Public health professionals have reported a lot of success in managing public health issues by proposing specific interventions to manage them (Edberg, 2010). For example, they have reported significant successes in family planning, diarrhea control, and immunization (Cunningham & Card, 2014). Some of these dramatic changes have happened when populations heed to public health advices. However, programs to manage HIV/AIDS have had mixed outcomes (Ansari, 2012). Since the AIDS epidemic started, scientists have dedicated a lot of time and resources to develop rigorous HIV prevention programs to prevent new cases of infection. For most parts of developing these interventions, governments and funding agencies have often chosen to make use of existing and well-tested HIV prevention interventions to manage the scourge, as opposed to focusing on coming up with innovative methods that would work in different social settings (Cunningham & Card, 2014). This issue highlights an adaptive problem in the implementation of public health interventions.
The adaptability of public health interventions is essential in replicating specific health interventions across different cultures. However, this attempt creates a tension between the fidelity of the original health interventions (to their intended audiences) and the replication of the same interventions to a different demographic (Morrison et al., 2009). The increased importance of replicating different interventions in public health has highlighted the limited “generalizability” of specific HIV prevention strategies. This paper recognizes this challenge and explores the issues that emerge in the implementation of public health programs to manage HIV/AIDS. The framework of our analysis tackles the problem from a leadership perspective. In other words, we present the issue as a public health leadership failure. To fill the gap in research, we propose a theory to explain how public health leaders could better transfer, or replicate, public health interventions in multiple settings.
According to Koh (2009b), public health practitioners need to adopt and implement evidence-based interventions in their intended contexts. However, based on resource limitations, different funding agencies have dedicated a lot of time and effort in translating effective HIV prevention programs in different settings (Cunningham & Card, 2014). The CDC’s Replicating Effective Program (REP) is one such example because it seeks to replicate HIV interventions in different community settings (Cunningham & Card, 2014). There are many other examples of similar organizations and programs that have the same intended consequences. To ensure the success of their proposed solutions, most of them have availed replication kits for people who would want to adapt their interventions in different community settings. However, as Ansari (2012) observes, this is no guarantee that their interventions would work in alternate settings. Morrison et al. (2009) cites a case where 162 agencies had applied to replicate a HIV prevention program, and got assistance through the availability of trained personnel to help them do so, but only achieved a 38% success rate because they could not implement the program on time. Despite recommendations to adopt existing HIV preventions as they are, organizations and funding agencies often alter the content of specific health programs for their benefit and so that their interventions apply to their target demographics (Ansari, 2012). They also do so to promote the maintenance and sustainability of the programs, but at the risk of compromising the effectiveness of the original interventions.
A growing body of literature has proposed different reasons to explain the unsuccessful replication of these interventions (Cunningham & Card, 2014). Most of them have suggested that the problem rests in the organizational context where these interventions are formulated (Morrison et al., 2009). Others have pointed out that the problem is a public health leadership issue (Ansari, 2012). Those who support this argument say organizational capacity, congruence with other health agencies, and resource limitations are some organizational factors that influence the replication of health interventions (Morrison et al., 2009). Although these factors have a strong perceptive influence on the implementation of existing HIV and AIDS management interventions, few researchers have investigated how such factors affect the implementation and maintenance of HIV-related interventions over time.
According to Edberg (2010), the diffusion of innovation theory explains why the implementation of HIV-related interventions is problematic. This theory has only four tenets, which include innovation (an idea, practice, or object that a community perceives as new), communication through specific channels, time for accepting interventions, and the presence of a social system – target audience (Edberg, 2010). Literature on diffusion of innovation concepts is comprised of different ideas of innovation. For example, hybrid corn, modern mathematics, new prescription drugs, and new family planning methods are some innovations that have characterized most applications of the theory (Ansari, 2012). Comparatively, according to Morrison et al. (2009), “preventive innovation” helps to decrease new incidences of HIV/AIDS infections. Morrison et al. (2009) explain preventive innovation as “an idea that an individual adopts at one time to lower the probability that some future unwanted event may occur” (p. 90). In the context of HIV prevention, public health workers have often advocated for the use of preventive innovation in countries where HIV transmission often occurs through sexual contact. In such countries, public health officials have often supported the adoption of HIV prevention programs. They include abstinence, being faithful and using a condom.
Although there are other interventions for preventing the spread of HIV, the diffusion of innovations theory mostly applies to the “ABCs” of HIV/AIDS prevention. According to Ansari (2012), there are six theoretical concepts that are most relevant to this topic area. The table below highlights and explains them
|Communication Channels||The means by which information is transmitted from one person to another|
|Innovation-decision process||An overtime sequence for which a target audience member passes information. The sequence has only five stages that include awareness, knowledge, persuasion, adoption, and implementation|
|Homophily||The extent to which two or more people who communicate perceive that they are similar to one another|
|Attribute||Characteristics of the innovation that most people perceive positively or negatively. They include relative advantage, comparability, complexity, trialability, and observability.|
|Adopter Categories||Classification of individual groups based on relative time which they adopted a new idea, technique or process|
|Opinion Leaders||People who are respected for their knowledge and reputation on a specific topic|
The above theoretical concepts could help to explain the effectiveness of HIV programs in countries that are most affected by the scourge. They are also important in explaining the failure of prevention efforts to stop the rapid spread of the disease.
The inability of public health officials to replicate, or adopt, one HIV/AIDS prevention tactic across different communities draws our attention to the works of Ansari (2012) who emphasizes the need to think about research, policy, and practice when improving health outcomes. Particularly, he draws our attention to the need for understanding the gap that exists when translating knowledge into action. Indeed, people’s thinking patterns and actions about research, policy, and practice have changed our mindsets through a realization of some key issues that characterize the failed ability of public health leaders to translate knowledge into action (Leischow & Milstein, 2006). Referring to this fact, researchers have pointed out that the translation of knowledge to action is only about 8% – 15% (Leischow & Milstein, 2006). Part of this problem stems from the failure of public health leaders to understand how they could use evidence-informed practice in their local communities. Relative to this view, Ansari (2012) says the problem rests on the failure of researchers to include more practice-informed evidence when implementing public health interventions. The above information is applicable to policy issues and has practical implications to the implementation of HIV programs.
Some literatures point out that the translation of knowledge into action, as conceptualized thus far, does not recognize the input of politics and social dynamics in public health leadership, or research (Best & Holmes, 2010). The common thinking is that public health problems are products of systematic failures; some of which we need to explore to understand the leadership challenges that affect the sector (Trochim, Cabrera, Milstein, Gallagher, & Leischow, 2006). A growing body of literature has come to recognize that the main challenges in public health leadership are the diffusion of knowledge and the implementation of health interventions (Nahavandi, 2014). However, implementation has emerged as a more problematic front, considering the increased dynamism of community health issues and the increased complexities of health challenges
Most of the problems highlighted above are products of public health leadership challenges (Koh, 2009a). Indeed, as Vroom and Jago (2007) observe, the failure of leaders to visualize how specific health challenges could work, or fail to work, in specific health situations is responsible for the failure of some of the most effective health interventions. According to Avolio, Walumbwa, and Weber (2009), the field of leadership is evolving to become holistic. People are also applying positive forms of leadership in the discipline. This is why multiple research studies are increasingly examining how leadership casually influences public health outcomes (Zaleznick, 2004). Indeed, researchers are no longer examining leadership within a narrow spectrum of personalities who lead organizations, but, rather, through expanded analytical scopes as part of a dynamic leadership cycle. This trend has precipitated the sharing of leadership structures in different organizations because public health professionals have come to understand leadership as a complex and emergent process in different organizations.
For more than three decades, studies on HIV and AIDS have mostly focused on three key areas that include intervention technologies (such as condom use and circumcision), promotion of healthy and safe sexual behaviors, and descriptive epidemiology (studies that seek to understand the distribution of AIDS across different demographics) (Cunningham & Card, 2014; Ansari, 2012). As highlighted in this paper, most of these studies have yielded interventions that have largely contributed to the decline of new HIV transmission rates, or a stagnation of the same. The findings of the literature review reveal that a key research gap is the missing investigations regarding the adaptability, transferability, and applicability of these interventions in new settings. This concern mostly arises from the fact that most HIV and AIDS research information comes from America and other western nations, while the most affected countries are not in these parts of the world. Therefore, public health leaders need to integrate most of these interventions in some of the most affected parts of the world, such as Sub-Saharan Africa, which have different economic, social, and political dynamics from western countries where these interventions come from.
How Problem Statement Incorporates Implications for Positive Social Change
Gaps in the implementation of HIV prevention programs pose a problem in the HIV/AIDS fight because they undermine the work of researchers who have used valuable time and resources to come up with workable interventions to reduce new HIV infections. By poorly implementing these interventions, communities fail to benefit from the useful research work that most scientists develop. In this regard, they suffer from compromised health and wellbeing. As a public health leadership problem, health workers should minimize such gaps to improve global human health outcomes, especially regarding sexual health and development. By doing so, there would be equality and uniformity in the HIV fight because, currently, some countries are making tremendous strides in the HIV fight, while others lag behind, or are retrogressing in the same fight. Indeed, by understanding how to minimize the implementation gaps through effective public health leadership, we could increase uniformity in the HIV/AIDS fight and help countries, or communities, that have failed to make gains in this aspect of human health, to join other countries in doing so. The failure to do so could undermine the steps made towards realizing the dream of having no new infections in the world. This social change is critical in today’s global world where human interconnectedness has increased because making strides in the HIV/AIDS fight in one part of the world and neglecting the implementation issues that would affect other parts of the world easily undermines the overall HIV fight because new infections would still occur through increased human interconnectivity. Collectively, this statement shows the implications for social change associated with the problem statement.
Personal Public Health Leadership Theory
The literature review section of this paper has shown that the HIV/AIDS fight has failed to register significant behavioral changes in different parts of the world. In this section of the paper, we narrow down the causes of this outcome to the failure of public health leaders to understand the nature of the health problem, its potential drivers, and community dynamics that would influence the adoption of behavior change initiatives. This statement comes from the understanding that behavior change interventions are relatively standard across different parts of the world. The rate of adoption is what differs, based on perceptive factors (Moreland-Russell & Brownson, 2016).
There is no specific theory to explain the efficacy of adopting HIV/AIDS prevention strategies. However, there are different theoretical bases that have attempted to do so. Moreland-Russell and Brownson (2016) categorize them into three clusters that include focus on individual change, social theories and models, and structural/environmental categories. The proposed theoretical framework corresponds to the second category “social theories and models” because it highlights how social systems could spread through different social systems. It suggests that public health leaders should achieve high degrees of success by identifying influential people in the community to spearhead public health campaigns, as opposed to using best practice, or international health professionals, to do so. Such influential people may vary, depending on who, or which group of people, is influential in a community. For example, celebrities may be influential in America; sports personalities may be influential in Europe, Africa, America, and Australia; and politicians may be influential in the Middle East, and some parts of Asia and Africa. In this theory, we argue that the main problem public health leaders do is to limit their thinking of how to implement public health programs into restricted groups of personalities to spearhead public health campaigns. This is the biggest undoing for public health leaders because they fail to understand how limiting their scope of opinion leaders also limits their chances of success. For example, many Australian public health campaigns have relied on sportsmen to promote positive behavior change with mixed success (Chapman & Leask, 2011).
In 1998, Australian Cricketer Shane Warne received $123,000 for a public health campaign to document his withdrawal from addiction to smoking (Chapman & Leask, 2011). The campaign was a failure because he failed to stop this habit. Consequently, there was an unprecedented rise in nicotine replacement therapy in the country (Chapman & Leask, 2011). The failure of this campaign caused widespread media controversy about the ethics of payment for charitable, or socially worthy, interventions and, more importantly, about the ethics of tobacco control use, in general, and the interests of private companies in health marketing/control (Chapman & Leask, 2011). Although Warne was among the most respected Australian personalities of his time, his sponsors failed to evaluate the risks associated with the campaign, such as the nature of the health problem and the possible risks associated with the use of celebrities in public health promotion. Therefore, failing to undertake a proper research about health campaigns could seriously jeopardize chances of success.
Visual Presentation of Public Health Leadership Theory
The proposed theory emerges from the quest to find implementation strategies that would work with multiple communities. Since every society has its pacesetters, health workers should take the initiative of approaching community leaders and educating them about the importance of joining a health campaign. In the context of this paper, it would only take the initiative of a respectable community member to encourage other people to adopt positive sexual health behaviors, such as going for screening, using a condom, or being faithful. Supporting this suggestion, Moreland-Russell and Brownson (2016) highlight the importance of recruiting members of the target community to support the health outreach programs because recruiting people from outside the community could cause some resistance among slow adopters. The proposed theory outlines five key steps that public health leaders should focus on to achieve high levels of success in disseminating public health campaigns to fight HIV/AIDS. The diagram below explains these five steps
How Theory Addresses Literature Gap
The tenets of the above-mentioned theory address the literature gap by providing a model for implementing public health campaigns aimed at reducing new HIV infections because they recognize community dynamics that would influence the adoption of HIV/AIDS interventions. This theory addresses some of the issues public health leaders have failed to address about local community dynamics, such as attitudes, beliefs, and values that influence the adoption of public health interventions. The proposed theory also delimits the available approaches for using opinion leaders to champion HIV/AIDS campaigns. Indeed, traditional public health campaigns have mostly focused on using celebrities and sports personalities as the main opinion leaders for spearheading public health campaigns. The proposed theory expands the scope of such opinion leaders by providing a model for choosing the best stakeholders for championing public health campaigns. This theory could work in different community settings, thereby minimizing the barriers to the adoption of HIV-related interventions. In this regard, it offers a near-universal approach for using opinion leaders to champion public health campaigns.
The proposed theory plays a crucial function of identifying the best public health leadership plan to implement HIV/AIDS prevention strategies. Its value proposition rests in selecting the best possible action plan for developing public health campaigns, coming from the need to use opinion leaders in public health marketing. In other words, it is a more effective and efficient way of selecting the best opinion leaders to champion a public health campaign. In this regard, it expands the scope of public health professionals regarding the choice of opinion leaders to choose from. Indeed, this paper has already shown that traditional public health campaigns have often limited their choice of opinion leaders to selected groups of individuals that mostly include celebrities and sports personalities. This limited selection similarly limits the potential for successfully implementing public health campaigns because it fails to recognize important opinion leaders in different societies. For example, celebrities and sports personalities may be popular in countries that appreciate a sports culture and pop culture; however, they are not effective in countries that do not. Therefore, the proposed theory is premised on the assumption that different communities, societies, or countries have different types of opinion leaders that could dramatically influence community behaviors and attitudes. Therefore, it increases the effectiveness, or efficiency, of using such personalities to improve the adoption of HIV interventions. Therefore, the proposed theory addresses the literature gap identified in this paper by proposing a model for improving the implementation gaps of HIV intervention plans.
How Theory Incorporates Aspects of Systems Thinking
In the context of this paper, system thinking refers to the understanding of how different tenets of the proposed theory influence one another, or work together. To understand the applicability of a systems thinking ideology, we need to reexamine the diagram above. We find that the theory has only five main steps, which highlight the fact that the theory comprises of several parts. These parts intertwine because they outline unique steps that public health leaders need to follow to find the best way to disseminate information to the public. In this regard, the theory outlines a dynamic and complex structure of disseminating public health information to create a functional and effective public health campaign.
The theory we propose in this paper builds on the works of researchers, such as Everett Rogers, Gabriel Tarde, Friedrich Ratzel, and Leo Frobenius, who have investigated how people disseminate information among societies, by proposing a more critical approach to health campaigns (Trochim et al., 2006). Some social researchers support the efficacy of this theoretical proposition because they say when trendsetters start to adopt a new behavior; they fundamentally change the new “normative behavior” in their societies (Cheng, Kotler, & Lee, 2010). Consequently, their followers start to adopt the new behaviors. This acceptance happens through the transition of their normative views from the innovation stage to the decision stage. This transition could occur through different steps, including awareness, knowledge, persuasion, or implementation.
Empirical Evaluation Plan for the Public Health Leadership Theory
Assessing the efficacy of the proposed theory rested in understanding its effectiveness in filling the research gap identified in the problem statement. To assess the efficacy of the proposed theory, we had to conduct small cohort studies in specific gay communities across Harlem, New York, to understand whether the theory would influence behavior change among the target population. We used the following methodologies to do so.
The data collection process involved the collection of HIV/AIDS infection data from national statistics. In other words, we obtained data from sampling published information about new infections in the selected sample areas. A reduction in the rate of new infections would imply behavior change and, by extension, the success of the proposed theory.
To measure the data obtained from the above-mentioned data sources, we did a comparative study to analyze changes in infection rates within the target population. By doing so, it was easier to understand the efficacy, or impact, of the proposed theory on the sample population. An increase of new infections (through a comparative study of data obtained from the “pre-theory” period to the “post-theory” period) signified the failure of the theory, while a decrease of new infections signified the theory’s success.
We analyzed the data using basic statistical assessment tools such as graphs and pie charts. These assessment tools helped to provide a holistic understanding of the research phenomenon, because it was easier to visualize changes in infection patterns for the pre-theory and post-theory period.
Based on the findings obtained from the assessments, we found that the theory had significant levels of success in reducing HIV infections among the target population. The early experience of HIV/AIDS in America supports this recommendation. Particularly, the success of the “STOP AIDS” campaign in San Francisco, among the Gay community, lends credence to the proposed theory because it prompted trendsetters in the gay community to start focus group discussions to evaluate the awareness of local people about the AIDS scourge (Cunningham & Card, 2014). Partly drawing from Kurt Lewin’s small group communication theory, proponents of the campaign used the information they obtained from the focus group discussions to design interventions that would directly appeal to the target audience. The result was an effective AIDS prevention campaign, as public health professionals realized that most of the people who attended the focus group discussions shared the same information with other members of the community, thereby leading to increased awareness of HIV among the San Francisco gay community (Cunningham & Card, 2014). Based on the success of this intervention, public health workers started employing outreach workers to reach community health workers in their homes. They reported the same effect using this strategy (Cunningham & Card, 2014). According to the success of the STOP AIDS campaign, it only takes the initiative of early adopters to make other people receptive to the AIDS campaign.
Based on this outcome, it is pertinent for public health leaders to use opinion leaders of specific communities as the main strategy to introduce behavior change. Some tenets of the diffusion theory and the works of researchers, such as Moreland-Russell and Brownson (2016), have also affirmed the success of using opinion leaders to introduce behavior change. In this regard, the proposed theory and the recommendations highlighted herein are grounded in preexisting research studies.
Some of the key tenets of the proposed theory highlight the importance of transformational leadership in the public health care delivery system. Borkowski, Deckard, Weber, Padron, and Luongo (2011) did a study to evaluate the impact of leadership on the perceptions of different demographics at individual, professional, and organizational levels. They did so by analyzing the views of their respondents using a mixture of in-person and telephone structured interviews (Borkowski et al., 2011). The researchers investigated the respondents’ perceptions of the leadership pillars of the Memorial Health Care System’s Pillars of Leadership. Their findings demonstrated that the organization’s leadership pillars successfully helped to develop effective leaders. This finding revealed that this was a good basis for improving organizational and individual performance.
This paper has shown that the HIV/AIDS fight has had significant implementation gaps, which have undermined the progress towards realizing a goal of no new infections, or a HIV-free world. In other words, some parts of the world lag behind in adopting some of the most successful interventions to stop the scourge, while others have made tremendous strides in this regard. These inequalities highlight the implementation gaps that exist in the adoption of HIV interventions around the world because some public health leaders have failed to understand how community dynamics affect the implementation of HIV management interventions. To fill this research gap, this paper has proposed a theory that outlines the most effective way of implementing HIV management plans. It stresses on the importance of developing sound public health leadership plans that recognize the need to choose the best opinion leaders to spearhead public health leadership plans. The theoretical plan hinges on five key processes that include identifying the health problem and its characteristics, identifying opinion leaders, educating the opinion leaders, choosing the most effective media engagement plan, and disseminating public health information. This theory builds on the works of existing theories that have focused on explaining the best way to diffuse health information to the public. However, it differs from them, based on its detailing. In this regard, the theory is holistic and more integrative than pre-existing theories. Furthermore, the interconnectedness of its different aspects demonstrates the incorporation of systematic thinking in the formulation of the theory.
Ansari, R. (2012). Applications of Public Health Education and Health Promotion Interventions. London, UK: Trafford Publishing.
Avolio, B. J., Walumbwa, F. O., & Weber, T. J. (2009). Leadership: Current theories, research, and future directions. Annual Review of Psychology, 60(1), 421–449.
Best, A., & Holmes, B. (2010). Systems thinking, knowledge, and action: Towards better models and methods. Evidence & Policy: A Journal of Research, Debate & Practice, 6(2), 145-159.
Borkowski, N., Deckard, G., Weber, M., Padron, L., & Luongo, S. (2011). Leadership development initiatives underlie individual and system performance in a US public healthcare delivery system. Leadership in Health Services, 24(4), 268 – 280.
Chapman, S., & Leask, J. (2011). Paid celebrity endorsement in health promotion: a case study from Australia. Health Promot. Int., 16(4), 333-338.
Cheng, H., Kotler, P., & Lee, N. (2010). Social Marketing for Public Health: Global Trends and Success Stories, London, UK: Jones & Bartlett Publishers.
Cunningham, S., & Card, J. (2014). Realities of replication: implementation of evidence-based interventions for HIV prevention in real-world settings. Implement Sci., 9(5), 1-10.
Edberg, M. (2010). Essential Readings in Health Behavior: Theory and Practice. London, UK: Jones & Bartlett Publishers.
Koh, H. (2009a). Leadership in public health. Journal of Cancer Education, 24(2), 11–18. Web.
Koh, H. (2009b). Fostering public health leadership. Journal of Public Health, 31(2), 199–201. Web.
Leischow, S. J., & Milstein, B. (2006). Systems thinking and modeling for public health practice. American Journal of Public Health, 96(3), 403–405.
Moreland-Russell, S., & Brownson, R. (2016). Prevention, Policy, and Public Health. Oxford, UK: Oxford University Press.
Morrison, D., Hoppe, M., Gillmore, M., Kluver, C., Higa, D., & Wells, E. (2009). Replicating an Intervention: The Tension between Fidelity and Adaptation. AIDS Educ Prev., 21(2), 128–140.
Nahavandi, A. (2014). The art and science of leadership (7th ed.). Upper Saddle River, NJ: Pearson.
Trochim, W. M., Cabrera, D.A., Milstein, B., Gallagher, R.S., & Leischow, S.J. (2006). Practical challenges of systems thinking and modeling in Public Health. American Journal of Public Health, 96(3), 538–546.
Vroom, V. H., & Jago, A.G. (2007). The role of the situation in leadership. American Psychologist, 62(1), 17–24.
Zaleznick, A. (2004). Managers and leaders: Are they different? Harvard Business Review, 82(1), 74–81.