Zika Health Campaign Proposal Jessica Lucas May 2, 2016
Problem Description In 2015, countries in South America experienced an outbreak of the Zika virus and it has been spreading ever since. The Zika virus is carried by mosquitoes and infection can occur through a mosquito bite or sexual contact with an infected individual. Tropical environments encourage mosquito propagation and are vulnerable to mosquito-bourn diseases, such as Zika. As a tropical Caribbean island, Puerto Rico is expected to experience a significant outbreak of the Zika virus. The virus is especially dangerous for pregnant women, causing a severe birth defect microcephaly, characterized by abnormally small heads and brain damage. While taking actions to prevent infection, such as use of insecticide, are useful, it is estimated that up to 80% of Puerto Rico’s population may become infected.1 Due to the fact that symptoms are mild and resemble flu, the true infection rate will be difficult to assess. 2 It is important that women of child-bearing age in Puerto Rico use birth control to prevent pregnancy during this Zika virus outbreak. Long-acting, reversible contraceptives (LARC) consist of intrauterine devices (IUD) and birth control implants that provide years of highly effective birth control and are “20 times more effective than birth control pills, the patch, or the ring” according to the American Congress of Obstetricians and Gynecologists (ACOG).3 In 2015, the ACOG strengthened its recommendation of LARC as the optimal birth control option.4 Results from the Contraceptive CHOICE project suggest that when barriers such as access and cost are removed and women are educated on LARC, two-thirds choose LARC as their primary birth control.5 Therefore, Puerto Rican women of child-bearing age need to know about the benefits of longterm, reversible contraceptives in order to prevent pregnancy and the possibility of severe birth defects during the Zika virus outbreak.
Primary Audience Women of child-bearing age are the primary audience members for this campaign strategy. Secondary audience member may include older women, who serve as trusted advisors to younger women. Almost 98% of the population of Puerto Rico identifies as Hispanic. The island has experienced a population decline in the last several decades, as economic stagnation and rising poverty levels have led to an exodus of native born Puerto Ricans to other states and cities. AS of 2014, there are an estimated 715,000 of women of child-bearing age (15 to 44) who live on the island and 34,000 births.6
There are three main factors affecting messages of long-acting, reversible contraception to the primary audience:
Historical context Religious association Access Education
Historical Context Birth control is a sensitive topic with cultural and historical issues, particularly for the population of Puerto Rico. In 1937, the United States passed Law 116, a policy that offered sterilization as the only birth control option to Puerto Rican women. 7 As many as one-third of Puerto Rican women opted for this, not fully understanding that the procedure was permanent. During the 1950’s the female citizens of Puerto Rico were the unknowing subjects in clinical trials of the birth control pill. 8 They were not informed that they were part of a trial or of the possible side effects, some that were quite severe at experimental dosages. This historical exploitation lingers in how Puerto Rican women may view birth control messages and particularly long-acting birth control options.
Religious Association In addition, roughly 85% of the population is Roman Catholic. While traditionally, Roman Catholics eschew forms of birth control as per the teachings of their church, research indicates that birth control is commonly used by Puerto Rican women, the most popular forms being the birth control pill and condoms.9
Access One of the biggest factors affecting birth control is access. A recent article about a program for free long acting reversible contraceptive (LARC) reveals that while most women are covered by government health plans, such as Medicaid, the reality of finding pharmacists who can fill such prescriptions is difficult and costly.10 Barriers also include a lack of qualified professionals with training on LARC, such as IUDs and contraceptive implants. Education
While many women use the oral birth control pill, there is a general lack of knowledge of the LARC options. 11 As a result, women do not seek out providers of long-acting, reversible contraceptives. Education on the LARC options, the benefits and risks, are vital to the……
Proposed Interventions The scope of this health campaign is limited and therefore will rely on educational messaging. The invention will consist of the following components: 1. Short messages designed to be shared on social media sites. 2. A more detailed flyer that for health officials post and distribute. 3. A short video for digital distribution.
Objectives Each intervention for this campaign must adhere to the following educational outcome objectives: Objective 1 – The intervention must educate women on the Zika virus and the high likelihood they will contract the virus. Objective 2 – The intervention must educate women that severe birth defects can result from infection while pregnant. Objective 3 – The intervention must educate women that health officials world-wide are advising that women delay pregnancy until the threat is abated. Objective 4 – The intervention must educate women about the benefits of long-acting, reversible contraception (LARC) as the optimal option in light of this outbreak. Objective 5 – The intervention must educate women on accessibility of LARC contraception.
Theoretical Model for Message Due to the Zika outbreak and possibly devastating birth defects that can result from infection while pregnant, this campaign will apply the extended parallel process model (EPPM) to construct messages guiding women toward long-acting, reversible contraception. The idea of the EPPM is that “perceived threat motivates action”.12 Perceived efficacy, or the perceived ability for one to control the outcome, is directly related to how a person responds to a threat. This type of fear appeal message aligns with the Zika outbreak problem and the factors that most affect the primary audience.
There are four theoretical variables in the EPPM: perceived severity, susceptibility, self-efficacy and response efficacy. Perceived severity is how a person thinks of the immediate threat and susceptibility is whether a person thinks the threat is a rick. Self-efficacy is the ability to control an outcome and response efficacy is the controlled outcome mitigates the risk. For the Zika outbreak in Puerto Rico, the variables are mapped as follows:
Variable Perceived Severity
Weak Belief Strength View mosquito-borne illness as a part of life and are not overly fearful.13
Susceptibility
Moderate Belief Strength
Accept that they will likely contract mosquito-borne illness. 14
Self-efficacy
Response efficacy
Strong Belief Strength
Birth control is routinely used – 75% of women use a form of birth control.15 Knowledge of LARC options is low.16
The perceived severity and susceptibility is weak to moderate but the self-efficacy and response efficacy is moderate to strong. This suggests a the need for a simple fear appeal 17 – directly addressing the severity of the possible birth defects, while giving a concrete response to this threat in the form of long term birth control.
Using MessageWorks from the CDC The Center for Disease Control (CDC) provides a comprehensive and free resource for health message designers to craft and test their messages. MessageWorks 18 uses research based recommendations to help you craft a targeted message. The tool helps identify the problem, goals and objectives for the health message campaign, as well as the demographics of the audience. The tool made the following recommendations for a message concerning long-acting reversible contraception to counter the Zika virus threat to pregnancy, in a Hispanic population of women, with an average age of 25:
Health Goal A – Encourage Healthy Behavior Health Goal B - Other (e.g., prevention, treatment) Gain/Loss Framing – Loss Frame Referencing – Other Referencing Physical Vs Social Consequences – Both Physical and Social Consequences Emotional – Unemotional Vividness – Low Vividness
These recommendations dovetail neatly with extended parallel process model (EPPM) and the need for a simple fear appeal – directly addressing the severity of the possible birth defects, while giving a concrete response to this threat in the form of long term birth control. The following message was tested using the MessageWorks tool:
The Zika Virus is coming to Puerto Rico and you are likely to contract it. This virus is linked to serious birth defects. You should avoid becoming pregnant during this outbreak. Long-acting reversible contraception (LARC) is the best option at this time.
Do not expose your possible child to a life-long birth defect. Delay pregnancy - Use LARCs.
MessageWorks returned the following score for my message based on the recommended message tactics:
The score means that the message has a 95% chance of influencing the intention of my audience. The second score is related to behavior change, which is not directly related to intention. The message has a 46% chance of influencing an actual behavior change. This is a good score considering the best possible score is only slightly above my coded score. Using this text, I created an unemotional, low vividness graphic that I ran through MessageWorks again, scoring the same:
This graphic can be used for posters at health clinics throughout Puerto Rico. It can also be used as content for health organizations social media efforts.
End Notes 1
http://www.nytimes.com/2016/03/20/health/zika-virus-puerto-rico.html?_r=0 http://www.who.int/mediacentre/factsheets/zika/en/ 3 http://www.acog.org/Patients/FAQs/Long-Acting-Reversible-Contraception-LARC-IUD-and-Implant 4 http://www.acog.org/About-ACOG/News-Room/News-Releases/2015/ACOG-Strengthens-LARCRecommendations 5 Secura, G. M., Allsworth, J. E., Madden, T., Mullersman, J. L., & Peipert, J. F. (2010). The Contraceptive CHOICE Project: Reducing barriers to long-acting reversible contraception. American Journal Of Obstetrics & Gynecology, 203(2). 6 http://www.cdc.gov/mmwr/volumes/65/wr/mm6512e1er.htm 7 http://www.ourbodiesourselves.org/health-info/forced-sterilization/ 8 http://www.pbs.org/wgbh/amex/pill/peopleevents/e_puertorico.html 9 http://www.kinseyinstitute.org/ccies/pr.php 10 http://www.medscape.com/viewarticle/860518 11 http://www.cdc.gov/mmwr/volumes/65/wr/mm6512e1er.htm 12 Basil, Michael & Kim Witte, 2012. “Health Risk Message Design Using the Extended Parallel Process Model.” In Health Communication Message Design: Theory and Practice, edited by Hyunyi Cho, 41-58. Los Angeles: SAGE Publications. 13 https://www.statnews.com/2016/03/04/zika-virus-puerto-rico/ 14 https://www.statnews.com/2016/03/04/zika-virus-puerto-rico/ 15 http://www.kinseyinstitute.org/ccies/pr.php 16 http://www.cdc.gov/mmwr/volumes/65/wr/mm6512e1er.htm 17 Basil, Michael & Kim Witte, 2012. “Health Risk Message Design Using the Extended Parallel Process Model.” In Health Communication Message Design: Theory and Practice, edited by Hyunyi Cho, 41-58. Los Angeles: SAGE Publications. 18 https://cdc.orau.gov/healthcommworks/ 2