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 (www.rubberrevolutiondc.com), 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.
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