A Solid Effort Falls Short in Addressing Youth Sexual Risk in Ottawa, Canada – Julia Bond

According to the Public Health Department in the city of Ottawa, Canada, the rates of sexually transmitted infections (STIs) such as chlamydia, gonorrhea, and HIV are on the rise among Ottawa’s young people. In an attempt to address this, Ottawa Public Health launched an intervention titled “Sex it Smart” (1). This program allows Ottawa residents to order 1 package of condoms to be mailed to their home address free of charge. The program website also contains a condom locator, which provides the addresses of locations where residents can pick up free condoms. This list includes health clinics, non-profit organizations, and some private businesses. Additionally, the website contains educational messaging around STIs. Though this intervention has many positive aspects that increase its chances of success, including being effectively branded with a logo, there are nonetheless aspects that need improvement.

A Distanced Tone Invites Psychological Reactance and Modeling Behavior

The “Sex It Smart” campaign homepage states, “Not using a condom is the top risk factor among individuals diagnosed with an STI...That’s why we launched Sex It Smart, a new condom campaign for youth.” There is also a scrolling banner at the bottom of the homepage that states “Think of all the qualities you want in a partner….is one of them Chlamydia?” These statements contribute to a feeling of significant separation between the “we” behind the campaign and the “you” to whom it is addressed that pervades the campaign’s website (1). Creating this distinction in the campaign’s messaging could result in 2 specific negative responses from young people when they engage with the campaign, which would significantly decrease its chances of success.

First, the separation between the public health workers who created the campaign and the young people they are trying to reach could incite psychological reactance. Psychological reactance is a phenomenon described by J.W. Brehm (2) in which people faced with a threat to their freedom respond by immediately taking steps to restore that freedom. A relevant example would be a parent forbidding their teenager from attending a party, and the teenager subsequently reasserting their freedom by sneaking out to the party that night. Studies have demonstrated that when it comes to messages that contain a threat to freedom (eg you must always use condoms), similarity of the messenger to the recipient of the message can significantly decrease reactance compared to a dissimilar messenger (3). The disparity between the messenger and the young people being addressed in the “Sex It Smart” campaign website could result in psychological reactance because young people will be made to feel as if their freedom to choose not to use condoms is being threatened. This will undermine the effectiveness of the campaign, as youth will subsequently seek to reassert their freedom to ignore the free condoms.

Secondly, the distanced tone of the campaign may influence youth behavior in an unintended way through social modeling. The campaign’s homepage references the following statistics about sexual health in Ottawa: “About a third of sexually active 15-29 year olds in Ottawa did not use a condom the last time they had sex.  Fifteen to 29 year olds account for approximately three-quarters of 2013 chlamydia and gonorrhea diagnoses in Ottawa” (1). Social modeling theory posits that one way people adopt new behaviors is by mirroring behaviors observed in others in response to certain situations (4). Because the campaign has set up a distinction between the “us” behind the campaign and the “you” engaging with it, emphasizing the fact that a full third of youths did not use a condom while having sex could backfire and normalize the lack of condom use. If young people who are interested in having sex but who are naïve or inexperienced happen upon the site, instead of focusing on sexual health risks they may instead choose to focus on the fact that a large number of their peers who are successfully having sex are doing so without a condom. This in turn may influence their decision-making when they are faced with the opportunity to have sex. If, due to the perceived prevalence of not using a condom, they successfully have sex without a condom for the first time, social modeling behavior theory suggests that they will make the connection between not using a condom and effectively having sex, and they will likely continue to abstain from condom use (4). One examination of a failed youth-targeted anti-marijuana campaign that ran in the United States from September 1998 to June 2004 suggests this very phenomenon as one possibility for its failure. Hornik et al (5) state that exposure to the campaign messaging may have inadvertently implied that marijuana use was commonplace, thereby increasing the likelihood that young people exposed to the campaign would try it. The “Sex It Smart” campaign runs the risk of eliciting a similar boomerang affect by communicating to youths that many of their peers are having sex without condoms.

Optimistic Bias Compounded by the Power of Partner Selection

The above statistics referenced by the “Sex It Smart” campaign do demonstrate that there is a need to address youth sexual practices in Ottawa and attempt to rectify the large number of young people contracting STIs. Unfortunately, studies have demonstrated that people consistently underestimate the likelihood of negative outcomes happening to them. This phenomenon is known as optimistic bias, and has been demonstrated in a variety of populations, including active smokers (6, 7). Thus even though the statistics revealing the high risk of STIs among 15-29 year olds in Ottawa are compelling, it is likely that an individual reading them will underestimate their own personal risk. Additionally, studies have demonstrated that perceived controllability of a behavior increases the optimistic bias associated with that behavior (6). In the case of STI risk, people likely feel a large measure of control over their risk because they are the ultimate arbiters of their own sexual experience. Feeling that they control who their partners are will contribute to a sense of confidence that they are at less risk than other people. When optimistic bias is taken into consideration, the decision to highlight statistics on the homepage of the “Sex It Smart” campaign is a strategy that has the potential to undermine the campaign. If people don’t think that they personally are at risk, it is unlikely that they will seek out free condoms.

The fallacy of rational decision making in the heat of the moment

              The “Sex It Smart” campaign improves upon the often-criticized health belief model because it acknowledges that everyone does not have equal access to condoms, and attempts to rectify that by providing them free of charge (8). Unfortunately, the campaign ends its efforts at getting condoms into the hands of young people, which suggests that the people who designed it believed that once people had condoms, they would then choose use them in the moment. This presumes that health-related decision making and behavior is the result of a rational, considered decision-making process, an assumption which has been demonstrated to be faulty in many situations (8). Designing the campaign to end with getting condoms to young people reduces its chance of being successful for a few reasons.

            Firstly, it has been demonstrated that sexual arousal significantly affects decision-making. Especially relevant to this campaign, one study of college-aged males demonstrated that self-reported willingness to engage in unsafe sex was significantly higher when males were sexually aroused as compared to when they were nonaroused. Of particular importance is that fact that subjects were unable to predict the effect that being aroused would have on their own tolerance for unprotected sex (9). This study indicates that even if the “Sex It Smart” campaign were successful in getting a nonaroused person to obtain condoms, this does not mean that in an aroused state they would use them.

            Further, a 2001 self-report study of almost 10,000 high school students across Canada revealed that alcohol use was an independent risk factor for inconsistent condom use (10). Alcohol has been demonstrated to affect women’s sexual decision making by increasing their perceptions of a situation as having sexual potential and increasing sexual interest, as well as potentially influencing women to focus more on the positive aspect of risk-taking behavior (11). Once again, in this context simply having condoms would not be sufficient to enable positive behavioral change. In order to be effective, this campaign needs to address the discrepancies between the initiative to obtain condoms and the drive to use them in the heat of the moment.

            Secondly, the “Sex It Smart” campaign fails to address the role of gender in sexual decision making. In her astute criticism of the health belief model, L. Thomas decries the “…model’s inability to allow for the inclusion of the relationship between health status and historical, social, and political structures” (12).  This lack of insight into the role gender of in sexual risk is present in the “Sex It Smart” communications. A recent study examining 15 Australian women who engage in non-romantic sex concluded that though these women may be partaking in “non-traditional sexual behavior,” (eg having sex outside of a committed relationship), they were nonetheless still constrained by traditional gender roles, and thus had limited sexual agency. The authors suggest that this is in part due to the limited availability of a social script that promotes empowered female sexual agency (13). These conclusions are borne out by an evaluation of the sexual attitudes of 161 women that demonstrated that despite initial assertiveness about condom use, even minor prompting from a male partner against condom use substantially reduced a woman’s likelihood to use a condom (11). In a survey of 24 English women between the ages of 16 and 20 who were about to have or had recently had an abortion, the women cited, among other reasons, a desire “not to break the spell” and pressure from a male partner, as reasons why they did not use condoms (14).

            When it comes to condom use, providing women with condoms is not sufficient to overcome the complex dynamics present in heterosexual sexual activity. These data suggest that despite being cognizant of the risks of unprotected sex, women often go along without using a condom, in part to please male partners. In order to more effectively increase condom usage among young women, initiatives need to empower women as sexual decision makers, and increase their perceptions of self-efficacy in sexual negotiation (15). Unfortunately, the “Sex It Smart” lacks compelling messaging addressing these issues.

            Clearly, an initiative that provides condoms with the assumption that they will be used when young people are in the midst of a complex sexual negotiation is erroneous. The calm, level-headed person who orders the condoms from the “Sex It Smart” campaign website thinks differently than the aroused person who will subsequently opt not to use them. In order to truly be effective, the “Sex It Smart” campaign needs to take pains to go beyond providing condoms and attempt to exert some influence over decision making during sexual activity.

Introducing We Sex It Smart – Uniting Youth for Healthier Sex

            In order to address the above flaws in the “Sex It Smart” campaign, a new campaign called “We Sex It Smart” could utilize the existing framework of free condom distribution but add components that would increase its chances of success. “We Sex It Smart” would be a youth-directed movement designed by young people themselves, and feedback from the target audience would be frequently solicited. “We Sex It Smart” would be branded as a movement to promote better, healthier sex, as opposed to being limited to reducing STI transmission. “We Sex It Smart” would house personal stories on its website, highlighting people brave enough to be open about their own experience with STIs.

To increase relevance during sexual activity, “We Sex It Smart” would add a ritualistic component to the free condoms. Condoms would come with stickers that could be gifted to partners or placed in sticker books that would come with orders of condoms. There would be a variety of stickers to encourage a “collect them all” attitude. Partners would be encouraged to create a joint sticker book, thereby providing a level of camaraderie in sexual decision making.

Finally, “We Sex It Smart” would host forums, discussion boards, and branded informational material on its website that would directly address the reality of sexual decision-making for young people. These areas would be called “We Ladies Sex It Smart,” and “If you sip, don’t slip,” and would be branded as distinct components of the “We Sex It Smart” campaign to increase memorability and impact. These message boards would openly acknowledge the fact that young people are often making sexual decisions while under the influence of alcohol, and would allow young people to share their own experiences.  There would also be educational material addressing female sexual agency and healthy decision-making even while drinking.

Striking the right tone for youth behavioral change

To address the issues associated with the current tone of “Sex It Smart,” “We Sex It Smart” would engage with youths from its conception to ensure that the tone of the campaign does not invite psychological reactance. As demonstrated by Silvia, similarities between the messenger and the audience reduce the risk of psychological reactance to messages that could be perceived as limiting freedom (3). To that end, using young people themselves to communicate the about the risk of STI transmission during unprotected sex will decrease the chance that other young people will react negatively to the information. Additionally, it has been demonstrated that designing public health campaigns with youth input and featuring youth leadership is exceptionally effective in inciting behavioral change. As described by Bauer, the “Truth” campaign in Florida had a significant effect in reducing youth smoking in the state. The hallmark of this campaign is that it is led by young people and relies heavily on the input of young people who are peers of the target audience (16). “We Sex It Smart” will borrow from this model, and thereby seek to put youth front and center in the quest to increase healthy sexual decision-making. The rebrand of the campaign to encompass healthy sexuality, as opposed to simply addressing STI risk, is also an effort to increase youth engagement. People are generally not moved by messaging and campaigns that only focus on health. Rebranding this campaign to focus on broader themes like autonomy, intimacy, and pleasure will help keep young people interested and engaged (17).

Making young people the face of the “We Sex It Smart” campaign will also address any concern with social modeling behavior. The campaign will no longer center on unhealthy adolescent sexual behavior, but rather will celebrate healthy sexual decisions. This will encourage youths looking to the campaign for information on sexual behavior to associate condom use with positive sexual outcomes (4).

Personal Stories as an Antidote to Optimistic Bias

“We Sex It Smart” will focus on the voices of young people – even those who have made risky sexual decisions in the past. According to “the law of small numbers,” people tend to be biased towards remembering and relating to individual stories as opposed to broad statistics (18). Additionally, it has been demonstrated that messages that are emotionally evocative and tell compelling personal stories are the most impactful, and have the most potential to incite behavioral change despite optimistic bias (19). To this end, “We Sex It Smart” will leverage the law of small numbers by highlighting the emotionally charged stories of people who have been affected by STIs in the past to encourage youth to recognize that anyone can be affected by them.

Due to the sensitive nature of STI status, “We Sex It Smart” could use the stories of adults who have since overcome their battles with STIs such as chlamydia and gonorrhea. Adult women who have had fertility struggles due to contracting these STIs in their youth would be particularly compelling for the campaign. These women could share emotional stories that would drive home the fact that despite perceived control over sexual decisions, it is impossible to know who has an STI. It would also help dispel any stereotypes that youths have as to who contracts STIs, as it has been demonstrated that in addition to perceived control, an existing stereotype of who is at risk is associated with optimistic bias (3).

Rituals and Empowerment to Encourage Relevancy in the Moment

Bridging the gap from the acquisition of condoms in a cold state to the actual use of condoms in an aroused state is likely the biggest challenge facing the “We Sex It Smart” campaign. This challenge is compounded by the addition of alcohol and gender dynamics into the equation. The “We Sex It Smart” campaign will have 2 components that will work together to attempt to address this issue.

Firstly, the addition of a ritual can make a behavior more likely to be adopted (18). To capitalize on this, the “We Sex It Smart” campaign will add a ritual to condom use to make it easier to remember, even in a state of arousal. Condoms obtained through the “We Sex It Smart” campaign will come with stickers attached to them. These stickers will be branded to match the campaign. The promotional messaging on the campaign website will encourage participants to use these stickers in one of a few recommended ways: 1) post it in public to show support for your campaign, 2) share them with friends or partners, or 3) put them in sticker booklets that are provided with orders of condoms. As a variety of stickers will be produced, these sticker booklets could encourage condom usage by making a game out of collecting the stickers. The option to choose which activity to do with your sticker would provide another layer of ownership over the ritual, which could increase individual investment (18). The sticker booklet will come emblazoned with promotional messaging encouraging participants to share stickers with their partner. This will attempt to make condom use a joint activity, which may deflect some of the gendered tension that has been reported in heterosexual sexual activity (13-15).

Secondly, “We Sex It Smart” will add forums and informational material that will help youth accurately address their sexual realities. For one thing, the role of alcohol in sexual decision-making is completely absent from the “Sex It Smart” messaging (1). “We Sex It Smart” will address alcohol as a component of young peoples’ lives, and contextualize healthy sexual decision-making within a social life that includes alcohol use. This aspect of the campaign will have its own brand, called “If you sip, don’t slip.” Branding can make a public health campaign more effective and memorable, and a critical component of branding is to acknowledge the reality of the target audience (20). “If you sip, don’t slip” will openly address the fact that adolescents sometimes make sexual decisions under the influence of alcohol (10), and would provide information on how alcohol affects sexual decision-making and suggestions for making healthy sexual decisions even in a state of inebriation.

“We Ladies Sex It Smart” would be another branded component of the “We Sex It Smart” campaign. This effort would focus entirely on young girls and empowering them to have sexual agency. It would openly acknowledge that oftentimes girls report feeling more embarrassed than boys purchasing condoms, and this directly impacts their usage patterns (21), and also that girls react to the influence of male partners when it comes to condom usage (11). “We Ladies Sex It Smart” would provide empowering messages to young girls around their ability to influence sexual decisions and speak up for their desires. It would also provide a forum where young women could share their experiences and encourage each other to speak up for healthy sexual experiences. This could contribute to positive modeling behavior. If young girls are exposed to women who have advocated for healthy sexual behavior in their own lives, it could create new social norms that empower girls to push for condom use if they want, even against the wishes of their male partner. Since women are reported to be struggling from the absence of a positive social script that ascribes them sexual agency (13), it will be up to “Ladies Sex It Smart” to create it.

Conclusion

The “Sex It Smart” campaign is strong start for an effective public health initiative. It strives to address one of the crucial problems in public health: access. By providing condoms to anyone in Ottawa who fills out an online form, it makes a laudable attempt to eliminate barriers to sexual health in a community that needs it.

Regardless, the campaign has many aspects that should be improved to maximize its efficacy and reach. For one thing, effective public health campaigns must work with their target audience, not speak down to them. Harnessing the energy and voice of Canadian youth would be a boon to this effort. Secondly, the use of statistics is not a compelling way to encourage change. Instead, this effort should use individual stories to make its message more relevant. Finally, the assumption that improving condom access is sufficient to improve condom usage misses much of the reality of sexual decision making. The addition of a fun ritual, as well as the open acknowledgement of some of the realities of adolescent sexual life in Canada, would make this campaign far more relevant, engaging, and effective.

References

1.     Ottawa Public Health. Sex It Smart Campaign. Ottawa, Canada. Ottawa Public Health. www.sexitsmart.ca.

2.     Brehm J. A Theory of Psychological Reactance (pp. 277-290). In: Burke W, Lake DG, and Paine JW, ed. Organization Change: A Comprehensive Reader. San Francisco, CA: Jossey-Bass, 2009.

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

4.     DeFleur ML, Ball-Rokeach SJ. Theories of Mass Communication (5^th edition), Chapter 5 (Socialization and Theories of Indirect Influence), pp. 202-227. White Plains, NY: Longman Inc., 1989.

5.     Hornik R, Jacobsohn L, Orwin R, Piesse A, Kalton G. Effects of the national youth anti-drug media campaign on youths. American Journal of Public Health 2008; 98:2229-2236.

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

7.     Ayanian JZ, Cleary PD. Perceived risks of heart disease and cancer among cigarette smokers. JAMA 1999; 281:1019-1021.

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

9.     Ariely D and Loewenstein G. The heat of the moment: the effect of sexual arousal on sexual decision making. Journal of Behavioral Decision Making. 2006; 19(2):87-98.

10. Poulain C and Graham L. The association between substance use, unplanned sexual intercourse and other sexual behaviours among adolescent students. Addiction. 2001; 96(4):607-621.

11.   Norris J, Stoner SA, Hessler DM, et al. Cognitive mediation of alcohol's effects on women's in-the-moment sexual decision making. Health Psychology. 2009; 28(1):20-28.

12.  Thomas LW. A critical feminist perspective of the health belief model: implications for nursing theory, research, practice, and education. Journal of Professional Nursing. 1995; 11:246-252.

13.  Moran C and Lee C. Women’s constructions of heterosexual non-romantic sex and the implications for sexual health. Psychology & Sexuality. 2014; 5(2):161-182.

14.  Brown S and Guthrie K. Why don't teenagers use contraception? A qualitative interview study. Eur J Contracept Reprod Health Care. 2010; 15(3):197-204.

15.  Pearson J. Personal Control, Self-Efficacy in Sexual Negotiation, and Contraceptive Risk among Adolescents: The Role of Gender. Sex Roles. 2006; 54(9-10):615-625.

16.  Bauer UE, Johnson TM, Hopkins RS, Brooks, RG. Changes in youth cigarette use and intentions following implementation of a tobacco control program: Findings from the Florida Youth Tobacco Survey, 1998-2000. JAMA 2000; 284:723-728.

17.  Siegel, Michael. “Social and Behavioral Sciences SB271 – Session 2.” Boston University. SB712. Fall 2014. September 11, 2014.

18.  Siegel, Michael. “Social and Behavioral Sciences SB271 – Session 13.” Boston University. SB712. Fall 2014. December 4, 2014.

19.  Durkin SJ, Biener L, Wakefield MA. Effects of different types of antismoking ads on reducing disparities in smoking cessation among socioeconomic subgroups. Am J Public Health. 2009; 99(12):2217-2223.

20. Siegel, Michael. “Social and Behavioral Sciences SB271 – Session 9.” Boston University. SB712. Fall 2014. October 30, 2014.

21.   Moore SG, Dahl DW, Gorn GJ, Weinberg CB. Coping with condom embarrassment. Psychology, Health & Medicine. 2006; 11(1):70-79.

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 code^4,7. 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 Youtube^4,15. 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 condoms^4,15. 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.

3

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 condom^6,7. 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.

Conclusion

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.

REFERENCES

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http://www.washingtonpost.com/blogs/dc-schools-insider/post/dc-releases-results-of-nations-first-ever-standardized-test-on-health-and-sex-ed/2012/12/12/c52da276-4494-11e2-8061-253bccfc7532_blog.html (accessed 4 December 2014)

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http://DOH.dc.gov/release/district-starts-%E2%80%9Crubber-revolution%E2%80%9D-increase-condom-use (accessed 5 December 2014)

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http://DOH.dc.gov/sites/default/files/dc/sites/DOH/publication/attachments/DC_Takes_on_HIV_Public_Awareness_Resident_Engagement_and_a_Call_to_Action.pdf (accessed 5 December 2014)

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http://www.judicialwatch.org/blog/2010/11/rubber-revolution-matches-condoms-personalities/

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

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http://www.examiner.com/article/the-rubber-revolution-begins-dc

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http://octanepra.com/rubber-revolution-dc/#! (accessed 4 December 2014)

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https://www.facebook.com/RubberRevolutionDC  (accessed 9 December 2014)

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https://twitter.com/freecondomsdc (accessed 9 December 2014)

17. Rubber Revolution DC. You Tube. 

https://www.youtube.com/user/RubberRevolutionDC (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. 

http://www.siecus.org/index.cfm?fuseaction=Feature.showFeature&featureid=1497&pageid=483&parentid=478 (access 5 December 2014)

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

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