Challenging Dogma - Spring 2011

Thursday, May 12, 2011

Improving Minnesota’s “Wrap It / Test It / Treat It” STD Prevention Campaign – Andrew Solomon

Sexually transmitted diseases (STDs) are a group of infectious diseases that include chlamydia, gonorrhea, and syphilis (1). These diseases are a major public health concern and have become “hidden epidemics of enormous health and economic consequence in the United States” (2). In 2009, the CDC reported that that there were 1,244,180 cases of sexual transmitted chlamydia infections (409.2 cases per 100,000), 301,174 cases of gonorrhea (99.1 cases per 100,000), and 13,977 cases of primary and secondary syphilis across the United States. The rate of Chlamydia was almost three times higher in women than men, while the rate was higher in Blacks, American Indians/Alaska Natives, and Hispanics compared Whites. There was no difference in the rate of gonorrhea between genders; however, the rate was higher in Blacks, American Indians/Alaska Natives, and Hispanics compared to Whites. The rate syphilis is higher in men than in women and is higher in minorities compared to Whites (3). Age also plays a major role in the incidence of STDs. In 2000, 49% of new STD cases were in those aged 15-24, although they only represent 25% of the sexually active population (4). The Mayo Clinic reports that risk factors for contracting these STDs include having unprotected vaginal, anal, or oral sex, multiple sex partners, a history of STDs, abusing alcohol or recreational and injection drugs, and being an adolescent female (5). Long term effects of chlymydia and gonorrhea can include pelvic inflammatory disease, ectopic pregnancy, and infertility. If left untreated, the late stages of syphilis can cause damage to the brain, heart, liver, and other internal organs and can cause stillbirths in pregnant women (1).

Like states across the country, Minnesota has been seriously impacted by a growing STD epidemic. In 2010, the Minnesota Department of Health reported 17,760 cases of STDs. Over the past 14 years, Minnesota has seen a significant increase in the incidence rate of chlamydia. In 1996, the rate of chlamydia was only 115 cases per 100,000. Today, this rate has reached 311 per 100,000 (6). The rate of Chlamydia in women was more than double the rate in men. The rate was 15 times higher in Blacks, 5 times higher in Hispanics, 3 times higher in American Indians and Asian/Pacific Islanders compared to white. Young adults (15-24) also had significantly higher rates that the rest of the population (7). The rate of gonorrhea has decreased from 65 cases per 100,000 to 43 cases per 100,000 (6). These rates were higher in females and young adults (15-24). The rate was higher in blacks, American Indians, Hispanics, but the same in Asian/Pacific Islanders compared to whites (7). The incidence rate of primary and secondary syphilis has increased from 0.2 cases per 100,00 in 1996 to 3 cases per 100,000 in 2010 (6). The rate in men was more than double the rate in women (7). Men who have sex with men accounted for the majority of men who became infected (89%) (6). Blacks and other minorities had significantly higher rates than whites. Young adults (20-24) also had the highest rates among all age groups (7). From 2009 to 2010, the rate of STDs increased 5% in Minnesota, with chlamydia rates increasing 6%, primary and secondary syphilis rates increasing 110%, and gonorrhea decreasing 9% (6).

In order to help control the STD epidemic, the Minnesota Department of Health created the “Wrap it / Test it / Treat it” STD Prevention Campaign for the Minneapolis/St. Paul area (Twin Cities). The campaign was primarily comprised of an informational website and an advertising campaign aimed at young adults. The website includes facts and symptoms on Chlamydia, syphilis, and gonorrhea, facts on safe sex, local testing locations, treatment options, and links for further information. The advertising campaign included posters and a radio ad. Some of posters focused around a photo of a urine sample cup full of bees, razor blades, or matches with the slogan “Don’t wait ‘till it hurts.” Other posters included statistics on the number of STD infections in Minnesota during the previous year. These posters were placed in public places, such as on bus shelters, inside light-rail trains, and inside bathrooms. The radio ad was played on local hip-hop radio stations and featured a local artists and a rap song encouraging people to wear condoms, get tested, and seek additional information (8).

The “Wrap it / Test it / Treat it” STD prevention campaign created a website and advertisement that were full of great information on STDs, STD prevention, STD testing, and STD treatment. The residents of the Twin Cities who read this information will likely have a better understanding of these diseases, but this program has several flaws that will prevent it from effectively changing the sexual health behavior of these individuals. This campaign relied on the Health Belief Model (HBM), a social and behavioral science model, that has been shown to be ineffective in changing behavior. They failed to consider differences between gender for those who contract STDs and for those who have power over the prevention methods. Finally, this campaign created an ineffective advertising campaign that failed to make an appropriate promise and should have used branding to get people’s attention.

A Health Belief Model campaign is an ineffective method

The Minnesota Department of Health has used the “Wrap it / Test it / Teat it” campaign to educate the young adults of the Twin Cities about STDs. They focused this education around the individual’s risk of getting an STD, the harm of an STD infection, the benefits of using protection, and the benefits and locations for getting tested and treated (8). Public health interventions like this one utilize the ineffective, Health Belief Model (HBM) and fail to address decision-making factors beyond basic health knowledge.

The HBM was first developed in the 1950’s by researchers at the Public Health Service (10). There are four major components in the HBM that will determine an individual’s behavior, including their perceived susceptibility, perceived severity, perceived benefits, and perceived barriers. When a public health program helps an individual weight these components, it will lead them to a healthier behavior (10-11). In order for these factors to lead to this healthy behavior, the HBM assumes that an individual is rational and will make rational decisions after weighing these four components (11-12).

The “Wrap it / Test it / Treat it” campaign uses facts about the rates of STDs to help education young adults on their susceptibility of becoming infected. They utilize facts about the symptoms and consequences of STDs to help them understand the severity of such an infection. They discuss the benefits of using protection and getting tested to avoid a painful experience. The program discusses the minimal barriers to the easy and painless treatment options and protection methods. This campaign assumes that, after learning these facts, individuals will make a rational decision to use protection and get tested to remain healthy (8).

The campaign presents good information to educate these young adults; however, only relying on the HBM will not be an effective strategy to change an individual’s behavior. Studies have shown that the components of the HBM account for a small percent of predictors for an individual’s sexual behavior; therefore, the HBM is not sufficient at predicting or effective in changing sexual health behavior in young adults (13-15). In fact, there are many other components that need to be considered that the HBM fails to address. Some of these may include influences such as sociocultural factors, social influences and pressure, group norms, and family (15-17). HBM and the “Wrap it / Test it/ Treat it” campaign focus on education, but it is clear that “Knowledge alone is known to be insufficient to change behavior” (16). With only facts and statistics on STDs, as provided by the HBM, this campaign will not address the necessary problems to make an effective impact on the sexual health behavior of the residents of the Twin Cities, whether its using protection or getting tested.

This campaign also assumes that people will make rational decisions when they are sexually active after they are educated about their susceptibility, severity, benefits, and barriers of these infections and treatment options. However, research has found that a major reason why most sexual health interventions are not effective is because they rely on a “rational model of decision making,” but those who are most likely to engage in sex are more likely to be “impulsive decisions makers” (18). These “impulsive decision makers” do not consider factors such as their susceptibility and severity when making a decision, unlike a rational person is expected to do (18). If these individuals are not making rational decisions, they will be less likely to use protection during intercourse or get tested for an infection. Rational decision-making will also be compromised when an individual is in the aroused state. Studies have shown while in the aroused state, individuals are less likely to make the rational decision towards safe sex, including using a condom (19). This indicates that the rational safe sex decisions explained through the HBM and the factors this campaign focuses on will be those that young adults consider least when it matters most.

Failure to consider the importance of gender differences

From the Minnesota surveillance data, we see that women are at greater risk for gonorrhea and chlamydia, while men are at greater risk syphilis (7). The differences between genders and their risk of contracting an STD may indicate differences in susceptibility or behavior and the need for gender specific interventions. The “Wrap it / Test it / Treat it” program failed to consider these possible gender differences when creating their program.

Research has shown that among high school students, females were more likely to discuss sex with parents, have sex more often, and more likely to have a pregnancy scare than males. However, males knew more about how to use a condom (20). Young men report that they have greater power over the emotional intimacy of the relationship and the person with this power as been shown to be the one who decided whether or not to use a condom (21). Studies have also shown that African-American women whose partner did not use a condom were more likely to have a partner who resisted using a condom and the women were less likely to be sexually assertive (22). This is an important implication for those women who may want to use a condom, but do not have the power over their partner to make that decision. Other reports have indicated that the majority of adolescent females have sex partners at least 2 years older than them, and this relationship promotes unsafe sex and increases the females STD risk (23). It has also been shown that STDs and HIV are more easily transmitted from men to women than from women to men, putting women at a greater risk of an infection from their partner (24). These differences between genders highlight the importance of gender-based interventions and the use of the Theory of Gender and Power.

The Theory of Gender and Power is composed of three sections that describe male and female relationships. These sections include sexual division of labor, sexual division of power, and a section known as cathexis, or social norms and affective attachments (24). Research has shown that the foundation for the theory of Gender and Power will lead to different exposure and risk factors for certain diseases in women compared to men – an important implication for public health interventions (25). In fact, STD programs that address gender difference are more likely to be effective (20). The “Wrap it / Test it / Treat it” STD campaign dedicates a page of its website for STD symptoms and prevention methods; unfortunately, it fails to address these issues related to gender differences (8).

Advertising without an appropriate promise or a brand

The “Wrap it / Test it / Treat it” program created an advertising campaign based on their utilization of the HBM. These advertisements attempted to send a message to certain residents in the Twin Cities about their susceptibility of getting an STD with statistics and threatening images of pain to convey their benefits of getting tested for an STD. These advertisements were placed in some areas that only targeted individuals who utilized public transportation and others who only listened to hip-hop radio stations (8-9). Most of these advertisements contained very little content except the promise that we can avoid painful urination by getting tested for STDs.

When only presenting limited information on the susceptibility to STDs and benefit of getting tested on STDs, the “Wrap it / Test it / Treat it” advertising campaign will not be effective. Other campaigns have attempted similar efforts using posters to help raise awareness of an individual’s knowledge and perception of risk to an STD, but these campaigns did not have a significant impact on behavior (26-27). These types of campaigns have been described as “traditional” with the belief that “sufficient exposure should lead to the desired behavior” (28). In order to create a successful message, the Minnesota Department of Public Health will have to go beyond this basic information and this “traditional” campaign.

Research has show that unlike campaigns like “Wrap it / Test it / Treat it”, marketing campaigns can be successful if the marketing includes a brand (29). In fact, a brand has been shown to help the campaign get attention and be more effective (30). Branding can, “overcome one of the major obstacles of social marketing, making the benefits of a health behavior salient enough for the priority audience to adopt it” (31). In fact, a recent campaign in Los Angelis, known as “Stop the Sores,” utilized branding and has reported very successful results in decreasing the rates of syphilis (31).

Branding is “among the most successful activities in the modern economy” and should therefore be included in any public health campaign (32). A brand has been described as “attaching a ‘label’ (for identification) and ‘meaning’ (for understanding) to a product…” (28). These components are key in a brand, but “the significance of brands is in the associations they represent, and the resulting behavior they engender” (32). The most important aspect of creating a brand is the promise that it makes, or what the campaign will do for its target audience, and an “external ideal to which consumers can aspire” (28, 32). The promise made should not be just a healthier life, but must consider our “aspirations, preferences, and other desires” (33). Factors that contribute to an effective brand that customers will associate with include brand loyalty, leadership/popularity, brand personality, and brand awareness (32).

Improving the Campaign with “Tested Sexy”

In the face of a growing STD epidemic, the public health campaign “Wrap it/ Test it / Treat it,” developed by the Minnesota Department of Health, has provided great information about STDs for residents of the Twin Cities. The information has been displayed in an aesthetically pleasing website and advertisements placed around the city (8). This campaign will likely improve knowledge with these great resources; however, it will not be successful in changing behavior. With the utilization of proper social science theories, an improved campaign can be created that will successfully change behavior and slow the STD epidemic in Minnesota.

An improved campaign will be created using a website and advertisements similar to “Wrap it/ Test it / Treat it,” but will also add group intervention programs at local STD clinics. The new campaign will be renamed, “Tested Sexy.” The campaign will consider the three major flaws of the Minnesota campaign, including using the Health Belief Model, Failure to consider the importance of gender differences, and Advertising without an appropriate promise or a brand. A brand will be created that promises a desirable lifestyle supported by being free of STDs. The brand will use a recognizable logo that will be similar to a red stamp mark of the name, “Tested Sexy.” This brand will promise the residents of the Twin Cities a lifestyle that young adults aspire to and will avoid focusing on the statistics and facts of STDs. The brand will address the values of men and women separately in an attempt to appeal to what each gender generally aspires to. For men, advertisements will focus on looking sexy, strong, handsome, and adventurous. For Women, the ads will look sexy, stylish, beautiful, in control, and powerful. Advertisements promoting the “Tested Sexy” lifestyle will use images of young adults who appear to have achieved these aspirations once they have “Tested Sexy.” These ads will imply that because they have tested negative for an STD, they have been able to achieve the values and aspirations as promised. Some ads will use the slogan, “Have you Tested Sexy?” to ask the young adults of the Twin Cities if they have been tested for an STD to verify that they are “sexy”. Some health information on STDs will be added to help support the promise of this appealing lifestyle. These images will be placed near clubs, on billboards, on college campuses, local magazines and newspapers, on Facebook, and in public transportation. The brand will also be sold on t-shirts and other items with the logo “Tested Sexy.” This will allow people to associate themselves with the image the brand represents because they have also test negative for an STD. After exposure to this brand, people will begin to have safer sex and get tested for STDs, so that they may be able to achieve the lifestyle portrayed by “Tested Sexy”.

These attractive advertisements will eventually lead people to the website. The website will continue to represent the values the brand represents. The website will be created with separate sections for males and females. There will be similar images of young adults who have obtained these values because they do not have an STD. The website will support the promise of obtaining these values by including information about how people can become sexier, stronger, or powerful through using protection and getting tested for STDs. The website will also show how people can become part of the “Tested Sexy” campaign by getting a T-shirt with the logo to let other knows they have “Tested Sexy.”

The campaign will also add an additional aspect called the “Tested Sexy Team.” This will involve small group intervention sessions at local STD clinics. These will be gender focused sessions that will help individuals learn how to become and stay STD free. These sessions will be primarily available for women and will help teach women how to be in control of their sexual health despite any possible sexual division of power. They will address a lack of control and how to gain power if their partner refuses to use protection or if their partner participates in risky behavior with others that places the woman at an increased risk for an STD. The ‘Tested Sexy Team” will also be available to address sexual division of labor and sexual division of social norms and affective attachment in a woman’s, as described by the Theory of Gender and Power (24). Programs will also be available for men to help them understand the importance of gender differences and how they can support their partner to “Test Sexy,” or live a lifestyle without an STD infection.

Addressing the Health Belief Model

Research has shown that relying on the Health Belief Model (HBM) is not a successful public health intervention method (13-18). The “Wrap it / Test it / Treat it” program used individuals’ susceptibility, severity, benefits and barriers (the major components of the HMB) to change behavior. It has been shown that information from the HBM is not enough (16). This method also assumes that people are rational and make rational decisions, even though this has been shown to be a poor assumption (18). To help remedy this flaw, the “Tested Sexy” campaign will avoid focusing only on the Health Belief Model and use other, more effective theories.

The “Tested Sexy” campaign utilizes alternative social science theories that avoid many of the issues the HBM presents. The campaign will create a brand with advertising that is not focused around health knowledge and the assumption that individuals will make a rational decision. This campaign will consider aspirations such as looking sexy, attractive, and powerful, rather than being healthy. A campaign that uses branding and focuses on these true aspirations of the target audience will not rely on individuals making rational decisions, like the HBM, but target the irrational side of people (34). Therefore, this method will address one of the biggest flaws in using the HBM; that individuals make rational decisions. This type of advertising also avoids only attempts to increase knowledge, like “Wrap it / Test it / Treat it” and many other ineffective interventions do (8, 16).

This campaign also will use the Theory of Gender and Power to avoid some the flaws of the HBM. The HBM only considers the perceived severity, susceptibility, benefits and barrier of a barrier of a behavior and fails to consider gender differences. Using this theory allows the “Tested Sexy” campaign to create advertising, a website, and intervention groups that is focused on each gender separately and address different issue for each gender. This will correct a major flaw in a sexual health campaign that only considers the HBM and fails to consider other important factors.

Addressing the failure to consider the importance of gender differences

A major flaw in the “Wrap it / Test it / Treat it” campaign is their failure to consider differences in gender. It has been proven that considering gender difference is an important part of sexual health education (20). In fact, programs that use the Theory of Gender and Power have become very successful (35). To address gender differences, the “Tested Sexy” campaign will consider gender differences in its advertising and website, as well as additional group programming through local STD clinics.

The “Tested Sexy” campaign uses separate advertisements and websites to reach each gender differently. The advertisements will promise values that may cause gender differences as described by the Theory of Gender and Power. One of these differences is the sexual division of power (24). The “Tested Sexy” campaign will use the values of control and power to help women bridge the gap in this division and prevent them from getting an STD because their partner refuses to use a condom or practices high-risk sex with other.

The “Test Sexy” campaign will also utilize “Tested Sexy Teams.” This will be an intervention group at local STD clinics that will help primarily women learn new techniques to address issues that may be putting them at increased risk of an STD due to gender differences. This type of intervention has been shown to be very successful in addressing differences in gender and power when it comes to sexual health (35).

Addressing Advertising without an appropriate promise or a brand

Another major flaw of the “Wrap it / Test it / Treat it” campaign is advertising without an appropriate promise or a brand, but the “Tested Sexy” campaign was specifically designed to create a successful promise and a brand. Using branding from ideas created from social and behavioral science, the “Tested Sexy” campaign will create an advertising campaign and a brand that promises the characteristics that we all aspire to. These characteristics will include things such as being sexy, handsome, powerful, or adventurous and will be gender specific. By utilizing a promise that is focused on true aspirations such as these, a successful brand can be created (32). The “Tested Sexy” campaign will also create a recognizable label that says “Tested Sexy” as a red stamp mark. A label like this will help people recognize the campaign and its association with the promises made. This is one aspect in creating a successful brand (32). A brand is created with unique associations, and the “Tested Sexy” campaign will accomplish this, like many other brands, by utilizing images that make promises, a recognized name, and a unique logo. (28). By creating a brand, people will begin to associate the “Tested Sexy” campaign, sexual health, and being STD free with these aspirations.


The STD epidemic has become a major public health concern in Minnesota and across the United States. This resulted in the Minnesota Department of Health created the “Wrap it / Test it / Treat it” STD prevention campaign to help the residents of Minneapolis and St. Paul better understand their risk of contracting an STD and the benefits of getting testing. Although this program provided valuable information, there existed major flaws that prevented the program from changing sexual health behavior. By utilizing social and behavioral science theories to identify these flaws, the “Tested Sexy” campaign is designed to correct the flaws. This new STD prevention campaign will be successful in changing sexual health behavior in young adults across the Twin Cities and will contribute in slowing the STD epidemic.


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