themselves from their HIV infected husbands because they do not have the right to refuse their husbands sex (5). For these women, the ABC approach does not protect them from HIV infection because of the ineffective prevention strategy of unilateral monogamy.

As the feminization of HIV/AIDS increases, public health interventions need to address the issues faced by women in order to decrease the number of HIV/AIDS cases in developing countries. If PEPFAR wants to prevent 7 million new infections, it needs to incorporate the concepts of self-efficacy in its ABC campaign. The preventive measure to “Be Faithful” is not enough to protect these women because of their unequal relationships with their husbands. “The presumption that marriage is somehow protective is misleading and potentially dangerous for young women” (2). Since marital sex has become a major risk factor for HIV among women, prevention programs need to make extramarital sex safer (6). For example, one way the ABC approach can be more effective is to incorporate a campaign within the “Be Faithful” campaign to promote gender equality. This could be accomplished through the media with the goal of changing society’s perception of the male/female relationship. Ultimately, if PEPFAR wants the ABC approach to be a sustainable preventive measure, it needs to give women the confidence and self-efficacy to take action.

PEPFAR and the Theory of Planned Behavior

Another reason why the ABC approach does not work in developing countries is because it fails to incorporate the ideas behind perceived behavioral control/power. According to the Theory of Planned Behavior, “behavioral intention alone is not a sufficient predictor of behavior” and as a result one needs to consider the concept of perceived behavioral control/power, which “refers to the degree to which someone believes they have control over whether they can take action and the strength of that belief” (1). This theory emphasizes the point that intention alone is not enough to alter one’s behavior if one does not believe he/she has the power or control to take the necessary actions to change his/her behavior. For example, one’s intent to have safe sex and/or decrease sexual partners is insufficient when one does not believe he/she has the power or control to overcome the external issues preventing him/her from changing one’s behavior.

This idea that intention must be coupled with an individual’s perceived behavioral control/power in order to successfully change behavior can be seen in the failed attempts to reduce HIV transmission rates in internally displaced person (IDP) camps. The unstable and fragile political situations found in most developing countries have contributed to the 1.6 million people living in IDPs (3). Reducing HIV/AIDS cases in these camps has proven to be difficult because of the lack of power/control individuals have in preventing HIV transmission due to its limited resources. “The HIV/AIDS prevalence rates in IDPs… may be attributed to insufficient condom provision and inadequate sexual education in an area where control over sexual exposure to HIV is limited” (2). Lack of resources in IDPs highlight the ineffectiveness of the “C” found in the ABC approach, which is the promotion of condom use. Even if an individual has the intent to use condoms and practice safe sex, it is difficult to expect a change in behavior when the individual does not have the power/control to access the necessary condoms.

By putting the emphasis on individual behaviors, the ABC campaign does not acknowledge the underlying factors that make people living in IDPs vulnerable to HIV/AIDS. Condom use to decrease HIV transmission is impractical when these camps do not have the resources to provide its community members condoms. If PEPFAR wants its beneficiaries to incorporate the ABC approach, it needs to make sure that these countries are providing its’ camps with the necessary resources. For example, one way to remedy this situation is to provide one condom for every dollar PEPFAR donates to its beneficiaries and monitor the distribution of these condoms in the IDPs. This provides people living in IDPs with the intent to practice safe sex also have the power/control to access the condoms needed to perform the behavior. Otherwise, the principles behind the “C” of the ABC approach are not enough to change behavior because it does not provide the power/control to overcome the external obstacles of living in IDPs.

Conclusion

Despite PEPFAR’s goal to reduce HIV/AIDS in developing countries, the “ABC strategies dismiss the real social, political, and economic causes of the epidemic, and end up blaming infected people, because it is implied that they failed to adopt and practice the ABCs” (2). Many of these programs fail because they do not incorporate the important concepts behind cultural anthropology, self-efficacy, and perceived behavioral control/power. The ideas behind abstinence fail to recognize that the definition of sex is different in different cultures and as a result is culturally ignorant. The ideas behind being faithful fail to recognize that marriage does not protect women in relationships of unequal power. The ideas behind condom use fail to recognize that condoms are not always available especially in areas of limited resources. These examples only highlight the multifaceted and complex nature of HIV/AIDS. As a result, in order to tackle this growing epidemic, PEPFAR needs to develop a new campaign that incorporates all these complex issues by referring to the many different levels of social and behavioral sciences.

REFERENCES

1. Edberg M. Essentials of Health Behavior Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett Publishers, 2007.

2. Murphy E. Was the “ABC” Approach (Abstinence, Being Faithful, Using Condoms) Responsible for Uganda’s Decline in HIV? PLoS Medicine 2006; 3:1443-1447.

3. Lowicki-Zucca M. AIDS, Conflict and the Media in Africa: Risks in Reporting Bad Data Badly. Emerg Themes Epidemiology 2005; 2:12.

4. Ntozi JP. Has the HIV/AIDS Epidemic Changed Sexual Behavior of High Risk Groups in Uganda? Afr Health Science 2003; 3:107-116.

5. Gage AJ. Factors Associated with Self-reported HIV Testing Among Men in Uganda. AIDS Care 2005; 17:153-165.

6. Hirsch JS. The Inevitability of Infidelity: Sexual Reputation, Social Geographies, and Martial HIV Risk in Rural Mexico. Am J Public Health 2007; 97:986-996.

7. Health Global Access Project. Health GAP Report – Between the Lines (GAO Report on PEPFAR Prevention Programs: U.S. Abstinence/Being Faithful-Only Programs Produce Stigma and Death). New York, NY: Health Global Access Project. Nttp://www.healthgap.org.

8. Office of the United States Global AIDS Coordinator (2004) Appendix 2: The Emergency Plan for AIDS Relief: Fiscal year 2004 Prevention Expenditures and Program Classification Criteria. Washington (D.C.): US Department of State.

“Assumptions” Fails to Reduce HIV Transmission– A Critique of the First HIV Prevention Campaign Targeting Gay Men in Canada – Danielle Finkelstein

The incidence of HIV among men who have sex with men (MSM) in Canada had been declining through 1996 due to effective prevention campaigns and widespread education about the importance of practicing safe sex. But, during the late 1990’s through 2000, researchers found an increase in incidence among all populations; however, gay men in Canada continue to be most affected by HIV. By the end of 2002, of approximately 56,000 Canadians living with HIV, 32,500 (58%) were MSM. MSM also made up the largest group of new infections for that year – approximately 40% of the nation’s total (1). Research conducted across all of the provinces in an effort to explore reasons for the recent change showed an increase in risky behavior among MSM, specifically related to unprotected anal intercourse (UAI). As a result, for the first time since HIV/AIDS first appeared in Canada, a handful of major health organizations began collaborating in order to implement the first nation-wide HIV prevention campaign targeting gay men: The Assumptions campaign.
The Assumptions campaign’s design was based on research data from San Francisco, California in the late 1990’s when researchers found that the increase in UAI among MSM was due to men’s faulty assumptions that their sexual partners were of the same serostatus as themselves (2); “serostatus” is a term that refers to HIV negative or HIV positive status. To address this issue, the Assumptions campaign was created with the intention of lowering HIV transmission by convincing men to disclose their serostatus to their partners. The message was specifically targeted towards men who have frequent, and sometimes anonymous, sex partners of unknown serostatus. The campaign consisted of billboards, posters, washroom ads, transit ads, coasters, and condom packages (2). A majority of the billboards and ads featured two men who were shirtless and, from their positioning, appeared to be engaged in various sexual acts. The text on the ads was placed so that one man is thinking “He’d tell me if he’s positive,” while his partner is thinking “He’d tell me if he’s negative.” Other variations of ads included the text “He does it raw. He must be positive,” “I don’t have it yet. I must be immune,” and the pair “He hasn’t asked for a condom. He must be positive; He hasn’t asked for a condom. He must be negative” (2). The text “How do you know what you know?” appeared on the bottom of all of the ads, along with the campaign’s website “think-again.ca” (2).
The campaign was initiated in San Francisco in 1999 and 2001, before Canadian organizations decided to implement it across the country. The Canadian health organizations slightly modified the campaign to better suit their population, specifically by developing identical advertisements in both English and French. Assumptions was implemented in Canada during the summer of 2004. This critique will discuss existing evidence that proves the Assumptions campaign was designed with fundamental flaws, such as reliance on ineffective theories, assumptions, and marketing tools. These flaws ultimately set the campaign up for failure and therefore explain its inability to reach the desired goal: to significantly increase disclosure of serostatus to reduce the transmission of HIV among MSM in Canada.
The theoretical design of the Assumptions campaign is based on an individual model of behavior change, such as the Health-Belief Model. This type of model assumes that invoking thought about a healthy or risk-reducing behavior, such as wearing a condom or disclosing HIV status, will lead to performing that behavior. Due to the faulty design, the campaign disregards the idea of self-efficacy and other factors known to influence behavior. The Health-Belief Model, which was developed in the 1950’s by social psychologists Hochbaum, Rosenstock, and Kegels, states that behavior is motivated by perceived susceptibility, severity, benefits, and barriers (3). Each of these terms is defined as the following: Perceived susceptibility is the degree to which a person feels at risk for a health problem; perceived severity is the degree to which a person believes the consequences of the health problem will be severe; perceived benefits are the positive outcomes a person believes will result from the action; and perceived barriers are the negative outcomes a person believes will result from the action (3). According to the Health-Belief Model, the individual weighs all of these elements when he decides whether or not to perform the behavior in question. The model assumes that as long as the perceived susceptibility and perceived benefits are strong enough to outweigh the barriers, the person will make the rational decision to perform the healthy behavior.
The Assumptions campaign applied elements of this model in its advertisements by presenting the perceived susceptibility and perceived benefits of disclosing one’s serostatus. Perceived susceptibility is represented by the text “He’d tell me if he’s positive” and “He’d tell me if he’s negative,” followed by the phrase “How do you know what you know?” (2). The message attempts to convince men that as long as they are unaware of their partner’s status, their guess could be wrong and therefore they might have a high risk of either contracting HIV or infecting their negative partner. Perceived benefits are implicit also in the phrase “How do you know what you know?” This phrase is used to subtly convince men that they would be better off knowing, rather than guessing, the serostatus of their partner. The advertisements are designed with these phrases to show that one is susceptible if he does not talk to his partner about serostatus. The benefits of this conversation are knowledge of serostatus and, consequently, the ability to decide whether protection against HIV is necessary. Unfortunately, behavior is not so easily swayed, and trying to convince men to disclose serostatus simply because their assumptions or guessing skills are not up to par is a one-dimensional, ineffective approach. This is a result of the lack of consideration of any factors that influence behavior outside of perceived susceptibility and perceived benefits.
One of the most important determining factors in health behavior is self-efficacy. Self-efficacy, which was developed by psychologist Albert Bandura, is defined as “a person’s belief in his or her ability to take action” (3). When applied to disclosing serostatus, self-efficacy is the belief that one can successfully disclose his serostatus to his partners or ask for his partner’s serostatus. A major reason the Assumptions campaign’s application of the Health-Belief Model is ineffective is because it lacks this construct. Research concerning serostatus disclosure among MSM has shown that low self-efficacy is a great risk factor for non-disclosure (4, 5, 8). A study that included 1168 seropositive gay and bisexual men in New York City and San Francisco showed that significantly higher levels of self-efficacy to disclose were reported by consistent disclosers (men who disclosed serostatus to all partners) as compared to inconsistent disclosers and non-disclosers (4). Additionally, seropositive non-disclosers report more frequent risky behavior, such as unprotected anal intercourse (UAI), with multiple partners of either HIV-negative status or unknown serostatus (4, 8).
Ultimately, if a man does not feel that he can disclose his status, then he will most likely not do so. The Assumptions campaign advertisements were not designed with self-efficacy in mind, and there is no attempt among the text or images to convey the message that serostatus disclosure is an achievable goal. No information is given on how to go about having this conversation, and therefore, one could argue that the lack of resources insinuates that disclosure is such a difficult act that not one piece of advice could possibly be relayed through a simple billboard or coaster.
The Assumptions campaign advertisements were designed to increase serostatus disclosure in hopes to reduce HIV infections; however, in 2002, after the Assumptions campaign had been implemented twice in San Francisco, research became available which showed that increasing serostatus disclosure does not necessarily lead to decreased HIV infection (8). There are a number of reasons for this, one of which is a relatively recent trend in the MSM community called “barebacking.”
Men in the MSM community who intentionally seek out UAI are called barebackers. Some men choose to participate in barebacking only with men of concordant serostatus, whereas others will participate with men of either serostatus, including those with unknown serostatus (6). This term has been defined in a number of different ways among MSM and behavioral researchers, and therefore many questions remain surrounding it and the men who consider themselves to be barebackers. In the following research, barebacking was defined as “intentional anal sex without a condom with men who are not a primary partner” (6). A study with a sample of 554 men in San Francisco in 2001 showed that 10% of MSM had participated in barebacking in the previous 12 months. Of these men, 35% were seropositive, 61% were seronegative, and 4% were of unknown serostatus (6). In another study of 1168 seropositive MSM in New York and San Francisco in 2005, 27.2% participated in barebacking. Of these men, 42.7% engaged in barebacking only with seropositive men, 2.2% only with seronegative men, and 11.7% only with men of unknown serostatus. The remaining 43% engaged in barebacking with all groups (7).
Ultimately, men who participate in barebacking are intentionally seeking high-risk sexual behaviors such as UAI, and an ad campaign like Assumptions will most likely be ineffective in this population. These men already know that they are putting themselves and/or their partners at risk of either spreading or contracting HIV; in fact, they make the conscious decision to do so. Consequently, an advertisement that informs them that they could be having UAI with non-concordant partners is old news. The reasons why men participate in barebacking, such as “greater physical stimulation” and “feeling emotionally connected with a partner,” (6) are not outweighed by the risk of HIV for men who engage in this behavior with discordant partners. And not surprisingly, the Assumptions campaign does nothing to address this issue. The advertisements carry the assumption that if men knew they were engaging in UAI with discordant partners, they would change their behavior. Research on barebacking has proven that this is not always the case.
Another reason why increasing serostatus disclosure is an ineffective way to reduce HIV infection is because disclosure does not necessarily increase use of condoms (8). For example, among seropositive men who disclosed to some of their seronegative or unknown status partners, 49% still engaged in UAI (8). These men believed that “they had done their part and that the responsibility for safer sex rested on their partner” since they had disclosed, and if their partner wanted to have unprotected sex, “they viewed it as his choice because he had been informed” (8). The researchers also stated that disclosure of seropositive status “may promote a greater sense of trust, intimacy, or emotional closeness that can cause some serodiscordant couples to be more willing to have unprotected sex” (8). Surprisingly, this research was conducted by the same organizations that designed the Assumptions campaign in San Francisco. And yet, even though they were aware that the basic design of the campaign was proven to be ineffective for a number of reasons, they still allowed Canadian health organizations to adapt the campaign for their use.
The extreme complexity of serostatus disclosure renders advertisements less effective, such as those in the Assumptions campaign. For example, some seropositive men will go to great lengths to avoid disclosing their serostatus by not having sexual relationships or by only being involved with anonymous partners (8). These issues need to be addressed in a much more in-depth and comprehensive manner.
The Assumptions campaign was designed and implemented with social marketing theory in mind. Social marketing theory is defined as an “approach to health communications and behavior change in groups or populations that incorporates principles of marketing to achieve health aims,” and it relies on “the four P’s: Product, price, place, and promotion” (3). When applied to the Assumptions campaign, the product being offered is disclosure of serostatus; the price is the difficulty involved in disclosure; the place is where the ads were distributed, including billboards and washrooms; and promotion is how the MSM population was informed about the campaign, possibly through the campaign’s website or through its sponsoring health organizations. While this approach may be effective for influencing other health behaviors such as HIV testing (9), in this case, social marketing was not practical. A great deal of research exists that shows the benefits of using a community-level approach in HIV prevention efforts, and furthermore, the researchers themselves who were behind the Assumptions campaign stated in 2002 that a “1-size-fits-all approach to prevention with HIV-positive MSM will not succeed” (8).
It seems apparent that social marketing theory would not be effective in a campaign such as the Assumptions campaign solely because the target population was so small and not confined to specific areas throughout Canada. The billboards used in the campaign were erected in major metropolitan areas of Canada’s provinces including Toronto, Montreal, Vancouver, Halifax, Edmonton, and Winnipeg; as expected, there was much negative feedback from local community members who felt that the advertisements were too graphic to be displayed in public areas visible to children (2). Some of the feedback from community members included “’Your subway posters are offensive and border on pornography!’” and “’This is pornography, not health,’” (2). Some companies even refused to display the billboards and public transportation ads because they could be “viewed as offensive to the general public and [the company’s] land owners” (2). Because of the public displays used, a majority of the population was unnecessarily exposed to the campaign, which created a lot of controversy and possibly took away from the initial message of the campaign.
Instead of social marketing, a community-level, evidence-based approach would have been much more effective since this type of intervention has “demonstrated impressive reductions in HIV risk behaviors […] among a range of target populations” (10). For example, a study of community-level HIV interventions in 5 cities across the US found that handing out condoms to high-risk populations was effective in increasing condom use and condom carrying, including among the MSM population (11). Another study of 8 US cities found that training a popular gay male in the community to discuss safe-sex practices with other MSM was an effective way to increase condom use and decrease UAI (12). The main difference between these community-level approaches and the social marketing used for the Assumptions campaign is human interaction. When billboard ads are used to deliver an important message, they should be clear and concise; however, many men found the ads to be confusing: “'Some people might see these as true statements’” [i.e. “I must be immune” or “He likes it raw. He must be positive”], “’I don’t get the message. I just get a little ‘thought,’’” and “’It takes a lot of work to actually get to the meaning’” (2). Therefore, even though a majority of the target population was exposed to the campaign in one way or another, many might have walked away either confused or with misunderstanding concerning the message of the campaign. Conversely, with a community-level approach, professionals are more likely to be available to answer questions and encourage communication between the target population, relevant local organizations, and other health professionals.
It is apparent that the initial design of the Assumptions campaign was flawed as a result of its reliance on the Health-Belief model, false assumptions about serostatus disclosure, and by choosing to use social marketing theory. Though it may have been deemed partially effective because a majority of MSM were exposed to the advertisements (2), greater efficacy should be expected from HIV prevention programs that have been used repeatedly. Even though there is still much to be done in HIV prevention, researchers and public health professionals can learn from those interventions that have been found to be effective, such as many community-level prevention programs, and build on these valuable resources to further promote health among gay men by reducing HIV infections.
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