[10 minute read]

Thailand would have been a very different kingdom today had it not been for public health official Wiwat Kojanapithayakorn. The first HIV case was reported to the country’s AIDS control center in late 1984[i]. Unfortunately, the AIDS reporting system at the time did not detect the rapid spread of the virus, which is usually asymptomatic for several years before displaying its true colours. It was four years later, when the government introduced HIV testing in treatment centers for heroin addicts did the catastrophic nature of HIV come to light. In a single year, infection rates among injection drug users shot up from almost zero to more than 40%[ii].

Subsequently, the government started sampling high-risk individuals including sex workers, men at STD (sexually transmitted diseases) clinics, pregnant women and current and ex-prisoners. The surveillance program took place annually, and the results painted a very grim picture. In 1989, HIV prevalence among commercial sex workers was 3.1%. This figure ballooned to 9.3% in 1990[iii],  and skyrocketed to 31% by 1994[iv]. HIV/AIDS was on a clear trajectory to become a national epidemic.

But that generalized epidemic was averted (for some time at least), and you may wonder why that is. In the below paragraphs, we share interesting tactics that the Thai government have implemented more than two decades ago and discuss two of the behavioural insights operating behind the scene.

Some Background Info

The virus in Thailand was first transmitted from infected men to a limited number of female sex workers, who, given the nature of their job, transmitted the disease to other people. Several attempts were made to eliminate the sex industry in the past and were abandoned, and consequently the government changed its tactic from that of banning to controlling. Thus, when the link between sex work and the spread of HIV was established, there were no attempts made to eradicate the sex business.

Instead, the authorities initiated a collaborative program between health services, police, local governments, commercial sex workers and commercial sex establishments with the aim of reducing the sexual transmission of HIV through the sex industry[v]. The 100% Condom Use Program, introduced by Wiwat Kojanapithayakorn, was an attempt by the Thai government to change the sexual behaviour of those involved in commercial sex by ensuring that condoms were used in all commercial sex establishments all the time[vi]. A huge undertaking to say the least.

Two years after the policy’s introduction, the percentage of condom use in sex work soared from 14% to over 90%, and the reported incidents of men infected with STDs declined by 85%[vii]. Since then, the program has been implemented in Cambodia, Philippines, China and other countries with some variations in the program between them[viii].

Two Behavioural Insights

When the program was introduced, the government made sure that all stakeholders had easy access to condoms. Local STD clinics provided commercial sex workers with a box of 100 condoms during their weekly routine check-up, and the sex workers were able to pick up more condoms from the clinics if they were used up before their next visit[ix]. Mobile clinics visited commercial sex establishments 12 times a month on average and distributed condoms to the sex workers and the managers of the establishments[x]. Each hotel room was supplied with two free condoms[xi]. In short, the government was taking measures to make it easier for people to engage in safe sex.

In the behavioural science literature, this is known as eliminating friction costs[xii]. According to the Behavioural Insights Team, people often procrastinate because small details could make tasks more effortful and tiresome[xiii]. We think you can all relate: when applying for university, switching your electricity provider, cleaning the kitchen, submitting a report, you say you want to do these things, but usually keep putting them off. As Garfield once said: all my diets start tomorrow. Some studies across various industries have shown that removing those tiny details that make things all the more tiresome could actually encourage people to complete that dreaded task. For example, if you’re a student applying for financial assistance, wouldn’t automating the process encourage you to finish and submit your application? Your answer is more likely to be ‘yes’. One study by the Behavioural Insight Team found that partially automating the process increased the attendance of students applying for the assistance by 8% compared to the control group[xiv].

When the 100% Condom Program was first launched, the government tried to convince CSE owners to adopt the program voluntarily[xv]. However, condom use was not normalized at the time, and many clients avoided CSEs that abided by the program. Consequently, the government implemented a hard measure by enforcing condom use in all CSEs, and threatened to shut down uncooperative CSEs. The Thai government was hoping that once condom use has been normalized, the behaviour would gain momentum with no need for more promotion and enforcement[xvi].

We will pause for a moment here to discuss social norms. Social norms are the unwritten behavioural rules, expectations or standards about how people should behave[xvii]. Social norms are so ingrained in our social interactions that we often do not realize their presence. Think of the next time you meet a friend; the first thing that you would do is reach out and shake hands. Then, when conversing, you make direct eye contact with them, but not for too long that you’re staring. You also stand close to them, but not too close to make them uncomfortable. What is guiding your behaviour here are those unwritten rules, those social norms, that govern and guide your behaviour when interacting with someone else.

The literature distinguishes between two types of norms: injunctive and descriptive. Injunctive norms specify the behaviour that should be performed, while descriptive norms inform people how others act in similar situations[xviii]. For example, if you believe that people recycle because they believe it is morally correct, then you perceive it as an injunctive norm. However, if you believe that most people recycle, then you would perceive it as a descriptive norm.

People often refer to descriptive norms when deciding what to do themselves. Their thinking is often as follows: If everyone is doing or thinking or believing it, it must be a sensible thing to do or think or believe[xix]. Several studies have shown the potency of descriptive norms on changing peoples’ behaviours. For example, one seatbelt-use campaign in Sweden used descriptive social norms to increase the number of individuals wearing seatbelts[xx]. The media campaign informed the target population about the high proportions of people wearing seatbelts, which eventually lead to a significant increase in the number of self-reported use of seatbelts[xxi].

By imposing a hard measure, the Thai government could have encouraged condom use to become the descriptive norm: when comparing their sexual behaviour with similar others, clients and CSWs would see that most individuals used condoms, thereby encouraging them to use condoms as well. Additionally, sanctions introduced by hard measures were hardly used: all CSEs agreed to abide by the condom-use requirement if all other establishments followed the rule as well[xxii]. The insignificant impact of sanctions on sustaining condom use in CSEs could suggest the success of social norms in instilling behaviour change.

Final Thoughts

Within three years of the program’s introduction, condom use among CSWs increased by more than 65%[xxiii]. And while the program costed the government 50 million baht for the distribution of free condoms, the behaviour change has saved the kingdom approximately 73 million baht in STD treatment and another 100 million baht for HIV treatment[xxiv]. These are successful achievements indeed, and yet, the devil is in the detail. For instance, by targeting condom use among CSWs, people began associating HIV transmission with CSWs only, thereby marginalising an already disadvantaged group[xxv]. Furthermore, though the program successfully boosted condom use in CSEs in the short-term, the latest studies on sexual behaviour among CSWs shows that measures such as normalizing condom use or eliminating friction costs may not be sufficient in sustaining consistent behaviour for the long-term.

The 100% Condom Program introduced several soft measures to prevent HIV from turning into an epidemic. It has raised the percentage of condom-use in CSEs for the short-term and saved the government millions in STD and HIV treatment. However, the program’s evaluators may have overlooked the personal welfare of stakeholders when assessing the success of the program.

 

References 

[i] [ii] [iv] [xxv] Ainsworth et al., 2003

[iii] [ix] [x] [xi] UNAIDS, 2000

[v] [viii] Rojanapithayakorn, 2006

[vi] [vii] [xv] [xvi] [xxii] Rojanapithayakorn & Hanenberg, 1996

[xii] [xiii] [xiv] Service et al., 2014

[xvii] Dolan et al., 2010

[xviii] Christian, Rivis, & Sheeran, 2003

[xix] Cialdini, 1991

[xx] [xxi] Perkins, Linkenbach, Lewis, & Neighbors, 2010

[xxiii] [xxiv] Treerutkuarkul, 2010