Assessment on the effectiveness of the AIDS Risk Reduction Model - Paolo Chanes-Mora

The AIDS Risk Reduction Model (ARRM), an approach to reducing AIDS, is one of several social and behavioral models to reduce the ever growing impact of HIV/AIDS. ARRM is grounded in several health behavior theories including the, Theory of Planned Behavior, Health Belief Model and the Transtheoretical Model. These three theories are flawed because they treat problems as if they existed in a vacuum when in reality they are complex and multidimensional. As a result of being based on these three models ARRM suffers similar weaknesses. ARRM does not take into account that individuals will not change just because they are shown their susceptibility, and severity, of a health issue, that fact that planning to change a behavior does not always translate to behavior change, and it heavily depends of the use of arbitrary stages of change. ARRM is a weak model to target the HIV/AIDS population and several adjustments and changes would benefit this model.
The Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS) have created a pandemic that takes approximately 2 million lives a year, with nearly 3 million new infections yearly (1). HIV/AIDS impacts many demographic areas and it is important to develop a specific approach to truly make an impact in risk reduction. College campuses, state health officials, and grassroots programs are investing time and resources to implement effective models that will reduce the infections of HIV/AIDS. There are multiple available models, interventions and approaches to decrease HIV infections and improve awareness, some of which have been proven to work better than others. ARRM is one several models that can benefit from change in order to have a greater impact.
ARRM focuses on reducing the spread of AIDS. It aims to explain and predict the behavior change of individuals in relation to the sexual transmission of HIV/AIDS (2). The approach is based on the Health Belief Model (HBM), Theory of Planned Behavior (TPB) and the Transtheoretical Model (TTM). It is composed of three stages: 1) recognition and labeling of one's behavior as high risk, 2) making a commitment to reduce high-risk sexual contacts and to increase low-risk activities, and 3) taking action. The last stage, taking action, is broken into three more steps: 1) information seeking, 2) obtaining remedies and 3) enacting solutions (2).
In stage one of ARRM, the individual is supposed understand susceptibility through education about the severity of sexual activities associated with HIV transmission, believe that he/she is personally susceptible to contracting HIV, believe that having AIDS is undesirable and learn about social norms and networking (2).
Stage two examines the cost and benefits of risky behavior. It takes into consideration enjoyment, response efficacy, self-efficacy, knowledge of the value of good health and enjoyability of a sexual practice, as well as social factors (2).
Lastly, in stage three social networks and problem-solving choices come into play. It includes prior experiences with problems and solutions, level of self-esteem; resource requirements of acquiring help, ability to communicate verbally with sexual partners, and sexual partner's beliefs and behaviors (2).
The Health Belief Model is the fundamental theory driving the three stages of ARRM. The HBM, one of the oldest and most commonly used models in public health, is one of several individual based theories (3). It relies on perceived susceptibility, severity, benefits and actions, and barriers to taking the action. Also, It takes into consideration the degree to which a person feels at risk for a health problem, the degree to which a person believes the consequences of the health problem will be severe, the positive outcomes a person believes will result from the action, the negative outcomes from the action, an external event that motivates a person to act, and a person’s belief in his or her ability to take action (3). Exactly because of several of these approaches in the HBM, that exists in ARRM, make ARRM weak because not everyone who is aware of their risk to HIV/AIDS will want to change their behavior
The TPB is also a core theory of ARRM. Like the HBM, TPB focuses on rational decision-making, and planned behavior. This theory believes that a person’s attitude towards a specific behavior, and their perception of the subjective norms associated with that behavior are the driving force to initiating, or not initiating, a new behavior (4). The TPB extends on the HBM to include social norms and acceptance by others due to the change, or lack of change, in the behavior. Though, this theory is also not strong enough to make ARRM change a behavior and move from planning to actions. The TPB still does not allow for ARRM to be a successful approach to risk reduction due to that fact that planning to change a behavior does not always translate to behavior change.
The TTM proposes that individuals move through a series of motivational stages before achieving the desired behavior. For ARRM the desired behavior change is the risky behavior (5). The five stages of change are precontemplation, in which an individual shows no intention to adopt the health behavior; contemplation, in which an individual shows awareness of personal risk and the need to change; preparation, in which an individual expresses intention to change; action, in which an individual has actively adopted the behavior for a period of less than six months; and maintenance, in which the behavior is sustained for more than six months. At each stage emotional, cognitive, and behavioral processes promote moving to the next stage. Behavioral change can be made by the use of intervention strategies customized to an individual’s stage of readiness to change (6). In addition, a person can move in various ways through this model and do not need to follow a linear transition (5). However, when this theory is applied to the ARRM risk reduction is less likely to work because people don’t always directly fall into these categorized stages and would probably benefit more from individualized approaches
Stage one of ARRM which follows closely the beliefs of the HBM, require a person to understand knowledge of sexual activities associated with HIV transmission, believe that one is personally susceptible to contracting HIV, believe that having AIDS is undesirable and learn about social norms and networking. While in theory this knowledge would lead a person into stage two, weigh the health costs and benefits, it does not always work this way. If a person has multiple partners and is at a much higher risk of contracting HIV/AIDS but enjoys having unprotected sex, they are unlikely to be willing to change their behavior by just someone exposing them to the information. Salazar, in his literature review agrees that in multiple studies perceived severity was of low significance, particularly as it related to preventive health behaviors (7). In addition, it has been stated the HBM, in which ARRM is grounded in, has contributed to the limited understanding and the devaluation of individuals which can easily be applied to those seeing risk reduction practices (8). If an ARRM practitioner believes that based on such implications, as just spreading knowledge to a person, the individual will want to stop risky behavior, it can be seen how indeed the model does add to the limited understanding and devaluating individuals. It is not that simple, the individuals the ARRM is targeting are dynamic, and ever changing, not static and predictable as it is proposed by the model.
Also tied to the BHM, ARRM’s first stage, as Kyung-Hee describes it, is a stage of labeling (9). The risk reduction is meant to occur by labeling the risky behavior with the new information that has been presented regarding the health benefits. However, labeling can be different from individual to individual. There is not a set standard, nor can there be an assumption, that with labeling an action based on presented information it will lead to the desired behavior change.
The assumption in the TPB that planning behavior change leads to the desired behavior change makes ARRM weak. It assumes that behavior is a result of rational decision-making, and that behavior is done in a mechanistic order (6). It does not take into consideration instincts of sudden emotion, habits, income, education level, and other demographic characteristics (6). ARRM assumes that one’s intentions are an immediate determinant of behavior (7).
Further explaining the TPB, Kyung-Hee studies the connection made by ARRM in planning and actually changing behavior in his studies of Asian males who have sex with males (MSM). The subjects who did not practice safe sex, was not because they didn’t plan to use a condom, nor because they didn’t know about their risky behavior. The reasons included, not wanting to show their sexual status in order to avoid community stigma, bringing shame to the family and disappointing parents. MSM is a very high risk population because as explained, they are led by sexual urges and seek sex in a quick way that does not always allow them to use protection even if planned on it before hand (9). ARRM doesn’t take into consideration these outside influences that need to be targeted in the model to actually have significant risk reduction.
Stage three of ARRM, based on the TTM, reduces a person’s behavioral change into steps and heavily relies on the transitional stages, which makes the ARRM an ineffective model. People don’t always progress nor desire to progress in a straight line, as proposed by the ARRM, and can evolve a cyclical pattern of trying to stop, stopping and then beginning at another stage for several cycles (6). In addition, it is difficult to develop an arbitrary set of criteria to measure stages such as contemplation vs. maintenance, or maintenance vs. termination. Categorical placing can result in focusing on trying to figure out what stage the person is in rather than trying to focus on the intervention they should get (6).
West, R, adds that besides creating arbitrary categories and classifying individuals, the transtheoretical model ARRM is grounded on, presupposes coherent and stable plans will be made by the individual (10). Prior to engaging in risky sexual behavior one does not schedule a place and a time. People, who have multiple sex partners, do not always leave their homes scheduling appointments to have sex, nor whether or not they will be practicing safe sex. Many times it is spontaneous, impulsive, and a result of outside uncontrollable factors, and the TTM and ARRM leave no room for non-coherent and unstable plans.
The TTM is also heavily criticized as a type of scientific assessment used to appear capable of developing an intervention based on the needs of the individual (10). It is critiqued on the “soft” results it acquires, for example, going from precontemplation to contemplation, which according to West has no proven value (10). ARRM attempts to bring risk reduction in matter that fits its possible beneficiaries into boxes—stages they will most often not fit into.
To find the effectiveness of ARRM, and at the same time assess the HBM, TPB, and TTM that support the risk reduction model, an evaluation was created for both high risk seekers and low risk seekers. Risk seeking individuals were described as having impulsivity, disinhibition and engagement in problem behaviors. The study associated high risk seeking individuals with lower condom use, having multiple sexual partners, and not knowing their HIV status (11). The subjects in the study were asked to rank from 1 (strong disagree) to 4 (strongly agree), and answer yes/no questions to assess their risk level. The four main types of ranking questions asked were about perceived infection risk, AIDS knowledge, peer norms—mainly related to the HBM. Then there were yes/no questions asked about self-efficacy and intention to use condoms—TTM (11).
The results of the study showed that ARRM worked well for predicting condom use in both high and low risk seekers in this specific group of individuals. The two risk level groups achieved different levels of success depending on the ARRM stages of the study. For the high risk group, the leverage points were “prior condom use” and “self-efficacy.” Meaning stage two of ARRM, based on TPB, was not as useful to them. However, for the low risk seekers the leverage points were “previous condom use” and” intention to condom use,” and were the most important factors in their risk reduction. The low risk seekers leverage point demonstrates the importance of stage two for these individuals, and also further emphasizes how ARRM is not suitable for individuals of all risk levels (11).
As the results of Connor’s studies show, individuals in the ARRM do not always perfectly fit into the three stages of the model. Therefore, while a model might appear to be overall effective, it needs to be further analyzed and developed to find the stages that are relevant to the desired population. In ARRM specifically, and the three health belief theories need to be further developed to understand that knowledge of severity and susceptibility does not lead to behavior change, planning behaviors change does not always lead to action of the desired behavior change, and lastly that a person’s progress which is reduced into steps and heavily relies on the TTM stages might not apply and be effective to all people.
To improve these three main flaws in the health belief theories, and as a result in ARRM, there should be three major changes. First, the assumption in the HBM that perceived susceptibility and severity leads to behavior change needs to be dismissed. Rather, a new approach that show the benefits of engaging in good sexual practices needs to be developed; scare tactics usually don’t work. Second, environmental factors that can lead a person to change planned behavior, which are not included in the TPB, need to be addressed. Problems like not having access to condoms, cultural beliefs, income, and education level need to be addressed. Thirdly, a model that includes motivational progress, not one that will set a person in boxes as the TTM, will be most beneficial.
To dismiss the belief ARRM has that perceived susceptibility and severity leads to behavior change, safer sex practices should be made fun. For example, showing the individual who is about to engage in risky behavior and does not have a condom that there are multiple ways to still receive pleasure from a sexual activity that is less risky. Oral sex and several other methods of foreplay that do not involve sexual intercourse, and are still pleasurable, can reduce their risk level for contracting HIV/AIDS.
In addition to foreplay there are several “toys” such as dice, cards, and fun condoms that can be used in a campaign, or new approach, to show high risk users that being safe, even when caught in unprepared moments, can still be arousing and very pleasurable. This method of showing the positives will greatly steer away from ARRM’s way of showing scary statistics and information to try to show severity and individual’s susceptibility. As discussed in class with the childhood obesity campaign, showing parents the issue won’t change much. Better tactics are to show the positive outcome of the wanted behavior change.
In addition, by focusing on the positive results of safe sex practices, a new approach to stage one of ARRM, and the HBM, should be developed. The new approach should highlight that those who engage in low risk behavior have better communication skills. Partners who get tested for HIV prior to having intercourse, who talk about condoms usage, sexual transmitted diseases (STDs) and sexually transmitted infections (STIs) are able to have a healthier sexual relationship. These are the positive aspects risk reduction models like ARRM should focus on.
Secondly, as ARRM and the TPB wrongly assumes, planning behavior does not lead to change in risk reduction practices. A new successful approach would be to provide risk reduction opportunities. These opportunities should include established outreach programs that provide information about lubes, condoms, sexual health. Also the new approach to risk reduction should provide free HIV testing for couples and individuals who want to know their HIV status, and free STD/STI screenings.
Referrals to centers where women, and men, who want to engage in safer sex but are experiencing domestic violence, should also be available. Providing a support system will lead to higher chances of engaging in safer sex practices that will decrease their vulnerability to risky behavior. In addition, counseling should be provided for these individuals who do not have a say in the risky behavior they are involved in. If they need to leave an abusive partner temporary housing such as shelters should be available.
For individuals like the MSM discussed in Kyung-Hee’s study who were scared of their loved ones realizing their sexual conduct, there should be tactics such as group therapy to help them learn how to express their sexuality openly. Seminars and workshops to help those who have decided to change their behavior achieve it by providing the necessary skills to accomplish them would be a great environmentally inclusive as well as productive approach.
Lastly, to further be inclusive of environmental factors that can result in an individual who has planned to change their behavior carry out the change, cultural awareness and norms need to be considered. Since ARRM and the TPB do not consider these factors it has resulted in making them weak models. Cultural norms for many people define their behavior and if this important factor is ignored public health cannot expect planned behavior to result in actions that will reduce risky behavior.
To address the issue that ARRM, and the TTM, has with arbitrarily formed stages, new motivational and encouraging steps need to be formed. As mentioned by Edberg, people sometimes have a cyclical pattern, and can follow different steps in a non-sequential matter proposed by ARRM. Rather than trying to find what stage a person is in, ARRM and the TTM should develop a more individual approach to helping reduce risky behavior. Taking into consideration the environmental factors that make a person not follow through with their plans should be addressed. Another note made by West, is that “soft” results are not useful and steps such as precontemplation and contemplation need to be eliminated to develop an effective approach. Motivational and self-assessed changes are more successful than just trying to move someone from stage to stage (12).
These three recommendations would greatly benefit ARRM, and serve as a new approach to risk reduction. ARRM failed by being based on three models that were already flawed, that as a result made this risk reduction model even weaker. The model did not take into account that individuals participate in irrational behavior regardless of being shown the severity and susceptibility of the desired health change, that fact that planning to change a behavior does not always translate to behavior change, and it heavily depended on the use of the stages of change, which cannot be applied to all high risk individuals. HIV/AIDS interventions in general need to be more population and target specific and since HIV/AIDS does not occur in a vacuum and it involves relationships is should not solely be based on individual interventions. It is difficult to have strong model that tries to apply an approach surrounded only on the individual to a pandemic that is so complex. With a more population specific approach, a risk reduction program that includes the noted recommendations will be successful.

References


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9. Choi K, Yep GA, Kumekawa E. HIV prevention among Asian and Pacific Islander men who have sex with men: a critical review of theoretical models and directions for future research. AIDS Education and Prevention 1998; 10(Supplement A):19-30.

10. West R. Time for a change: Putting the Transtheoretical (Stages of Change) Model to rest. Addiction 2005; 100:1036-1039.

11. Connor, B. Are cognitive AIDS risk-reduction models equally applicable among high- and low-risk seekers? Personality and Individual Differences 2005; 38: 379–393

12. Adams, J. and White, M. (2003) Are activity promotion interventions based on the transtheoretical model effective? A critical review. British Journal of Sports Medicine, 37, 106–114.

Public Health Prevention of Violence Against Women: A critique of current strategies and a suggestion for future intervention – Erica Perlman - Hensen

It is not uncommon to see posters or signs in American cities advertising hotlines to report rape or other forms of violence against females. These hotlines offer much needed support to victims and raise awareness of the violence committed against women, but provide little preventative help. When hotlines and images of battered women compose the vast majority of the current public health interventions, one must ask how effective these interventions are at preventing this type of violence?

Violence against women is a term used to encompass many different types of aggression that can be directed toward women. Included in this term is intimate partner violence, such as domestic abuse, spousal and date rape, and any form of sexual violence, including rape, molestation, harassment, and even threats of these acts (1-2). More specifically, sexual violence is defined as a sexual act where consent is not obtained or freely given (3). In this paper I will use the term violence against women to specifically address violence that is perpetrated by males toward females. With the acknowledgement that other types of violent crimes exist, this is the most predominant form of violence present in our culture and will be the focus of this paper (4).

Violence against women is a significant problem in the United States. One of every six women and 20 -25% of women in college report having experienced attempted or completed rape (3). Of these rape victims, 74% said that the perpetrator was an intimate partner, family member, or acquaintance (3). Additionally, there appears to be greater sexual violence against minorities. In one study that surveyed high school students, 9.3% of African American students and 7.8% of Hispanic students reported having forced sexual intercourse, compared to the 6.9% of white students (3). In fact, intimate partner violence is the leading cause of injury to women 15 to 44 years of age. This makes intimate partner induced injuries more common than automobile accidents, muggings, and rapes from unknown perpetrators combined (5).

The effects of violence against females are devastating. For the victim it almost always results in serious physical, sexual, and/or physiological harm. Women who have been subjected to sexual violence have been shown to have a high incidence of eating disorders, depression, abuse alcohol, drug use, and are more likely to engage in risky sexual activity (3). But the effects of this type of violence do not stop at the victim; it affects family, friends, and communities of these victims as well (7). Violence against women appears to be a learned behavior. People who are frequently exposed to violence are more likely to be perpetrators as well as victims of violence against women (8). The theory that violence is learned is well documented in relation to intergenerational cycling of violence. Sons of men who beat their intimate partners are more likely to be perpetrators of violence to women and women who are daughters of victims of violence are more likely to be beaten or subjected to other forms of violence from their intimate partners later in life (8). On the social level, men’s physical and sexual violence against women is a fundamental barrier to gender equality and without amelioration of this form of violence, women will never be able to overcome the great gender divide that exists in the United States and worldwide (9).

Although there is great prevalence of violence against females in the United States and the ramifications of this abuse are immense, it has been an often-neglected public health concern (7, 10). Furthermore, the public health interventions that have been in place to address the problem of violence against females are greatly flawed in their approach and target. I will begin this paper by critiquing the current public health approach to combating violence against women. I will follow this with a personal recommendation for an intervention that would close the current gaps in public health policy pertaining to violence against women prevention.

Critique

There are three major critiques of the public health approach to dealing with violence against women. First, the majority of interventions in the United States are directed toward women and little to none toward men. Second, the interventions are directed toward individuals, often after the event has already occurred, and not whole communities or society. Third, the interventions to prevent this behavior are usually based on the threat of law enforcement, focusing on punishment of bad behavior, rather than encouraging positive behavior.

The most common public health interventions pertaining to violence against females is focused on the female victim (5). These strategies have included education, awareness, self-defense, hotlines for reporting, and crisis intervention services for survivors (7). Examples of the female focus of interventions and organizations revolving around reducing violence against females are websites such as janedoe.org and womenshealth.gov (11-12). Jane Doe Inc. is the website for the Massachusetts coalition against sexual assault and domestic violence and is considered the leading organization in Massachusetts for organizing and unifying many groups that are fighting violence against women. Yet, this site, like most other websites pertaining to this issue, is directed toward a female audience. It is constructed in pastel colors and the vast majority of pictures on the site are of women. Additionally, under recommendations to aid in prevention it states, “joining a self defense class.” Similarly, it is within the womenshealth.gov website under the U.S. department of Health and Human Services, that information regarding violence against women is found. Womenshealth.gov is the federal government’s website to distribute information about women’s health. Instead of placing violence against women as a category in the main health and human services section of the website, this aspect of health has been placed within the confines of women’s health, thus specifically targeting female viewers and not the entire population. Furthermore, this cite, like Jane Doe Inc., is constructed with pastel colors. This placement and presentation of the issue of violence against women is clearly being made to attract a female audience, within both state and federally created public health intervention websites.

Another example of the female focus of these public health interventions is the Take Back the Night campaign. The Take Back the Night Organization is one of the largest activist campaigns against sexual violence (13). Although this international organization has made great strides in raising awareness about sexual violence and in encouraging the reporting of sexual violence, it’s message, like so many other interventions, is directed toward women. It encourages women to ban together to help fight this problem and largely neglects the influence of male behavior in curbing sexual violence.

Although all of these female focused interventions are significant in their attention to the protection and empowerment of past and/or future victims, public health measures have failed to address the perpetrator. By focusing the vast majority of interventions on females, public health has made this a woman’s issue – a problem with women. Furthermore, this focus is feeding into the blaming of women and the gender inequalities that are at the root of violence against women (8). Wingood and DiClemente, in their discussion of the theory of gender and power, discuss how our culture sees women as lesser beings and are defined in relation to men instead of themselves (14). By focusing public health interventions on women, it is asking women to change their behaviors to fix the problem, versus changing men’s behaviors.

Since men are the vast majority of the source of violence against females, this approach is completely contradictory to the majority of other public health measures that focus on prevention (8). To truly fight against the origins of violence against women, preventative measures must be focused on the perpetrators and the issue should be seen as one that affects both sexes (15). This means that intervention campaigns that raise awareness and educate need to be geared to both men and women, if not more toward men. By continuing to provide interventions that are mostly focused on a female audience, not only is public health failing to address the true origins of this issue but also propagating the biased gender roles of our society.

The second critique will address the fact that most interventions to reduce violence toward women have been based at the individual level and have neglected the shaping of behavior at a societal level. Many current interventions for victims, such as hotlines, and interventions for perpetrators, such as offender treatment services and surveillance, are all based at the individual level (4, 16). Hyman et al. discuss in their article “Primary Prevention of Violence Against Women,”

[Interventions against violence toward women] include reactive interventions such as crisis management, emergency care, and criminal justice against perpetrators, rather then societal or proactive interventions. However, it is increasingly being recognized that successful interventions in reducing violence toward women in society need to be focused on primary prevention and to involve multiple levels of service providers and government (6).

As suggested by Hyman et al., there needs to be a greater focus on interventions at numerous levels of a person’s environment, from individual to society. Societal-level influences on violence against women include but are not limited to gender inequalities, religious or cultural beliefs, societal norms, and social and economic policies that “create or sustain gaps and tension between groups (16).” By addressing these societal influences, a more comprehensive approach can be created to fight violence against women.

Additionally, many feminist researchers believe that a society’s overall norm and practices of male dominance have greater significance in contributing to violence against women than learned behavior from specific individuals, such as parents (17). By neglecting social based interventions, public health is not truly addressing the underlying risk factors that create the threat of violence toward women, such as cultural norms.

Additionally, interventions that are based on shaping groups and cultural norms can be much more effective than individually based interventions. First, these group-oriented interventions can affect many individuals at the same time by targeting a group, making them more powerful (18). Second, by creating interventions that are directed at changing the perceptions of the entire community and the social norms of that community one can affect the immediate decision-making of an individual. As explained in social expectations theory, how one is socialized largely affects their perception of how they should act as well as how others should act. These perceived roles and norms largely define one’s behavior (19). Based on this theory, a person would not batter their wife because it was seen as unacceptable in their community and was not the social norm, not because they considered how this action might hurt their wife physically or mentally. This form of behavioral control can often be more powerful and long lasting. Third, by changing the norms of a society, the desired beliefs and behaviors can continue to be diffused through a society, even after the active intervention has ended (18). By not having social based interventions, public health is not addressing the issue of violence against women at its roots nor utilizing a broader, more efficient form of intervention.

My third critique of public health’s approach of dealing with violence against women is that the majority of interventions that exist that target males are focused on punishment and law enforcement. Many local and state governments have public service announcements aimed at preventing violence against women by threatening perpetrators or future perpetrators that violence against women is a punishable crime. One Montana public service announcement commercial begins by showing a man yelling and hitting his wife for burning his dinner followed by him eating in a jail cafeteria (20). Several Canadian public service announcement commercials created by the public health organization, Home Front, show men brutally beating and yelling at women in public and end by stating the slogan “You wouldn’t get away with it here, you shouldn’t get away with it at home (21-22).

Although these commercials are attempting to prevent future abuse and are focused on male audiences, they are not likely to be effective for several reasons. First, showing negative imagery regarding a behavior is often much less effective than encouraging positive behavior that appeals to an individual’s core values and desires (23). Second, the use of threats to curtail the individual’s behavioral freedom is likely to create reactance, a rebellion from the desired behavior (24). Psychological reactance theory is described as the increased desire for a freedom that has been threatened (25). In the case of violence against females, offenders or future offenders may reject or even be provoked by messages that remind them of the fact that violence against women may cause incarceration and thus, a loss of freedom. To a lesser degree, the offender may experience reactance simply to the fact that the intervention is identifying his behavior as bad. If these ads are creating reactance behaviors, they are not only ineffective public health interventions, but they could be actively working against the goal of the intervention by propagating this behavior.

These three critiques of the current public health approach to curtailing violence against women are neither a thorough examination of all of the public health interventions dealing with these issues nor a complete critique of the programs analyzed. These are simply three critiques of some of the most predominant forms of intervention that are present in American culture. Despite this brief overview of the topic, there are very important issues suggested by the above discussion. First, the lack of focus on males when fighting violence against women is neglecting the fact that men are the perpetrators of these acts and only perpetuates the sexism that is present in American culture by making this a women’s issue. Second, by focusing on individuals, and not the entire society, public health interventions are not being as effective as possible in changing overall cultural norms pertaining to violence against women. Third, the focus on law enforcement and punishment of males in many interventions may be causing psychological reactants, which could be furthering this unwanted behavior instead of discouraging it.

Proposed Intervention

Public health has to develop a more comprehensive approach to dealing with violence against women and return to its roots by creating preventative solutions that encourage healthy behaviors (26). To create preventative measures, the risk factors that lead to the unwanted behavior must be identified. Yet, understanding the risk factors that contribute to the threat of violence against females are largely unknown since violence against women is not biologically based, such as many other public health concerns (8).

Despite this, sociological theories of behavior can help create new interventions to aid in the prevention of future violence against women. Some past recommendations for preventative measures are early identification of individuals at risk of being victim or offender, empowerment and life skill development for women, safety and support programs, and legal policy (6, 8). Although these recommendations would likely be effective public health interventions to prevent violence against women, I will focus on the changing of social norms particularly within the male population through increased awareness and education.

My proposed intervention would increase awareness and education through a large-scale advertisement campaign. An advertisement campaign is best for reaching a large population simultaneously. Because there are few demographics and/or social characteristics that are associated with violence against women, it is most appropriate to target the entire population (8). Additionally, since the goal of the campaign is to change an entire society’s cultural norm, a far-reaching campaign that is experienced by many different groups within the society is necessary. Flood, in his article, “Engaging Men in Ending Men’s Violence Toward Women” describes the aim of preventive public health measures,

Preventions aim to lessen the likelihood of men using violence in the first place by undermining the beliefs, values, and discourses which support violence, challenging the patriarchal power relations which promote and are maintained by violence, and promoting alternative constructions of masculinity, gender and selfhood which foster non-violence and gender justice (9).

This form of prevention is key in stopping violence against women before it begins.

This campaign would be largely focused on television advertisements but would also include run/walks and other large gatherings to gain support and encourage additional awareness. It would revolve around the slogan “Be a Man.” The concept that would be propagated would be that true men are men who don’t victimize women. The advertisement commercials would star major athletes in all different sports: football, hockey, basketball, soccer, NASCAR, etc. The majority of the commercial would be of the athlete playing his sport in a very aggressive masculine light but would end with a shot of him in his sports attire standing happily with his wife or girlfriend, showing tasteful affection and saying “Join me in preventing violence against women. Be a man.” Additionally, there could be merchandise created with the slogan as well as athletes’ names to increase visibility and keep the idea of preventing violence against women very closely tied to men and their personal interests.

There are three major components of this campaign that would make it largely successful. First, the campaign would be geared specifically for men and would play off one’s desire to be labeled as masculine. Second, the campaign would be empowering to men, showing men in a positive light and as a cohesive group banding together to help, creating group ownership of the issue. Third, because the positive message would be delivered by men to men, it would reduce the psychological reactance that is present in many of the current campaigns described previously.

To begin the discussion, I would like to address why this advertisement campaign would be specifically geared toward men. This focus is effective and significant because it enables the campaign to target the problem before it begins, and would be delivered by males. If men do not decide to end the violence themselves, women will always be victims. Thus, men must be a central part of the solution (9, 15).

This intervention will be effective toward men because of its marketing and focus on masculinity. The advertisement is mainly focused on one concept, masculinity. Masculinity is considered a core value for men (9). By redefining masculinity to include rejection of violence toward women, an association is created between the public health message and male masculinity. In this way, one can more easily sell the product of ending violence against women (23). Masculinity will be sold in this advertisement campaign by using athletes as spokesmen; as athletes are known symbols of masculinity in our culture (15). Furthermore, the vast majority of the commercial would show the athlete being strong and powerful, increasing the association of their masculinity with their message. Additionally, by showing the athlete happy with his significant other, the advertisement is also providing the promise of a healthy relationship, another basic desire for many men.

The second major component of this campaign that will make it successful is that it is being focused solely on men. Because this campaign is encouraging men to unite to deal with this issue, it is creating a type of group around the message of opposing violence against women. Michael Kaufman discusses this topic when he states,

One reason for the effectiveness of such participation [in male-focused campaigns] is that through participation, men and boys will feel a sense of “ownership” in the problem. They will feel they have a personal relationship to the issue and a stake in the process of change (15).

By creating the idea that one is an member of a group, there is increased personal enthusiasm. Additionally, with increased adopters of this belief, there is a greater likelihood that the message will become part of the social norms of that community (27).

Similar to the proposed intervention, the white ribbon campaign, an international male focused campaign against violence toward women, heightens the feeling of inclusiveness by having men and boys wear white ribbons on November 25^th to show their support. Thus, there is a specific symbol unifying the group and creating a brand for the concept (28). The white ribbon campaign in Australia has gone even further by having men “swear” that they will not contribute the problem of violence against women. They have the slogan “All Aussie men should swear (29).” This added concept not only furthers the group mentality of men and boys who have all sworn to support this issue, but it also plays off of the word “swear,” creating an element of rebellion in the message. This sense of rebellion is likely to especially appeal to adolescents who often seek rebellion and freedom from established ideas (30). In many of the same ways, the “Be a man” campaign would aim at creating ownership of the intervention and a sense of male comradery associated with it. This would help sell and propagate the message of opposing violence against females through male social networks (31).

Finally, the third major component of the success of the proposed intervention would be that it would be able to combat the physiological reactants in men that are likely produced by interventions that focus on the criminality of violence against women. This intervention would focus on the positive nature of men, showing their strength and kindness toward women. It would not depict men villains and thus would encourage involvement from males and not create a greater divide and further animosity about gender relations (24, 15). Moreover, the message would be delivered from men to men. Using peers to deliver a message has been shown to decrease reactance toward a coercive message such as this. Thus, men would no longer feel as threatened by the public health messages and would be far more likely to be persuaded by them (24).

By using sociological theories and concepts such as appealing to core values, branding, ownership, and deflecting reactants, a public health campaign can be created to effectively promote the prevention of violence against women. This advertisement campaign would not solve the problem of violence against women but it would likely be a good start in addressing the risk factors that contribute to this significant public health concern.

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