Introduction
infection, ’ health-protective behaviors, infections
DISEASE, INFECTIONS, STIS, WEST, INFECTION
The HIV/AIDS epidemic threatens the health of countless people and undermines efforts to reduce poverty and inequality. In Senegal and other West African countries, where the infection rate ranges from 1 to 4.5% of the population, infections are concentrated among high-risk individuals [FSWs in Senegal have both opportunity and incentive to take certain steps to reduce the spread of HIV. The government requires FSWs to register with a health center, where they must receive subsidized testing and treatment (if applicable) for STIs every month (with a free HIV test offered annually), and where they may take free condoms. A government-issued registration card records these monthly health visits; FSWs who fail to present an up-to-date registration card on demand (e.g., because they are not registered, or have not regularly visited the health center) face a prison sentence of 2–6 months (cf. Penal Code articles 319/325). Thus, FSWs in Senegal not only can protect their health by obtaining free condoms and testing, but they also face legal consequences if they decline to get tested.However, these opportunities and incentives do not guarantee that people will procure condoms and get tested; psychological barriers may stand in the way. People tend to respond defensively to information that suggests their behavior puts them at risk of negative health outcomes [Several interventions that encourage condom use and testing in similar populations in other African countries have neglected such psychological barriers. Instead, these interventions provide information about HIV prevention, promote condom use, and distribute free condoms [The first psychological barrier is that engaging in HIV-prevention behaviors could require FSWs to admit to themselves that their work puts them at high risk of contracting a deadly disease. Motivated to downplay or ignore this risk, FSWs may be reluctant to procure condoms or get tested. This motivation is not unique to FSWs—aversion to acknowledging their risk status is a common reason people avoid improving their health behaviors and getting screened for disease [The second psychological barrier is that sex work in Senegal, though legal, is highly stigmatized. Indeed, prior research identifies this stigma as the main reason Senegalese women who do sex work ignore the legal requirement to register as sex workers [To address this threat to self-worth, the present research tested a By testing these hypotheses, we make theoretical and practical contributions to the literatures on health interventions and on self-affirmation theory. On the theoretical side, we examine how psychological barriers may inhibit FSWs’ health-protective behaviors, and we test the generalizability of a self-affirmation intervention to an understudied context. Because most self-affirmation health interventions have been conducted in the United States (US) and United Kingdom (UK), it is unclear how effective such interventions would be in other countries and cultural contexts. Ours is among the first self-affirmation experiments conducted in a low- or middle-income country (cf. [Our experiment has several methodological strengths. First, as one of the largest self-affirmation experiments that targets health behavior change, our experiment provides high statistical power to reliably detect even small effects [In the next sections, we briefly review the self-affirmation literature and its limitations. After describing our hypotheses and methods, we report the results of a high-powered experiment that finds no evidence that self-affirmation can improve HIV-prevention behaviors among FSWs in Senegal. Finally, we suggest several explanations for these null results, and discuss what they suggest about the limits of self-affirmation interventions.