Research program in Northern provinces aims to save lives by changing behavior

When Somchai’s health began to deteriorate in March of 2004, both he and his family suspected that HIV might be the culprit. He experienced fever, diarrhea, and a significant weight loss. His wife and mother had already begun to distance themselves from him, avoiding even casual contact, refusing even to share the same eating utensils for fear of contracting the dreaded AIDS virus.

A 38 year-old woodcarver in Hang Dong District near Chiang Mai, Somchai had already made up his mind. If his blood test came back positive for HIV, he would end his own life. The reputation of HIV/AIDS as a killer is firmly established within this rural community, and the high cost of medical treatment beyond the reach of Somchai’s 4,000 to 5,000 baht per month income.

When he went for his results, however, Somchai was met by a nurse counselor who provided not only the unfortunate news of his positive test results, but also reassuring information about the free availability of an HIV treatment regimen known as highly active antiretroviral therapy (HAART), capable of controlling what was once a routinely fatal progression of the disease.

This was followed by a counseling session directed towards his family, aimed at providing accurate and up-to-date information concerning the prognosis and care of people living with HIV/AIDS. Arrangements were also made for Somchai to meet with others in his community who are successfully living with the virus, a process known as “peer counseling.”

Somchai no longer contemplates suicide. His mother has developed into a community activist of sorts, educating the people of the village to the facts about HIV, a serious and life-threatening illness, but one that is capable of effective management. His family no longer fears infection by casual contact.

The main challenge facing Somchai now is to maintain very strict adherence to the treatment regimen. This requires him to take his antiretroviral (ARV) medications every 12 hours, with minimal variation or missed dosages.

Patients like Somchai, however, typically find the required level of adherence a major challenge. Less than 95% adherence to ARV treatment allows the virus to develop drug resistant strains. Unchecked by the antiretroviral treatment, the virus can once again begin to replicate, attacking and destroying the body’s protective immune system. A weakened immune system allows opportunistic infections to occur, placing the patient’s life at risk, and requiring treatment with other expensive drugs.

Adherence to a treatment regimen is, by its nature a psychological issue, since it requires changing patients’ attitudes and behavior. For this reason, Dr. Sombat Tapanya, a psychologist with previous research experience on issues of treatment adherence, provided a valuable psychological perspective. The outcome of this research is expected to demonstrate that both medical and psychological components are necessary in order to achieve maximal treatment effectiveness.

To assist him with strict adherence, Somchai was provided with an alarm watch, which signals him each time he must take his medications. He meets monthly with his assigned counselor who monitors his adherence to treatment, and tries to address social and economic issues that could adversely affect him and his family. He also participates regularly in peer counseling, in which he and other patients provide mutual support and encouragement to maintain adherence to ARV treatment and avoid infecting others.

Somchai is one of about 700 participants in a research project aimed at increasing treatment adherence among people living with HIV/AIDS. The project, jointly funded by the Population Council, an international nonprofit NGO, and the Thai Ministry of Public Health, is being carried out in 45 hospitals in Chiang Mai, Chiang Rai, Lampang and Lampoon provinces. The project utilizes four teams of workers; a clinical team, led by Tasana Leusaree, M.D., a counseling team, led by psychologist Sombat Tapanya, Ph.D. and Sangworn Sombatmai, peer intervention, led by Sureerat Treemakara, and an evaluation team, led by Suwat Chariyalertsak, M.D., Ph.D.

Armed with life saving medications, knowledge, and psychosocial support, Somchai and others living with HIV/AIDS in Northern Thailand are empowered to resume their lives, after receiving a diagnosis that formerly would have meant a death sentence.

This innovative program to increase adherence to ARV treatment is the first of its kind in Southeast Asia. Plans are now underway to make similar programs available in other areas of Thailand, as well as other countries in the region.

Ugly smokes and the psychology of persuasion

By now, many have seen the new cigarette packs bearing graphic images of people with ailments caused by tobacco use. Since March 25, color photos depicting stained and misshapen teeth, diseased lungs, breathing tubes, and other gruesome smoking-related diseases and deformities have been required on all cigarette packs sold in the Kingdom.

The intent of this move, of course, is to remind smokers of the cosmetic and health risks of smoking, and presumably discourage some from engaging in this noxious habit. Psychologists use the term “persuasion” to characterize messages like these, which are intended to influence people’s attitudes and behavior. Because persuasion is so prevalent in contemporary life, we might not always be attuned to its presence.

One common form of persuasion, the television commercial has long been a mainstay of our popular culture, enticing us to favor one product over its competitors. Advertising billboards clutter our urban landscapes with words and images intended to persuade onlookers to adopt the latest fashion or consume the hippest beverage. During election campaigns, posters bearing the solemn faces of the Thai political elite sprout like mushrooms after a monsoon rain. E-marketers and scamsters litter our inboxes with spam, hoping to pique our interest in elaborate schemes to transfer large sums of money from Nigeria, or convince us that certain parts of our anatomy are in dire need of artificial enhancement.

You might try to escape the onslaught of persuasion by retreating to the local beaches. There, too, vendors and hawkers regularly approach, offering an endless variety of products and services; belts, hammocks, pendants, watches, lighters, fabrics, or a relaxing seaside massage and manicure. If you are male, try walking down Pattaya’s Soi Six to experience a variety of persuasion that is particularly enticing. Even friends, coworkers, and family members attempt to influence our attitudes and actions with their respective arsenals of persuasive tactics.

Psychologists have identified at least four major ingredients of persuasion: the communicator, the message, the medium by which the message is delivered, and the audience. Researchers have investigated how each of these ingredients can influence the effectiveness of messages intended to persuade.

The credibility of the communicator is an important factor in determining the persuasiveness of a message. Communicators without apparent selfish motives are generally more believable than those who stand to benefit from a change in our attitudes or behaviors. Using Thailand’s anti-smoking campaign as an example, if smokers perceive the messages as coming from impartial scientists and health experts, they are more likely to be favorably influenced, than if they view them as originating with opportunistic bureaucrats, or corrupt public officials. Also, we are inclined to be more influenced by those we perceive to be attractive, and more similar to us.

The content of the message is another important factor. Here, researchers have investigated whether well-reasoned logical appeals are more effective than appeals that target the emotions. The answer seems to depend upon characteristics of the audience. Those who are highly educated, analytical, thoughtful or involved, respond best to more logical appeals. Less well-educated audiences, and those that are disinterested, seem more influenced by peripheral cues, such as the appearance or likeability of the communicator. The cigarette campaign seems to have chosen an appeal that is primarily emotional, possibly eliciting fear or disgust.

Will the Thai antismoking campaign be successful? If the existing research is any indication, it might make a difference for some. In order to reach more educated and thoughtful individuals, however, these efforts could be enhanced by programs to educate the public about the serious health risks inherent in regular exposure to tobacco smoke. To be optimally successful, educational campaigns would likely do well to rely heavily upon authoritative communicators with a high degree of integrity and credibility.