Chase McMillan and Dr. Kerry Patterson, Organizational Behavior
Thailand was the first country in Asia to publicly admit a serious HIV/AIDS problem. Within this acceptance came the commitment to curb the outbreak. The first cases of HIV/AIDS in Thailand were recorded in 1984, but by the late 1980’s, HIV/AIDS spread across the country like a wildfire, noticeably among certain “sentinel” groups, such as sex workers. Between 1989 and 1990, the percentage of infected sex workers tripled from 3.1 percent to 9.3 percent; a year later it had reached 15 percent. To end the spreading of infection, the Thai government realized they must begin with the commercial sex industry.
The good news: HIV/AIDS is largely behaviorally based. That is, if a person can engage in simple behaviors such as abstaining from unprotected sex or avoiding the use of dirty needles, the spread of this pernicious disease can be slowed. The bad news: changing people’s behaviors is easier said than done. Trying to get an entire population to abstain from having sex, for example, would be almost impossible. This leads to an age old question, “How do you change human behavior?” Therein lies the solution to many of the world’s most plaguing problems.
Fortunately, the Thai government had tremendous success in doing just that—changing human behavior. By 1991, the Thai government implemented the 100% Condom Campaign nationwide and experienced significant results. Condom use in brothels has seen an increase from 14 percent to more than 90 percent from 1990 to 1992. The number of reported HIV cases has dropped by 80 percent from 1991 to 2001, with 200,000 reported STI cases in 1989 to 27,597 in 1994. The review conducted by the World Bank estimated that the program has prevented at least 200,000 cases of AIDS in the 1990s alone and concluded that Thailand’s success “is an accomplishment that few other countries, if any, have been able to replicate.”
In this project, I sought to identify the key factors contributing to the success of the 100% Condom Campaign. My methods for achieving this aim are the following: 1. I interviewed two key leaders in the formation, implementation, and propagation of the 100% Condom Campaign —the first, Dr. Wiwat Rojanapithayakorn, the architect, pilot leader, initial promoter of the program, and former Director of the AIDS Program in Thailand, and second, Senator Mechai Viravaidya, the public promoter of the program and former Minister of the Prime Minister’s Office and National AIDS Prevention Coordinator, 2. I conducted a simple literature review covering the development, implementation, statistics, and results of the intervention, 3. in order to provide clarity and structure to the insights gleaned from the interviews and literature review, I analyzed the intervention through the framework of the Six Source Model for Human Influence methods.
The Six Source Model for Human Influence
The Six Source Model of Human Influence is a model that explains the forces of human influence. The Six Source Model builds on Social Cognitive Theory, stating that behavior is driven by two factors: motivation and ability. Does an individual want to enact the given behavior? Is the individual able to enact the given behavior? The model expands this idea, explaining that an individual’s motivation and ability can be analyzed on three dimensions: the personal, the social, and the structural, and can be represented in a six source model (see figure 1).
These six sources of influence are:
1. Personal Motivation. Does an individual, in the absence of outside influence, want to enact the behavior?
2. Personal Ability. Is the individual, in the absence of outside influence, able to engage in the behavior?
3. Social Motivation. Does the influence of others affect the individual’s motivation?
4. Social Ability. Does the influence of others affect the individual’s ability?
5. Structural Motivation. Do the nonhuman factors in the individual’s environment affect the individual’s motivation?
6. Structural Ability. Do the nonhuman factors in an individual’s environment affect the individual’s ability?
The idea behind the model is the more sources incorporated by an intervention to influence an individual, the more effectively the intervention will likely change behavior: Thailand’s 100% Condom Campaign succeeded because it was effective in influencing individuals using all six sources.
100% Condom Campaign
Because HIV/AIDS is a behavior-based infection, the key to slowing the epidemic was to identify and change vital behaviors that lead to the contraction of the disease. As Senator Viravaidya explains, “What causes AIDS? Behavior. AIDS is a behavioral problem. You have to tackle the behavior and in this case it is sex.” The riskiest sexual behavior contributing to the epidemic was occurring through the rampant commercial sex industry. As Dr. Rojanapithayakorn explains, “The main cause of the serious HIV/AIDS epidemic in Thailand came from the sexual transmission of HIV happening through the commercial sex industry. An infected sex worker has about one hundred clients per year; these clients get infected and spread the disease to their families. So we decided the best target would be the sex workers.” Rojanapithayakorn continues, “Every effort in the past to fight sexually transmitted diseases among sex workers through post-infection treatment was a failure. We had to prevent sex workers from getting the disease in the first place. The answer was to get the sex workers to use condoms.” Focusing solely on the use of condoms among sex workers ensured that intervention efforts were not rendered ineffectual by being too widely diffused. The Family Health Institute speculates that “perhaps the main reason for the campaign’s success was its concentration on a limited objective—the consistent and widespread use of condoms in commercial sex—rather than on wider goals, such as eliminating commercial sex altogether, or the improvement of public morality.”
Influencing the entire sex worker population to use condoms, however, was no easy task. There were many obstacles in convincing brothel owners, sex workers, and customers to participate in condom use. Owners of commercial sex establishments feared that forcing the sex workers at their establishments to use condoms would be economically damaging to their business. “Those participating owners would have less income, as clients who use condoms would go to any place, and those who do not like to use condoms would not come to their places,” said Rojanapithayakorn.
In addition to sharing the same fear of decreased income, the sex workers did not possess the negotiation skills required to dissuade customers wanting to have sex without a condom. This issue is articulated well by Rojanapithayakorn: “Most sex workers in Asia are powerless. They are subjected to triple vulnerability: being women (more vulnerable than men), being under financial dependency that forces them to be sex workers, and being involved in a profession considered to be illegal. In most Asian countries, sex workers are often low educated, working under pressure, and with limited capability to negotiate with other sectors in the society.”
Other issues were also significant obstacles of consistent condom use, such as limited access to a supply of condoms, ignorance among sex workers and customers concerning the benefit of condoms, and the fact that the commercial sex industry in Thailand is illegal, making it an entity incapable for the government to work with.
The first order of action was to create a “monopolistic environment” among all commercial sex establishments, where all establishments function under the policy of No Condom, No Sex. “In such situations, payers have no power. The keyword is ‘Monopoly.’ I thought that if this monopoly situation was to be used in sex business in the sense that no condom – no sex everywhere, it would bring sexually transmitted infections (and AIDS) down,” states Rojanapithayakorn. The government ensured compliance by tracing any reported sexually transmitted disease back to the establishment of origin and then penalizing the establishment for non-compliance. “First we would give the establishments a verbal warning, next a written warning. After that, we would shut them down for one day, then one week, a month, and then permanently. But it never had to get that far before they would follow the rules,” recalls Viravaidya. Such measures served to provide structural motivation for every establishment to comply [Source 5: Structural Motivation]. Industry-wide compliance created an environment that enabled establishments to abide by the policy and remain competitive, no longer threatened by economic disincentive for compliance [Source 6: Structural Ability].
This monopolistic environment empowered each individual sex worker with the personal ability to negotiate with the customer [Source 6: Structural Ability]. No longer could the customer go somewhere else if they did not want to use a condom. Upon any indication that a commercial sex establishment was not participating in the program, a health worker would visit the establishment and provide educational training to the sex workers. The training focused on the vital importance of condom use [Source 1: Individual Motivation] and provided the sex workers with negotiation skills [Source 2: Individual Ability]. “We would tell the girls that they are risking their lives and that they needed to protect themselves,” remembers Viravaidya. “And then we would show them how to make it happen; how to reduce the risks.”
A strategy that was frequently used was to identify the sex workers who were successful in negotiating with clients and use them to serve as a sort of model and instructor to the other workers. Creating such models gave the other sex workers a form of social motivation and support, which created personal efficacy to perform the task of negotiation [Source 3: Social Motivation]. “You must get someone who has done it to teach. I can stand up and teach negotiation skills all day and have no effect,” explains Viravaidya. “If a sex worker was having a difficult time negotiating with a customer, she would go get the more experienced girl to help. Two-on-one negotiations are much more simple.” Such strong social support dramatically increased the sex workers’ ability to protect themselves in risky situations [Source 4: Social Ability]. Accessibility to condoms was ensured by the government through providing free condoms to sex workers and commercial sex establishments [Source 6: Structural Ability].
Additional social support came from having media role models and opinion leaders endorse the use of condoms [Source 3: Social Motivation]. “We called the producers of movies, television and radio and gave them subsidies to insert messages about condom use in their programs,” recalls Viravaidya. “We got Buddhist Monks to bless and sprinkle holy water on the condoms.” These measures served to destigmatize the use of condoms among sex workers and the general public, as well as to educate people concerning the importance of protected sex in combating the spread of HIV/AIDS [Source 1: Individual Motivation]. Rojanapithayakorn explains that “a positive feature of the 100% Condom Campaign was that it decreased the reluctance of condom use that existed for cultural and societal reasons.”
Additionally, such bombardment with messages concerning condoms created “a social dialogue and openness about the use of condoms,” explains Arvind Singhal, an expert in the field of behavior change. Studies have shown that a “dominant influence on individuals adopting safer sex practices [occurs] by stimulating interpersonal communication about HIV.” Such communication serves as a strong social motivator to adopt the use of condoms and encourage others to do the same [Sources 3 and 4: Social Motivation and Ability].
Conclusion
The 100% Condom Campaign in Thailand is an unparalleled success. According to the report of an independent research group who presented at the International Conference on HIV/AIDS in Vancouver in 1996, “the 100% Condom Programme adopted by the Thai Government may have already prevented more than 2 million HIV infections in Thailand”. The program succeeded in identifying a behavior critical to the reversal of the HIV/AIDS epidemic in Thailand—condom use in the commercial sex industry—and effectively influenced thousands of people to change their behavior accordingly. A large part of this success, I believe, was the intervention’s ability to influence people by utilizing all six sources of human influence, as explained by the Six Source Model of Human Influence. In a world rampant with behaviorally based social problems and failing behavior change interventions, Thailand’s 100% Condom Campaign can serve as a powerful example of how to influence positive behavior change.
References
- Rojanapithayakorn, Wiwat, and Robert Hanenberg. 1996. The 100% Condom Programme in Thailand. Editorial Review. AIDS 10, 1: 1–7.
- World Bank 2000. Thailand’s Response to AIDS: Building on Success, Confronting the Future. Thailand
Social Monitor V. Bangkok: World Bank Office. - World Bank 2000. Thailand’s Response to AIDS: Building on Success, Confronting the Future. Thailand
Social Monitor V. Bangkok: World Bank Office. - Thanks to the BYU ORCA Grant, I was able to travel to Bangkok to conduct the interviews
- Developed by Kerry, Grenny, McMillan, and Switzler
- Patterson, Kerry, et al. The Balancing Act: Mastering the Competing Demands of Leadership Cincinnati: Thomson Executive Press, 1996.
- Viravaidya, Mechai. Personal Interview. 18
- Viravaidya, Mechai. Personal Interview. 18 February 2006.
- Rojanapithayakorn, Wiwat. Personal Interview. 22 August 2006.
- Prevention as Policy: How Thailand Reduced STD and HIV Transmission. AIDScaptions: Volume III, May 1996.
- Singhal, Arvind. Personal Interview. Jan 2006
- Singhal, Arvind. Entertainment-Education and Social Change: History, Research, and Practice New Jersey: Lawrence Erlbaum Associates, 2004.