Thursday, December 18, 2014

Critique of the “Don’t Be a Lab Rat” Campaign-Xiaohui Cao


The “Don’t Be a Lab Rat” campaign, launched August 2014, is a marijuana-education campaign focusing on teens in Colorado. The $2 million campaign is created by the state of Colorado and the city of Denver, and founded by legal settlements with pharmaceutical companies.
The “Don’t Be a Lab Rat” campaign includes a website, interactive theater ads and TV commercials. Besides, 12-foot-long, 8-foot-high rat cages are used at the corner of street in Denver to raise teens’ attention on marijuana use. The campaign’s online website has a lot of statistics on adverse effects of using marijuana in teens. The TV commercials also suggest that marijuana impairs teens’ brain and causes long-term mental problems. By using disputed facts, the campaign want to warn the teens not to be a lab rat in finding the adverse health effects of the drug.

Marijuana use by adolescents has been a problem in the US for a long time. According to the National Institute on Drug Abuse (1), marijuana use among teens has been increasing since the mid-to-late 2000s. In 2013, 7.0 percent of 8th graders, 18.0 percent of 10th graders, and 22.7 percent of 12th graders used marijuana in the past month. Also, studies have shown that drug abuse could lead to other problem behaviors such as fighting, stealing, vandalism, and early sexual activity. Therefore, effective anti-drug campaigns targeting on adolescents are important to decrease the prevalence of drug use in this population. However, the “Don’t Be a Lab Rat” campaign has been controversial since it was created. In this paper, the flaws of this campaign will be discussed and new intervention will be proposed.

Part One: Critique Arguments

Argument one: Scare tactics do not work well on teens
The most obvious flaw the “Don’t Be a Lab Rat” campaign makes is that the campaign relies heavily on scare tactics such as fear-based statistics. On the website of the campaign, there are a lot of scary statistics from research that connect marijuana use to high risk of certain disease such as schizophrenia, depression, stroke, heart attack and etc. The website also emphasizes the negative effects of the drug on the teens’ brain, saying that marijuana could shrink parts of the teenage brain and that teen marijuana users may lose an IQ of 8 points permanently. In addition to the scary statistics, the campaign also put giant human-sized “lab rat cages” all over Colorado, trying to warn teens to stay away from experimenting such adverse health risks. However, it is shown that teens are less likely to believe the message and tend to discredit the messenger when exaggerated dangers, false information are delivered (2).

These threatening statistics and “lab rat cages” are used by the campaign with regard of the Health Belief Model. Health Belief Model, developed in the 1950s, argues that individuals are ready to change their health behavior if they believe that they are susceptible to the condition and the condition has serious consequences (3). By using the model, the campaign is intending to raise the teens’ awareness of severity of the outcomes and simply assuming that the teens will realize the terrible consequences of smoking drug and thereby stay away from it. However, the Health Belief Model may not work very well on teens because its limitations under the condition.
One assumption the campaign makes is that teens are rational so that they will weigh their degree of risk and analyze the cost-benefit of their behavior and make the right decision to stay away from drugs (4). However, the reality is that individuals may not be rational thinking when making decisions (5).  This is especially true when it comes to teens. For example, one study shows that “a youth’s reason for using tobacco had everything to do with emotion and nothing to do with rational decision making” (6). In the campaign, teens may be aware of all the adverse effects of marijuana might have on their health but still use the drug. One theory that might suitable for this case is the Optimistic Bias Theory. According to optimistic bias theory, individuals tend to underestimate their own risk of having a bad outcome in the future (7).  For example, one study shows that optimistic bias is linked to sexual risk taking in youth (8). In the “Don’t be a lab rat” campaign, teens may think they are invulnerable to the adverse effects, and such optimistic expectations make the fear-based statistics ineffective.

Also, health may not be a strong core value appealing to teens. The “Don’t Be a Lab Rat” campaign focuses on raising the teens’ awareness of adverse health effects of using marijuana. It emphasizes the relationship between teenage marijuana use and risks of many serious diseases such as schizophrenia, depression, stroke, and heart attack. Unfortunately, teens may in fact have less care about their health. In other words, health is not a strong core value for this particular population. In advertising theory, it is important to know what your target audiences really want and need. If health is not the most important value teens have been seeking, it is less likely that raising awareness of health would work in the campaign.

Argument two: Psychological reactance is created among the teens
Another reason why the “Don’t Be a Lab Rat” campaign is flawed is that it may introduce psychological reactance among the teens through wrong messages and wrong messagers. According to psychological reactance theory (9), when people are told to do something or not to do something, they think their freedom is threatened or lost. As a result, they will experience a motivating pressure towards reestablishing their threatened freedom by doing the things that they are told not to do (10). When teens see the slogan of the campaign “Don’t be a lab rat”, they may think their freedom is being taken away because they are asked not to use the drug. In order to reform their freedom, teens will instead begin to use marijuana, which is the opposite of behavior that the campaign suggests. Therefore, exposing to the campaign may in fact motivate their willingness to initiate using of marijuana rather than keeping them away from the drug.

Also, the campaign incorrectly uses “researchers” as their messagers to deliver the message that using drug is bad for teens. Psychological reactance could arise because such authoritative messagers have little in common with the teens and therefore are less persuasive. This disconnection between teens and messagers would make it hard for messagers to successfully persuade teens to stay away from marijuana.

Argument three: Failing to account for social norms
The third reason why the campaign is considered flawed is that it only focuses on the change of individual teens’ behaviors to using marijuana rather than taking into account the effect of social norms, which is another limitation of the Health Belief Model (4). Health Belief Model is most suitable for one time decision such as getting a flu shot. When coming to the decision of quitting from drug, HBM may not work in such a complex condition where other factors involved. Instead, drug use is the outcome of the interaction between intrapersonal factors and social factors such as influence from peers and parents (5). In this situation, social norms theory is more proper to use since it emphasizes the importance of understanding environment and interpersonal influences in changing behaviors in teens.

According to the Social Norms Theory (11,12), misperceptions of how peers think and act will influence teens’ behavior. When information on peer group norms is incorrectly present, teens are more likely to overestimate or underestimate the prevalence of the behavior among their peers. Usually, they overestimate the value of problem behaviors and underestimate healthy behaviors, tending to adopt the problem behavior (12). Studies have shown that American students usually misperceived the norms of their peers by perceiving considerably exaggerated drug use as typical at their school (13). This perceived norm is that the typical student is a much more frequent user than the self-reports indicated. Therefore, it is quite likely that in the “Don’t Be a Lab Rat” campaign, teens may incorrectly perceive a higher prevalence of marijuana use among their peers and thereby initiate using of the drug. In addition, if their peers who use the drug seem to be some cool guys, their likelihood of engaging in the drug may increase further. Based on the report of the National Survey On American Attitudes On Substance Abuse Xvii: Teens (2012), 47% of teens who have seen pictures of their peers partying with alcohol or marijuana on social networking site such as Facebook and MySpace said that it seemed like the teens in the pictures were having a good time (14).

Part Two: Proposed Intervention
The “Don’t Be a Lab Rat” campaign seems to be flawed and ineffective because of the above reasons. Therefore, a more effective campaign that may be needed to reduce the prevalence of drug use among teens in Colorado. Three more effective approaches that address the above problems in the campaign are discussed below.

First, to address the problem that teens do not concern much on health risks presented in the scary statistics, the campaign should use personal stories and focus on core values that are more important to teens. Second, in order to avoid or reduce psychological reactance, use similar messagers and positive message to make the messagers more persuasive and to make the message more compelling. Third, using Social Norms Theory instead of Social Belief model to account for environmental and interpersonal influences.

Defense one: Using stories instead of scare tactics
The first approach for the proposed intervention is to use personal stories instead of scary statistics. Based on the Optimistic Bias Theory, teens are likely to think their own risks of getting disease are lower than the present risks in the general population. Therefore, instead of using statistics that show risks of disease among the general population, the campaign could use personal stories to raise awareness. For example, put stories of their peers on the website and create videos with images and music. One thing need to be aware is that using health as a core value in the story seems to be ineffective. The campaign should do research and find values that their target audiences really want and use that value in their stories. For example, since most teens regard independence and freedom as important values, the story could be a peer losing independence because of using drug.

Defense two: Using similar communicators and positive messages
In order to avoid psychological reactance, the campaign should change their message to a more positive one and use communicators who are familiar and similar to the teens. For example, using peers, especially the most popular ones in school to deliver the message could better make the message persuasive. Popular peers are similar to and welcomed in the teens, and thereby will be more persuasive than researchers. Research suggests that similarity can increase the positive force toward compliance and decrease the negative force toward resistance (15). Also, studies show that similarity increases the likelihood of compliance by increasing liking for the communicators (16). In addition to change of communicators, the campaign should also change their message to one that makes teen feel their freedom is ensured rather than threatened.

Defense three: Telling the truth and creating sense of belonging
To address the problem where teens are likely to overestimate the prevalence of marijuana use in their peers and engage in using the drug, correction of misperception is needed. Studies have shown that correction of the misperception could reduce prevalence of certain problem behavior (17). One possible way to correct the misperception is to let individuals know the actual healthier norms. This is based on the power of the Social Norms Theory, which indicates that social norms could influence people in both unhealthy and healthy ways (12). When individuals have a perception that most people do not use drugs, they will also less likely to use drugs. Therefore, rather than presenting a lot of unreliable information on potential dangers of marijuana and unintentionally making them perceive an overestimated prevalence of drug use, the campaign should show teens the truth -- accurate information about the actual healthier norms among their peers. For example, the campaign could do surveys to find out the teens’ perceived prevalence of marijuana use among peers and the actual normative prevalence, and then show these figures to the teens.

Another approach to account for peer influence on drug use among teens is to create sense of association and belonging. This could be done through branding and creating an identical logo for the campaign. In order to make the teens join and embrace in their campaign, the Florida’s “truth” campaign make “truth” a brand, successfully gaining wide awareness (6). The “Don’t Be a Lab Rat” campaign could also make their own brand similar to “truth” and create a cute and identical logo to let more teens join their campaign. Based on the Social Norms Theory, since teens are likely to be influenced by their peers, the campaign could also create sense of belonging through their online website and social networking site such as Facebook. Teens could join their peer group online, share their positive experience and stories, and get positive feedbacks from their peers. If they see a majority of their peers are living a positive and healthy lifestyle, they will less likely to engage in an unhealthy behavior such as using drugs. Researchers have analyzed studies on college students’ binge drinking and found that web-based feedback could have a positive effect on the problem (18).

1. National Institute on Drug Abuse. DrugFacts: High School and Youth Trends.

2. Botvin GJ, Malgady RG, Griffin KW, Scheier LM, Epstein JA. (). Alcohol and marijuana use among rural youth: Interaction of social and intrapersonal influences. Addictive Behaviors 1998; 23: 379–387.

3. National Cancer Institute. Theory at a glance: a guide for health promotion practice. (2nd ed.) NIH Publication 2005; 05- 3896

4. Edberg M. Individual health behavior theories (pp. 35-49). In: Essentials of Health Behavior: Social jand Behavioral Theory in Public Health. Jones and Bartlett Publishers, 2007.

5. Dan A. Predictably Irrational: The Hidden Forces that Shape our Decisions. New York: HarperCollins Publishers, 2008.

6. Hicks JJ. The strategy behind Florida’s “truth” campaign. Tobacco Control 2001; 10:3-5.

7. Weinstein ND. Unrealistic optimism about future life events. Journal of Personality and Social Psychology 1980; 39:806-820.

8. Chapin J. It Won't Happen to Me: The Role of Optimistic Bias in African-American Teens' Risky Sexual Practices. Howard journal of Communications 2001; 12; 1: 49-59.

9. Brehm, JW. A Theory of Psychological Reactance. New York Academic Press, 1966. 

10. Grandpre J, Alvaro EM, Burgoon M, Miller CH, Hall JR. Adolescent reactance and anti-smoking campaigns: a theoretical approach. Health Commun 2003;15; 3:349-66.

11. Berkowitz AD, Perkins HW. Problem drinking among college students: A review of recent literature. Journal of American College Health 1986; 35: 21-28.

12. Berkowitz AD. The Social Norms Approach: Theory, Research and Annotated Bibliography. Trumansburg, NY, 2003.

13. Bruce EC, Beth RH, Cynthia AG. Adolescent Development: Pathways and Processes of Risk and Resilience. Annual Review of Psychology 1995; 46: 265-293.

14. Perkins HW, Meilman PW, Leichliter JS, Cashin MA, Presley CA. Misperceptions of the Norms for the Frequency of Alcohol and Other Drug Use on College Campuses. Journal of American College Health 1999, 47:253-258.

15. National survey on american attitudes on substance abuse xvii: teens.

16. Silvia PJ. Deflecting reactance: The role of similarity in increasing compliance and reducing resistance. Basic and Applied Social Psychology 2005; 27:277-284.

17. Byrne D. An overview of research and theory within the attraction paradigm. Journal of Social and Personal Relationships 1997; 14: 417–431.

18. Moreira MT, Smith LA, Foxcroft D. Social norms interventions to reduce alcohol misuse in university or college students. Cochrane Database of Systematic Reviews 2009; 3.

Primary Violence Prevention And Asking The Right Questions: Why School-based Interventions Fail To Change Behaviors – Sylvie Hundley

1.0 Introduction

On an average day in the United States, sixty-five people die and more than 6,000 people are physically injured from interpersonal/intimate partner violence (9). In recent years this violence seems to be occurring with greater frequency and severity in our society (2-3,9,15-17). Intimate partner violence (IPV), generally termed to encompass physical, sexual, or psychological harm by a current or former partner or spouse, (14) is a growing public health concern that affects billions globally (2-3,9,15-17).

1.1 Public Health, Psychopathology and Intimate Partner Violence

Integrating the public health model for IPV prevention has caused a shift in the way we respond to violence from a reactive approach to a preventative approach (2-3,6,9-10,12-13,15-17). Additionally, research on developmental psychopathology, supported by the National Institute of Health, has expanded our understanding of violence. Psychopathology studies have shown that adolescent and adult violent behavior almost always can be traced back to origins in early life. They have demonstrated with statistical accuracy that adolescent violence can be predicted from indicators demonstrated as early as five years of age (3). Public health and psychopathology studies indicate that the development of violent behavior is an interaction between cultural forces and failures in development. These studies support the popular belief that youth violence prevention is the most effective way to end IPV (3,9).

1.2 Forming Prevention Programs: Focus On Youth Prevention

In the past two decades youth violence rates have stabilized suggesting that the problem is no longer an epidemic but instead has become endemic to our society (3). In response, scores of IPV intervention programs have been haphazardly assembled to squelch violent behavior. Many prevention programs focus on interrupting the development of violent behavioral in youth before violence begins. (3,9). To capitalize on the adolescent “window of opportunity” for learning and early intervention efforts, most primary prevention programs are conducted in middle school to high-school settings. While there is no universal model for IPV prevention, given the social and (usually) gendered nature of the problem most youth programs appear to be loosely based on social learning theory and feminist theory (3,6,11,15-17).

1.3 Program Evaluation

In an attempt to find the cure-all program that can be implemented to end IPV, violence interventions have been rigorously analyzed for efficacy. Unfortunately Meta analysis of IPV prevention programs report that the overwhelming majority cannot demonstrate measurable outcomes (11,15-17). The few programs that do manage to document statistical significance report slight changes in in knowledge and attitudes among the intervention group. However, knowledge and attitudes are easier to change than behaviors (3) and there remain few effective adolescent IPV preventions available (11). Additionally, among some interventions the change in attitude was documented in the undesired direction (16,17).

1.4 Asking “Why?”

This lack of efficacy is not surprising, given that IPV is not only pervasive in many communities, but also vastly underreported and often construed as a normal part of immature relationships (2-3,6,9-10,12-13,15-17). Despite the fact that our approach to eliminating IPV from society is broadening in scope under the public health lens, our response is still too reactionary and too focused on the violent outcome.  This is demonstrated by the overwhelming attention placed on measuring program effectiveness instead of measuring the mediators of behavior change. It is crucial that programs measure the skills that intervention strategies intend to change in order to determine which changes in specific skills ultimately lead to changes in behavior. The goal should not only be determining which programs work, but to understand why (17).  Public health has provided a bridge between conceptualization of how chronic violence develops and application of how prevention programs can interrupt that development. But in order to accurately implement prevention programs that work in the real world, their needs to be another bridge connecting the sciences, social theories and preventions to the public at large (3).

2.0 Criticisms
            There are three main elements of consideration that have not been properly evaluated in IPV primary prevention programs that inhibit substantial measures of behavior change.    

2.1 Missing The Critical Components Of Social Learning And Cognitive-behavioral Theories

Almost all youth IPV prevention programs employ feminist and social learning theories as a basis for intervention. However, the extent to which interventions use critical components of these theories is unclear, especially social learning theory. Social learning and cognitive-behavioral theories emphasize the importance of identifying potential factors that influence the development of new skills in the adoption of new behaviors. However, few interventions examine the acquisition of previously absent behaviors as part of their intervention (11).

2.1.1 Limited Setting and Social Learning Theory
It is clear that violence is a learned behavior any exposure to violence in early age is highly predictive of entering a violent relationship later in life (2-3,6,9-10,12-13,15-17). Social learning theory acknowledging that learning does not happen in isolation of ones environment; stressing the importance of external influences on various internal processes. The theory postulates that a large contribution to behavioral development is the product of observing and then emulating the actions of others within an individual’s community (1). This is known as modeling. Modeling behavior is common among adolescents given the overwhelming need to attain peer acceptance and “fit in” with a group (1-3,6-7,11,14-17). School programs that focus on changing the nature of violence among peer-group interactions and peer-group norms can be extremely influential in behavior modification but programs of this nature are less common than individual approaches (2). Furthermore, just as peers and schools exert their own influence on behavior, so too do the other environments children inhabit and confront on a daily basis (2,11). For this reason, school-based IPV intervention programs that apply social learning theory in a “microenvironment” are inherently flaw. School-based programs for IPV interventions are isolating the school environment from the home environment and so create unrealistic circumstances that fail to address real-world situations, and fail to produce real-world results. Without connecting school-life and home-life school-based interventions are putting youth in opposition with their origin and limiting potential to influence behavior. It is important that school interventions do not come at the expense of parent-teen communication, mistrust, or conflict.

2.1.2 Social Ecological Model and Excluded Populations
As youth might observe violence in their home, they may also look to the larger community to teach them about healthy relationships (8). To account for the multiple ways the environment influences youth behavior, the CDC utilizes the social ecological model as a basis for IPV prevention initiatives. Similar to social learning theory, the social ecological model identifies the interactions between external and internal processes in the development of behaviors. The social ecological model conceives of relationships as operating on different levels: interpersonal, community, and society level (13). School interventions largely ignore community or population level interactions by focusing instead on individual choices (3,11,15-17). The social ecological model proposes that there are multiple levels at which behaviors can be influenced. School-based interventions focusing on only one level of the model may be overlooking whole segments of the population.
Additionally, some students, especially those most at risk may not be accessible by schools (17) Many students may lack school engagement and/or have difficulty getting involved in school-related activities. Many school-based interventions systems use a messy, one-classroom-at-a-time educational approach to IPV prevention. They usually bring in a speaker from outside of the community who addresses a class with an isolated, presentation about IPV (17). This approach can evoke strong psychological reactants. This has been demonstrated in some programs that reported a “backlash” among the male population who developed attitudes in opposition to program messages (16,17).

2.1.3 Family Environment
Social learning theory suggests that through teaching and shaping their children’s behavior, parents dramatically affect acceptance or rejection of acceptable behaviors (1) yet family venues have received relatively little attention in IPV prevention programs (17). This is surprising given the mounting evidence for the intergenerational predictors of violence. The popular notion of a cycle of violence suggests that witnessing partner violence or experiencing family violence at a young age is strongly associated with increased risk for children to develop attitudes, beliefs, and behaviors that lead to their own involvement in violent relationships (1-4,6-9,11-13,15-17).

2.2 Universal Interventions and Limited Theoretical Approach.

School-based interventions appear to be advantageous for many reasons. They can easily reach large numbers of students in a short time, create safe environments, promote learning, and affect social interactions and peer modeling behavior. Most IPV interventions are universal, that is, they are directed towards one or only a few targeted skills, contexts, or persons without regard for risk or personal factors (3,11,15-17). Although universal interventions are an excellent way to provide basic information to a large population, different people experience IPV in different ways (3,8-9,11,15-17).
Studies show that IPV is a multidimensional problem that spans across a constellation of risks factors (2-4,6-9,11-13,15-17). Risks do not exist in isolation from one another; each uniquely contributes to the development of violent behavior and outcomes (3,17). The complexity of IPV require interventions to either focus simultaneously on multiple risk factors or target specific prevention efforts to specific children (3). Selective interventions allow for targeting of specific at-risk populations or environments, and thus the content of those interventions can directly address whatever risk factors are believed to lead to partner violence.  Ultimately, the development of selective interventions requires a solid theoretical framework in order to identify the vulnerable population to target interventions (16,17).

2.2.1 Narrow Focus On Theories
The majority of IPV programs represent a fairly limited range of theoretical approaches (15,17).  The background-situation model of courtship aggression developed by Riggs & Oleary, attachment theory, social expectations theory, and the social ecological model are all important behavioral theories that are largely underutilized by school intervention programs (3,11,15-17).
2.2.1a Background-Situational model
The background-situation model of courtship aggression takes into account the interaction background factors that may affect an individual’s tendency to be generally aggressive, and situational factors that result in the expression of partner violence. Background factors include modeling of antagonism by parents, parent–child aggression, prior use of violence, arousability, and certain personality factors. Situational factors include relationships conflict, stress, alcohol use, and partner aggression. In essence, background factors explain who might be involved with partner violence and situational factors explain when partner violence might occur (17). The background-situational model may be important for identifying specific variables as predictors of IPV.
2.2.1b Attachment Theory
Attachment theory focuses on cognitive formations of relationship processes. Attachment theory proposes that children conceptualize relationships based on their history with significant caregivers. The theory suggests that this cognitive-affective understanding of relationship elements, (the relationship, the self, and the other) functions both as a prototype and template for developing future relationships. Although cognition develops and changes over time, internal working models, which operate outside of awareness, are thought to remain generally consistent (16). Studies suggest that power, reciprocity, and intimacy are developmentally important for adolescents, their development of intimate relationships and violence within those relationships ( 2-4,6-9,11-13,15-17). Thus focusing on the role of coercive interactional processes in the development of IPV using Attachment theory may be beneficial.

2.3 Multiple Risk Factors And The Lack Of Generalizability

Studies show that dating violence begins in middle school and disproportionately affects minority groups yet there are minimal interventions that target this demographic (11,17). Two school-interventions such as Safe Dates and fourth R: Skills for youth Relationship (fourth R) programs have been shown to produce significant behavioral effects: both reduced dating violence perpetration or victimization. However, these programs may not be as effective in ethnic-minority middle school youths because they were developed for and evaluated in older, predominantly White youths (11).
There are a number of factors that contribute to keeping the interpersonal pattern of violence and aggressive behavior consistent over time. The emerging conceptualization is that chronic violent behavior results from life-course developmental experiences (3). The life-course perspective (18) helps to understand how the combination of early programing experiences at critical/sensitive life stages and the cumulative effect of lifetime exposure to IPV impacts individual’s risk and protective factors. Studies suggest that the source of violent behavior resides at the intersection of the individual and the culture interacting over time.

2.3.1. Intergenerational cycles of IPV
The social learning model would predict that those who witness violence in their upbringing would be more likely to repeat behavior in their own relationships (1). Supporting the concept of modeling, several studies have documented a relationship between witnessing violence in the home and increased risk of being both a victim and a perpetrator of violence. Family risk factors, particularly those associated with parental behavior and the home environment are highly associated with IPV risk (1-4,6-9,11-13,15-17). Youth who experience IPV report witnessing their parents exhibiting acceptance of abuse or engaging in violent relationships and perceive the abuse to be normal because they, “grew up in an environment where that’s what they see people do.”(7, p.568). 

2.3.2 Cultural Competence
Studies suggest that abuse is as a learned behavior in which cultural norms played an important role. Often parental acceptance or downplay of adolescent IPV was attributed to cultural beliefs that supported traditional gender roles and permissive attitudes toward violence. Supporting feminist theory, studies find that adherence to traditional sex roles is among the most powerful predictor of attitudes supporting tolerance of IPV (7,17). The importance of underlying attitudes about sex roles, power, and control are strongly influenced by culture (2,4,7,8). Studies show that across many Latino communities “gender roles not only serve as a justification for abuse, but they also increase women’s vulnerability to abuse by keeping them isolated, subservient to male partners, and self-sacrificing to community and family” (7, p.568). Additionally, In some cultures abuse is not viewed as an issue. If the child is brought up in an environment where abuse is normal and the community says the abuse is within what they consider normal, then it becomes difficult, and possibly insulting to label their relationships as “undesirable.”

2.3.3 Adolescence
The adolescent life stage is a period of heightened risk for IPV given the developmentally distinct ways they experience violence (4,7). Adolescents are highly susceptible to modeling behavior and tend to conform to rigid gender stereotypes and social norms. Adolescence is a period of value and identity formation as well as a time when youth are creating their ideas of love and attachment (2-4,6-9,11-13,15-17). Additionally, pubertal development and social influences aid in the formation of romantic interests and sexual motivations increasing sensation seeking, risk taking and reckless behavior. Taken together, the reorganization of regulatory systems that occurs in adolescents’ development and social influences shape the adolescent life stage as a critical period, tangled with both risks and opportunities (14).
            It may also be important to consider whether partner violence is merely one component of the characteristic risk-seeking behaviors that occur in adolescence. It may be that adolescent are “hard wired” to take risks of this nature because their brain is not fully developed (16,17). In this instance it is important for interventions to work on building an environments that are as safe as possible for adolescents to take risks.

3.0 Conclusion: Bridging The Gaps

IPV prevention programs are still in early development, but are likely to be an important component of prevention strategies (2,3,6,9,11-13,15-17).  Current primary prevention efforts for partner violence consist almost exclusively of universal, school-based, dating violence prevention programs that target individual-level factors. These programs show little variability with regard to theoretical foundations, intervention strategies, or targeted populations. Additionally, prevention programs fail to incorporate key components of the few models they do use by limiting interventions to school venues (3,11,15-17). School-based interventions need to find a community outlet (8) and incorporate a more accurate use of social learning theory (11) that acknowledges the differences between the home and school environments. More work is needed regarding program development to expand the theoretical basis for interventions, and to develop targeted and culturally sensitive interventions that understand the complex interactions of youth development and environmental influences. Interventions that utilize these theories must be culturally competent and address the different ways that people may experience or be predisposed to violence.

4.0 Proposed Intervention: Making IPV Prevention Programs “Sexy”

            Given the nature of IPV, it is essential the intervention happen early. School-based interventions accomplish this goal, but they must have a structured curriculum that is supported by behavioral theories/models along with community-based activities. In order to yield the best overall outcomes for families impacted by IPV prevention programs must utilize a combination of outreach and collaborative strategies that are rooted in the community and connect to personal values. This can be accomplished with effective use of social marketing theory and advertising theory.

4.1 Social Marketing And Advertising

Social marketing and advertising theory have been growing in popularity within the public health arena (5). Social marketing theory is a way to create and package intervention programs so that it fulfills the needs of a target population’s wants. There are certain basic cultural values that are held in common and have a strong impact within community networks (5,7,17). Social marketing and advertising theory are able to create mass universal appeal for a product by offering desirable benefits that grab the attention of communities of interest. Programs that properly utilize these theories have been proven to facilitate the acceptance, rejection, modification, abandonment, or maintenance of particular behaviors by groups of individuals (5). Once a target population has been identified a combination of advertising theory, social expectations theory, and social networking theory can be used to effectively seed a campaign.

4.1.1 Using Social Networks To Insert Desirable Behaviors
Social expectations theory states that people will follow societal norms. Adolescents are especially susceptible to following cultural norms and so can be more easily persuaded using advertising theory. Social Expectations theory evaluates behavior on a population level, targeting social norms, as a predictor of how whole groups might behave. Social networking theory works as a means to focus interventions by mapping out out networks within groups. Understanding the social norms within one cluster of a social network and targeting that population with an effective use of advertising theory can effectively seed behavior changes that increase positive peer modeling, community endorsement of acceptable dating behavior, and social support for IPV prevention.
In order to effectively package and sell anti-violence, IPV programs must conduct extensive marketing research with youth, their parents, and other influencers inside and outside school compounds (5). The social-ecological model can be used to better understand violence and the effect of potential prevention strategies. In considering the complex interplay between individual, relationship, community, and societal factors the social ecological model helps to address the dynamics that put people at risk for experiencing or perpetrating violence (13).

4.2 The Notion Of Exchange

IPV intervention programs need to address deep desires, inspirations and aspirations of their young audience. Most programs assume that freedom from violence is a big enough promise to catch interests however, as adolescents is a time when many youth are still forming their ideas of love violence may not be a deterring factor for them. In fact, many service providers report that they found it difficult to get some youth to see that they were being abused in a relationship (7). Some adolescents may be so focused on “being in love” and belonging to someone that jealousy and possessive behaviors are often misinterpreted as signs of affection (2-4,7,11,15-17). Programs to target youth and their communities need to utilize advertising theory to create mass universal appeal for IPV prevention initiatives. This may involve celebrity endorsement or social media, which highlights the attractiveness of strong women and caring men.

4.3 Researched Based Preventions, Targeting Interventions To Appeal To Core Values

It is important that vulnerable populations receive IPV prevention services specific to the unique way they perceive violence (2-9,11,15-17). This means evaluating core values specific to cultural identities to convey messages that will be well received by the target population (5). School-based universal interventions are missing their mark by assuming that education leads to prevention (5,17). The educational model believes that creating awareness is the best way to create behavior change. However, knowledge is not as strong of a core value as love and acceptance. The educational model works best works when the benefits of the behavior change are inherently attractive, immediate, and obvious and costs are low (i.e. SIDS campaign, educating parents to put baby to sleep on it’s back to prevent sudden infant death syndrome). In contrast, marketing is the most effective strategy when program goals are not directly consistent with self-internalized beliefs because it offers alternative choices that invite voluntary behavior exchange. Programs need to have a greater focus on selective interventions that allow for targeting of specific at-risk populations or environments. The content of those interventions can then directly address whatever risk factors are believed to lead to partner violence.

4.3.1 Enforcing Freedom
It is important not to over generalize and apply labels. Message should reinforce freedom not take it away. In these way, IPV intervention programs need to give out positive stereotypes, avoid psychological reactants, and construct messages in a way that reinforces freedom not box people into categories. Using marketing gives IPV programs a brand, reinforces core values, and ensures sustained intervention (5). Marketing and advertising theory would ensure that messages are applicable to real-world environments and are delivered effectively.

4.4 Taking Control
Studies on IPV prevention have found that the community must take responsibility for ongoing program activities, and advertising theory is a way to get the communities interested in a campaign (5). Furthermore, the community must assume ownership of their campaign (8). This involves giving youth the ability to develop their own campaigns, create advertisements for their campaign, develop social networks, and ultimately enhance executive functioning and subconsciously change behaviors.

5.0 Conclusion: A Call to Action

            For an IPV prevention campaign to be successful, it must consist of a promise that provides a solution to issues that the target population considers important and offer a benefit they truly value. Promotional strategies must carefully design a specific message using appropriate communication techniques that resonate within communities. Community-based preventions that utilize marketing theory have the potential to harness community strengths by facilitating mobilization, empowerment, and participation, balances power differentials which ultimately benefit social changes (5).

1.        Bandura A. SocialLearningTheory. General Learning Corporation; 1971. p. 1–41.
2.        Dahlberg L. Youth Violence in the United States Major Trends, Risk Factos, and Prevention Approaches. Am J Prev Med. 1998;14(4):259–72.
3.        Dodge K a. The science of youth violence prevention. Am J Prev Med [Internet]. 2001 Jan;20(1):63–70. Available from:
4.        Goff HW, Shelton a J, Byrd TL, Parcel GS. Preparedness of health care practitioners to screen women for domestic violence in a border community. Health Care Women Int [Internet]. 2003 Feb [cited 2014 Nov 19];24(2):135–48. Available from:
5.        Grier S, Bryant C a. Social marketing in public health. Annu Rev Public Health [Internet]. 2005 Jan [cited 2014 Dec 1];26(9):319–39. Available from:
6.        Jaffe PG, Reitzel D, Killip SM. An Evaluation of a Secondary School Primary Prevention Program on Violence in Intimate Relationships. 1992;7(2).
7.        Kulkarni SJ, Lewis CM, Rhodes DM. Clinical Challenges in Addressing Intimate Partner Violence (IPV) with Pregnant and Parenting Adolescents. J Fam Violence [Internet]. 2011 Aug 21 [cited 2014 Nov 9];26(8):565–74. Available from:
8.       Moya EM, Chávez-Baray S, Martinez O. Intimate partner violence and sexual health: voices and images of latina immigrant survivors in southwestern United States. Health Promot Pract [Internet]. 2014 Nov [cited 2014 Nov 24];15(6):881–93. Available from:
9.        Mercy J a., Rosenberg ML, Powell KE, Broome C V., Roper WL. Public health policy for preventing violence. Health Aff [Internet]. 1993 Nov 1 [cited 2014 Nov 25];12(4):7–29. Available from:
10.      Perilla JL. Domestic Violence as a Human Rights Issue: The Case of Immigrant Latinos. Hisp J Behav Sci [Internet]. 1999 May 1 [cited 2014 Nov 23];21(2):107–33. Available from:
11.      Peskin MF, Markham CM, Shegog R, Baumler ER, Addy RC, Tortolero SR. Effects of the It’s Your Game . . . Keep It Real program on dating violence in ethnic-minority middle school youths: a group randomized trial. Am J Public Health [Internet]. 2014 Aug [cited 2014 Nov 19];104(8):1471–7. Available from:
12.      States U. Intimate Partner Violence: Consequences Cost to Society. J Fam Violence. 2011;26(8):565–74.
13.      States U. Injury Prevention & Control: Division of Violence Prevention The Social-Ecological Model: A Framework for Prevention. 2002;
14.      Steinberg L. Cognitive and affective development in adolescence. Trends Cogn Sci [Internet]. 2005 Feb [cited 2014 Jul 10];9(2):69–74. Available from:
15.      Stover CS, Meadows AL, Kaufman J. Interventions for intimate partner violence: Review and implications for evidence-based practice. Prof Psychol Res Pract [Internet]. 2009 [cited 2014 Nov 11];40(3):223–33. Available from:
16.      Wekerle C, Wolfe DA. Dating Violence In Mid-Adolescence: Theory Significance, And Emerging Prevention Initiatives. 1999;19(4):435–56.
17.      Whitaker DJ, Morrison S, Lindquist C, Hawkins SR, O’Neil J a., Nesius AM, et al. A critical review of interventions for the primary prevention of perpetration of partner violence. Aggress Violent Behav [Internet]. 2006 Mar [cited 2014 Oct 30];11(2):151–66. Available from:
18.     Qu MC, Halfron N.  Racial and ethnic disparities in birth outcomes: a life-course perspective.  Maternal and Child Health J 2003; 7(1):13-30.

Getting Wrapped Up In The Moment With Condom Use: A Critique of the DC Rubber Revolution Campaign –Ashley Mayo

Introduction: DC Takes on HIV
Our nation’s capital, Washington DC, is known for its political savviness, cultural diversity, and business oriented-nature; however, when it comes to public health, this city continues to struggle in the fight against HIV/AIDS. DC is one of the cities hardest hit by HIV in the United States, with an epidemic on par with some developing nations8. In addition, it has the highest AIDS diagnosis rate of any state in the U.S.8. This shows a dire need to not only further explore factors associated with HIV/AIDS prevalence, but also, find proactive methods to better education and equip residents. In 2008, the Department of Health (DOH) created DC Takes on HIV, a multi-pronged prevention program with three distinct parts:
·         Ask for the Test (HIV testing campaign)
·         I Got This (HIV Treatment campaign)
·         Know Where You Stand (Intimate partner communication campaign)5

The DC Takes on HIV campaign was intended to create awareness of HIV testing and treatment; however, the program struggled to contain DC’s soaring HIV prevalence rate. In 2010, the DOH conducted a study to evaluate socio-economic factors contributing to HIV rates and found that the campaign was missing a major component—condoms4. It was found that between 40% and 70% of all DC adults and adolescents reported not regularly using condoms4. As a result, The Rubber Revolution campaign was created to raise awareness about the city’s free condom distribution program, encourage condom use, and dispel misconceptions regarding condoms4.  The program offers four ways for residents to obtain condoms, including direct mailing of up to 10 free condoms, telephone hotline to determine nearby condom distribution location, and text messaging services to find free condom locations by zip code4,7. The Rubber Revolution promotional campaign includes a public website (, ads on radio, newspapers, and transit (which can be found at the end of this paper in “Images” section), and social media pages, on Facebook, Twitter, and Youtube4,15. By increasing access and awareness of free condoms, the DOH hoped to see an increase in condom use and ultimately decrease in the spread of HIV. However, after four years of health messaging, it is unclear of the actual success of the Rubber Revolution. A recent evaluation of the DC Takes on HIV program found that 28% of residents report frequent use of condoms during sexual activity5. Yet, the same report also showed that only 14% of residents could recall or was aware of the Rubber Revolution condom distribution program in the district5. Although the DOH attributes increased condom use to the campaign, this discrepancy shows the need to further improve campaign efforts.  

The Theoretical Approach of the Rubber Revolution
Although on the surface this program is a health campaign for condom use, the Rubber Revolution is a social movement for safer sex in DC. Sociologist Mancur Olsen’s “resource mobilization theory” explains the importance of societal structure factors within mobilizing a population towards a cause10. The theory suggests that both persuasion and access to a limited yet necessary resources are essential for increasing participation of any social movement10. The Rubber Revolution models this theory in its attempt to increase access to condoms and cleverly persuade residents to increase condom use through advertisement. However, it unequally focuses its attention on increasing access without effectively stressing the importance of joining the safer sex movement.  
Therefore, the major shortcoming within the Rubber Revolution is its inability to captivate and motivate participation and mobilization10. When the intervention was first created, a study found that 40% of heterosexual couples were not using condoms and a whopping 70% of intravenous drug users were not using them in DC12. After four years of the campaign, it was found that 71% of all DC residents are aware of condom distribution locations, but only 28% reported using them more frequently5. While this is a small victory for the Rubber Revolution, there is still a barrier blocking individuals from using condoms—the desire and understanding of why this is important. Following the resource mobilization theory, the Rubber Revolution must work to complement increased access efforts with a campaign strategy that evokes community involvement10.  If the campaign is unable to engage the community, then it will not have the participation it needs to successfully reach DC residents.
Although it is not formally stated how one can join the “revolution”, it appears that it is defined by increased condom use, social media engagement on Facebook and Twitter, or a commitment to practice safer sex. According to the theory, participation within a movement results from "weighing" costs against benefits, which the intervention is not successfully achieving10. If residents are not seeing the major benefits of joining the revolution, then they are less likely to do so. Although the Rubber Revolution could greatly benefit the community, there is a need to improve the major methods of persuasion by: clarifying the intended audience, providing educational opportunities for residents, and increasing the campaigns social presence in DC.

Critique 1: The Rubber Revolution Lacks Focus in its Intended Audience
The Rubber Revolution diminishes its efforts by not having a clear intended audience is for the campaign. Since this is a multi-pronged intervention, it appears the DOH chose to dilute messaging about condom use to all residents. According to framing theory, a one-size fits-all approach hinders a campaign’s potential benefits of changing perceived attitudes toward a behavior3.  Framing theory refers to the process by which people develop a particular conceptualization of an issue or reorient their thinking about an issue3. By broadly framing this condom intervention, the Rubber Revolution could appear not relatable to many residents who already have a low perceived risk of HIV and other STDs. Therefore, in some cases, it is better to have an identified intended audience to better relay health messaging. Nevertheless, by exploring advertisement marketing and media communication, it appears that the Rubber Revolution is framed to engage males and teens.
First, framing theory suggests that a frame is always related to a specific issue or event in media communications3. For the Rubber Revolution, it appears that males are a possible intended audience, as a result of startling statistics regarding this population. In 2007, heterosexual contact and men who have sex with men (MSM) contact were the two leading sexual transmission modes of new HIV cases5. More recently it was also found that 72% of people living with HIV and new HIV diagnoses in DC are males8. These two findings show a clear need to engage males through campaign efforts, which the Rubber Revolution successful accomplishes. Every promotional piece depicts a male figure and refer to condom misconception involving males. For example, one campaign advertisement depicts an African American male preparing to play basketball but instead of a basketball hoop, there is a huge condom15. The ads simply says, “Big Enuf 4 U”, which the DOH identified as a common reason why DC residents refused to use condoms4,15. This messaging to males could serve as evidence that this is the intended audience, but it is still unclear if that was the DOH intention.
Secondly, framing theory describes the production of frames as a constant interaction between the media and the public articles3. Since the Rubber Revolution lacked to provide a target audience, the media framed messages towards a population that they perceived was best—teens. Media outlets, including Fox News, has coined the Rubber Revolution as an “increased ability to protect teens from diseases and unwanted teen pregnancy”, which are above average in the city7. Media agenda setting theory (which is closely related to framing theory) suggest that media coverage leads to changes in importance to different considerations3. Although most of the research regarding HIV in DC is for adults, the media has found teens as the biggest benefactor of the campaign, due to common perceptions of overly sexual teens. In support of this frame, the literature does suggest that the HIV epidemic is beginning to impact DC youth and could be a great starting place to lessen the epidemic8.
Another major defense for the teen population  is the use of social media as a major form of communication within this campaign. The Rubber Revolution features a website equipped with blogs, fun quizzes, and information, a text messaging service and social media profiles on Twitter, YouTube, and Facebook4. Although anyone can access these communication channels, it appears that the campaign seeks to engage the teen population who use these social outlets more frequently4. Therefore, it is possible that the campaign is indirectly choosing teens as the intended audience, yet neglects to frame messages to them. For the sake of clarity and consistency, I will assume that the Rubber Revolution targets teens, as opposed to males in general.

Critique 2: The Rubber Revolution Fails To Include Educational Opportunities for Residents
Since the Rubber Revolution focuses heavily on condom accessibility, it appears that the campaign assumes that DC residents are educated on proper condom use. Currently, condom distribution occurs in over 100 locations around the city, but residents must rely on the Rubber Revolution website for a three step condom instructional picture6. In addition, the program also offers a webpage for discrete condom package mailings and a toll-free number to order condoms, but again there lacks educational information in packaging6. This is problematic because it places greater responsibility on the individual to access information about proper use, as opposed to having it readily available.  It is possible that the Rubber Revolution is overlooking potential educational gaps, due to DC incorporation of comprehensive sex programs in schools or prior knowledge. A recent citywide survey found that that 85% of parents agreed DC schools are responsible for teaching their children age-appropriate HIV prevention and sex education, yet 90% believe that the school’s role is to provide “biological and scientific” sex education information19. As a result, teens are receiving mixed or incomplete messages regarding sex from school, family, the media, and peers.
It is arguable that the Rubber Revolution’s emphasis on condom use also sends a confused message to teens regarding sex. As a condom focused intervention, it is essential to promote the benefits of condoms without sending a message that condoms are the ultimate protection from STDs and unwanted pregnancy. When the Rubber Revolution was first created, it was accused of encouraging sexual activity among teens by distinguishing condom use as social normative behavior. As a response, Michael Kharfen, the Health Department's community outreach bureau chief, attempted to clarify the message by asserting the campaign doesn’t “recruit people to have sex” but promotes that “condoms are the only device that protects you from these diseases and unwanted pregnancy"7. By framing condom use as an ultimate form of protection, teens could perceive their risk of unwanted circumstance unlikely with condom use. Nevertheless, this protection frame doesn’t take into account the importance of proper condom use as a way to ensure optimal protection. This shows a need to not only encouraging teens to use condoms, but also ensuring that they are using it correctly.
Another consequence to having a solely condom-focused program is the impact of psychological self-filling prophesies among teens.  Psychologist Robert Merton coined the phrase self-fulfilling prophecy to describe “situations that evoke a new behavior, in response to an originally false conception”1. Within the Rubber Revolution, condoms are distributed as a means to encourage teens to participate in safer sex practices; however, by vigorously promoting condom use, the program could motivate teens that were not sexual active to begin having sex, in order to fulfill the “prophesy” of the program1. Although there is not sufficient evidence to prove that the program is encouraging adolescents to become sexually active, the protection core value used to describe condoms could be a strong motivator for teens. If teens perceive their risks of unwanted pregnancy and STDs as minimal with condom use, then engaging in sexual activity is perceived as simply satisfying social norms. It may be important for this intervention to find ways to counteract self-fulfilling prophesy, while also encouraging condom use among sexually active teens.


Critique 3: The Rubber Revolution Has a Limited Social Presence
The Rubber Revolution is described as a social campaign for DC residents, yet residents are seemingly unaware of the program. In a city-wide sample, only 14% of DC residents could recall seeing campaign related materials find the majority of those individuals saw transit ads and TV commercial5. In response, DC residents are less likely to use these services because they don’t of its existence. A recent evaluation of the program found that 5% of residents reported using social media sites and websites, 6% for telephone services, and 3% for text messaging services, regarding condom distribution5. This shows that the outreach’s limited scope and messaging is not reaching the community as planned. The DOH has identified this low social media presence as a problem, but there doesn’t appear to be any major changes suggested to improve this effort5. According to the theory of preventative innovation, new ideas that are perceived by individuals as having greater relative advantage, compatibility, and less complexity will be adopted more rapidly than other innovations14. The Rubber Revolution is likely experiencing limited new adopters in the innovations model due to limited perception of program benefits. Therefore, the campaign must consider a strategy to increase the number of new adopters by activating peer networks through the use of program “champions”14.
According to the theory of preventative innovations, the Rubber Revolution is missing the opportunity to engage DC residents due to lacking social processes. By encouraging people to talk about the condom use, it will give increased condom use a new meaning within the social setting and potentially encourage others to adopt14. The theory describes the use of “champions” as the best way to increase peer networks. Program “champions” are individuals who devote their personal influence to encourage adoption of an innovation14. Currently, the Rubber Revolution media partner is radio/TV personality Big Tigger who was one of the campaign’s first ambassador to encourage condom use and safe sex4. While Big Tigger is beloved in the DC community, the use of one champion for the Rubber Revolution doesn’t increase peer networks in the same effect as many champions would.   
Also, the theory of preventative innovations identifies the importance of changing the perceived attributes towards the desired activity, as a means to increase new adopters14. Kharfen promotes the Rubber Revolution as a way to remove the stigma regarding condom use by “changing the conversation”7. The campaign has made a commendable effort to inform misconception involving condom use, such as “Life Feels Better with a Condom”, “Big Enuf 4 U”, and “A Condom Fits Any Head”4. Neverhteless, the campaign neither relays the relative advantage of this preventive innovation of condom use nor provides clear information on where to get condoms on advertisement and how to join the revolution14. This lack of vital information could impact ones intention to adopt the Rubber Revolution promotion of condom use as a new innovation because it appears inaccessible and too complex.
The campaign also needs to become more aware of the “new conversations” that it seeks to start regarding condom use. The campaign received backlash for its “What Condom are You?” pop quiz, as a way to “engage people in a different way"7.  For example, if you prefer cheeseburgers to a salad, club soda to champagne, work a 9-to-5 day and enjoy network comedies and reggae, you're a standard latex condom6,7. Although the test seems like a fun and harmless quiz, it is unclear of what message it seeks to send to residents.

Proposed Improvements for the Rubber Revolution
Although this intervention poses many theoretical dilemmas, in terms of influencing behaviors, it is still a unique and progressive in its approach to decrease HIV/AIDS prevalence. For a city, like DC, a promotional campaign is the best option because of the amount of people that commute, travel, and are physically inside the city daily. Nevertheless, the program must work toward really encouraging individuals to join a revolution of people who understand the benefits of condom use.

Use the Rubber Revolution to Target Teens and Condom Use
            Based on services provided and media framing of the campaign, the Rubber Revolution should direct its focus on DC teens. Although the impact of HIV varies by age in DC, there are some indications that the epidemic is starting to take a greater toll on younger residents8. If the campaign creates additional ads that focus on this population, it could increase future condom use and decrease rates of HIV/AIDS in the city. By applying social norm theory, it could reframe condom use as a popular behavior for teens, which would serve as a normative influence for other teens to engage in the practice11. But in order to do this, the Rubber Revolution must design settings and messages that are relatable and familiar for teens. For example, the Rubber Revolution commercial depicts a group of adults enjoying a night out at a lounge, with each individual committing to safer sex by using a condom18. The commercial does provide a diverse casting of middle-age heterosexual and homosexual couples of various ethnicities to represent DC residents. Yet, this setting is not relatable to the teen population because it depicts scenarios that teens are not allowed to do. This could lead teens to underestimating their perceived risk, which defeats the purpose of the campaign.
Therefore, there is a need to include teen appropriate advertisement that uses values that are important to this population. For example, there could be a commercial where a group of teens are going to a homecoming dance or prom and commit to safer sex practices by using a condom. By simply changing the actors and setting, the commercial now evokes values that are important to teens. In addition, the Rubber Revolution should also incorporate non-male dominant promotional pieces to promote condom use as a gender neutral activity. Condom use is often perceived as a male initiated activity, but by reframing this perception, the campaign includes women in the conversation about safer sex. For example, there can be an ad that depicts a women initiating condom use with the tagline, “I am always prepared”. This ad evokes the core values of independence and equality for women who want to take control of their sex lives. As a result, the revolution is presented as a less male-dominated effort and encourages female participation in the movement. 
Within social norm theory, a change in behavior can only occur when an injunctive norm (beliefs about what ought to be done) becomes a descriptive norm (beliefs about what is actually done in a social group)11. Currently, condom use is seen as an injunctive norm in DC, but it could become a descriptive norm, if the Rubber Revolution improves its methods of outreach to teens and women. By actively engaging this population using commercials, promotional ads, social media sets, and YouTube, there is no telling the amount of support and success that can be achieved for the revolution.

Incorporating an Educational Component to Rubber Revolution
Based on the Sexual Health Model, the theoretical framework for improving individuals overall sexual well-being would be the inclusion of additional information regarding sex and condom use13. Through DOH partnerships with local organizations, condom distribution was found most popular in local health clinics, hair salons and barbershops, restaurants, and community-based organization5. Yet, there doesn’t appear to be any major forms of educational pieces provided alongside condom distribution. By simply providing, educational brochure or miniature condom instructions at each location could increase efficacy of condom use.  In addition, the DOH should consider distributing safer sex kits, as opposed to single condoms. Each safer sex kit could be equipped with two condoms (in the case that one breaks during use), condom instructions, and water-based lubricate. Incorporating safer sex kits would allow for all residents to have easily accessible information regarding proper condo, as opposed to leading residents to a website to obtain information. The DOH could also create an exclusive Rubber Revolution condom card collection that can be placed alongside safer sex packets. (Note: It should not be included inside of safer sex kits to prevent puncturing condom). The condom cards would include condom tips, such as check for expiration before use, ensure that you leave room at the tip, and avoid wearing two condoms at one time. The goal of this collection of cards is to creatively address common misperceptions of condom uses and reduce stigma, which have been identified as major barriers in DC condom use4.
Although it is arguable that DC teens are fully knowledgeable about sexual health, the Sexual Health model encourages a comprehensive approach to sex. In 2012, DC released the results of its first ever standardized test on health and sexual education, which high school scored on average 75% in sexual health questions2. Although these are great scores, the Sexual Health Model warns against interventions overly assuming that individuals are sex literate and more likely to make healthy decision regarding sex, including condom use13. Therefore, it is important that the campaign sends accurate and consistent messages regarding condom use and protection to teens. By incorporating peer educator models within the Rubber Revolution, the campaign will not only activate social observation and role modeling, but also reinforce accurate information regarding sexual health20. Peer health educators would be volunteer teens from around the city who are given extensive training regarding comprehensive sexual health. Once trained, they will serve as teen representations of the Rubber revolution, encourage peers to practice safer sex, and establish a brand for the campaign.
In order to counteract the potential effects of self-fulfilling prophesy, there could be the inclusion of promotional advertisements framed to include abstinence as an even better preventative measure. For example, an ad could depict a couple hugging with the tagline, “Waiting never felt so good, but I am always prepared”. This ad sends the messages that it is okay to abstain from sexual behavior, but also good to protect yourself, if the choice is made to have sex. By including abstinence, the campaign not removes the stigma regarding abstinence and creates awareness to sexually active individuals the importance of condom use. This would also satisfy the Sexual Health Models that encourage a comprehensive and inclusive approach to sex education.

Increase the Rubber Revolution Presence Using Social Media
There is a need to increase the Rubber Revolution’s social presence in DC by improving social networks. Currently, the Rubber Revolution has 850 Twitter followers, 185 likes on Facebook, and 4 You Tube videos (with two of the videos offering instructional videos for female condom use, which is not offered within this program)16-18.  Considering this program has existed for four years, this shows the minimal social presence of the campaign the Rubber Revolution. In order to quickly increase followership, the DOH could implement membership strategies on social media profiles. First, there could be a major raffle or giveaway to encourage new followers on social on Twitter and Facebook. The promotion could raffle free VIP tickets to a local basketball or baseball for the first 1000 followers on both Facebook and Instagram. Secondly, thre could be a YouTube contest for DC teens to post videos of why they believe in safer sex. Residents with the best videos will be combined and premiered on the website and local television channels. By actively engaging teens, the Rubber Revolution could increase social presence on multiple social mediums and have an array of promotional videos to use for future campaign strategies. Immediately following promotional contest, it is crucial for the campaign to compose eye-catching, interesting facts regarding condom use and sexual health to post on Twitter and Facebook to maintain followership. In addition to each post, the campaign should increase social branding, through the use of hashtags (#). For example, each post she conclude with #RubberRevolutionDC and #FreeCondomsDC, in order to increase social searchability and awareness of the program.
Next, there is a need for more media role models and champions for the campaign. The Natural helper model suggests that an individual, who is respected, empathetic, trusted, who listen well, sufficiently in control of their own life circumstances, and responsive to the needs of others, could increase social networks9. While this may be difficult to determine, the Rubber Revolution could instead identify individuals at local recreational centers and schools to serve as natural helpers, in the efforts to increase condom use. For example, they could target local basketball teams and cheerleaders as program champion because of the level of popularity within the school. If popular groups within school settings perceive condom use as important, then others are more likely to adopt this new practice. According to the theory of preventative innovation, this should result in an increase in social networks for the campaign and most importantly, increase in condom use.
In order to “change the conversation” regarding condom use, the DOH should include advertisements that cleverly display the perceived benefits of condom use. For example, the Rubber Revolution addresses a common misconception that condoms are too small for some individuals by using the advertisement taglines, “Big Enuf 4 U” and “A Condom Fits Any Head”19. While these are eye catching, the DOH could must find a way to show the perceived benefits of condom use without relying too heavily on statistics. It is clear that condom lowers one’s chances of STI transmission and unwanted pregnancy so the campaign must find a way to cleverly state these facts. By using a frame of protection, the DOH could use taglines, such as “Actively protected with condoms”, “Condom Status: Protected and Free” or “The Safest Hat for Any Head” would better express perceived benefits of use.

In closing, the DOH and Rubber Revolution presents a compelling campaign to encourage resident to “get those rubbers out of your wallet, remove them from your purses and pull them out from under the beds of every ward in the city”4. Nevertheless, it gets too wrapped up in the moment because there remains a dire need for improved program direction, greater educational opportunities, and increased social presence for the Rubber Revolution in DC.

1. Bearman, Peter and Hedström, Peter. Self-Fulfilling Prophecies. Oxford University Press. 2009.  (accessed 8 December 2014)

2. Brown, Emma. D.C. releases results of nation’s first-ever standardized test on health and sex ed. The Washington Post. December 12, 2012. (accessed 4 December 2014)

3. Chong, Dennis and Druckman, James. Framing Theory. Annual Review of Political Science 2007; 10:103–26

4. DC Department of Health. The District Starts a “Rubber Revolution” to Increase Condom Use. The Department of Health. November 18, 2010. (accessed 5 December 2014)

5. DC Department of Health and HIV/AIDS, Hepatitis, STD and TB Administration (HAHSTA). DC Takes on HIV: Public Awareness, Resident Engagement and a Call to Action. Octane Public Relations and Advertising. November 2014. (accessed 5 December 2014)

6. D.C.’s “Rubber Revolution” Matches Condoms to Personalities. Judicial Watch. November 18, 2010.

7. Fox News. D.C. Condom Program Sends Wrong Message, Abstinence Group Says. Fox News- Politics. November 18, 2010. (access 25 November 2014)

8. Israel, Barbara A. Social Networks and Social Support: Implications for Natural Helper and Community Level Interventions. SOPHE Health Education Quarterly 1985; 12(1): 65-80.

9. Klandermans, Bert. Mobilization and Participation: Social-Psychological Expansions of Resource Mobilization. American Sociological Review 1984; 49(5): 583-600. 

10. Knight Lapinski, Maria and Rimal, Rajiv N. An Explication of Social Norms. International Communication Association 2005; 15(2): 127–147. 

11. Montague, Candice  Y.A. The Rubber Revolution begins in DC. The Examiner Newspaper. October 28, 2010

12. Robinson, Beatrice; Bockting, Walter. Rosser, Simon. Miner, Michael; and Coleman Eli. The Sexual Health Model: application of a sexological approach to HIV prevention 2002; 17(1): 43-57.

13. Rogers, Everett. Diffusion of preventative innovations. Addictive Behavior 2002; 27 (2002): 989-993.

14. Rubber Revolution DC. Octane Public Relation Advertising. 2014.! (accessed 4 December 2014)

15. Rubber Revolution DC. Facebook, 2014.  (accessed 9 December 2014)

16. Rubber Revolution DC. Twitter. (accessed 9 December 2014)

17. Rubber Revolution DC. You Tube. (accessed 9 December 2014)

18. Sexuality Information and Education Council of the United States. Poll Shows DC Parents Strongly Support Comprehensive Sex Education in Schools. 2008. (access 5 December 2014)

19. The Henry J. Kaiser Family Foundation. The HIV/AIDS Epidemic in Washington, D.C. Fact sheet.  July 2012.

20. Turner, G. and Shepherd, J. A method in search of a theory: peer education and health promotion. Health Education Research Theory and Practice 1999; 14 (2): 235–247.