How the Framing of Mental Illness in Public Health has Contributed to the Social Problem of Stigma - Lisa Pinnow

Mental illness, defined by the National Mental Health Association is “a disease that causes mild to severe disturbances in thinking, perception and behavior”. (NMHA) Over 44 million people suffer from mental health disorders each year and yet only one-third are diagnosed. (Bossolo) In this paper I will criticize public health for not including mental illness as an integral part of the public health system. Like cancer and other physical diseases this illness can be stabilized and even cured. However, unlike other chronic and infectious diseases, it bears a heavy stigma due to the prejudice associated with mental illness. The Labeling Theory states that society has certain norms and rules that individuals must follow and failure to adhere to these rules defines abnormal behavior. The mentally ill are often discriminated against because their behavior does not always correspond with that of the general public. (SparkNotes) Limited access to information from the public health community has caused society to fear and reject those with mental illness. The lack of empathy and misunderstanding towards this illness has created emotional, physical, and social barriers.

The treatment of mental illness has come a long way since the prehistoric treatment of spells and rituals and the barbaric lobotomies of the 1940s. (History of Psychiatry) The history of mental illness demonstrates how deep its roots of rejection extend. The first asylums in the United States during the 19th century were established to ‘remove people with mental illness from the flux and disorder of urban life and to provide them with orderly regimens that could bring equilibrium to their disordered minds’. (Link) In 18th century England, the first hospital to accept mentally ill patients allowed the public to pay a penny to see those labeled as ‘lunatics’. (Wikipedia) The stigma of mental illness has been created over time due to society initially believing that mental illness was controlled by the sufferer, however, when it wasn’t, they were labeled as unpredictable and considered a community risk. The portrayal of the mentally ill as violent, erratic, and unstable has contributed to the negative attitude of society, often viewing these individuals as a threat to the community. Over time this negative response has created a stigma of mental illness, which has affected acceptance and course of treatment. These stereotypes have shaped the misconceptions of mental illness and are the basis for related stigma and discrimination.

Public health has fallen short in creating parity between mental, infectious and chronic diseases in terms of discriminatory limits on treatment and insurance. Mental illness is a term that groups together all illnesses affecting the brain, in the same way that heart disease groups together illnesses affecting the heart. With this in mind, shouldn’t mental illness be treated in the same way as infectious and chronic disease? Individuals who have experienced heart attacks often fully recover, which can also be true for someone who has been appropriately diagnosed and treated for a mental illness. But most of the general public is unaware of this because information about mental illness is not readily available. The lack of similarity in treatment of these patients compared to those with other diseases such as diabetes, heart disease, and obesity has contributed to the stigma of mental illness. The significant level of inequality in treatment has enhanced negative public opinion.

Prevention and intervention are major factors in treating physical health, but these factors do not apply in the treatment of mental illness. Obesity is one example of a physical illness that has become a public health precedent. As a result of the growing epidemic of obesity, it has become a priority of public health. The publicity about obesity not only has caused society to become more comfortable discussing it but also the discrimination associated with this topic has declined. Obesity is now considered to be a disease and that being overweight is a symptom. In 1985, Tufts-NEMC’s opened the Obesity Consultation Center, which offers patients several weight loss options to maintain a healthy weight and prevent health problems that can accompany excess weight. (Tufts) The problems of obesity have also created a niche in marketing by selling a range of larger items for those who suffer from this disease. Mental illness is not as highly publicized nor is the general public knowledgeable or comfortable in dealing with the subject. Where is public health’s intervention and prevention for mental illness?

There have been multiple programs launched to educate society, however, the success rate is too small to change the cultures of the time. The public health system has failed in their responsibility to educate the entire population about mental illness. A substantial number of the population with mental illness do not seek medical treatment due to fear of prejudice, rejection, and misunderstanding. Without treatment this can also cause other health risk behaviors such as smoking and binge drinking.

Public health needs to change the way that society and health professionals perceive those who are mentally ill. Health professionals’ awareness and knowledge about the multiple components of treating the mentally ill is inadequate due to the fact that many are misdiagnosed. Incorrect diagnoses and labeling can cause various negative side effects for patients being treated. One major component of treating patients is the many cultures that make up the population within the United States. For instance, some cultures look disapprovingly or do not believe in expressing emotion and/or weakness so they often do not obtain treatment. Public health has failed at properly training and educating professionals in cultural competence. Health professionals have a duty to assist those who are ill however, particularly in treating mental illness some clinicians can sometimes cause more harm than good. It is also important to realize that health professionals are individuals with personal beliefs and opinions too and their attitude may affect those they treat. They also have the task of improving public opinion about mental illness and providing resources to educate and therefore reduce the stigma.

The media is often used to sway public opinion. Unfortunately, the media often belittles and degrades those who are mentally ill therefore influencing society to reject the mentally ill. Frequently, the news portrays those who are mentally ill as violent and dangerous and labels them as ‘crazy’ or ‘mad’. Media adds to the reservoir of this stigma by presenting the mentally ill as unacceptable. Yet public health does nothing to correct the inaccurate information that is communicated to society.

An example of media misrepresenting mental illness is “Crumbs”, a new sitcom about two brothers who return home to deal with their mother who is being discharged from a psychiatric facility. (ABC) The National Mental Health Association (NMHA) requested that ABC pull the sitcom because it did not only make light of someone with a serious mental illness but depicted mental health professionals as unethical. (MHA) One episode revealed the main character having an affair with an orderly while receiving treatment for their mental illness. (MHA) Although this series did not last through its first season it fed on the stigma surrounding mental health by poking fun at it.

According to the American Psychological Association in 2004, 87% of the population lacks insurance coverage and 81% of Americans state that high costs keep them from seeing a mental health specialist. (Bossolo) As a manager in an outpatient psychiatry department I have seen firsthand how caps on inpatient days, outpatient visits, and limited mental health insurance coverage only hurt and financially burdened the mentally ill. By limiting mental health benefits and coverage the public health is setting the example to society that it is less important than other diseases. Even those patients with insurance are often restricted in terms of their treatment options because of the high costs of treatment and the yearly limits on mental health visits with a varying scale in copayments. The public health system has to realize that individuals with mental illness need treatment in order to manage everyday life and some treatments require visiting their clinician weekly for medication and/or psychotherapy. Lack of treatment for mental illness due to the high cost or lack of access can also cause the patient to suffer concurrent physical illnesses such as high blood pressure, and high blood cholesterol and asthma.

Changing the culture of society to accept and equally treat the mentally ill will not occur in one day or one year. The current programs working towards educating the public and reducing the stigma of mental illness are not sufficient enough to accomplish this goal. The American Psychiatric Association’s 2006 Consumer Survey on Mental Health stated that “forty-four percent of American adults report knowing only ‘a little’ or ‘almost nothing at all’ about mental illness”. (2006consumersurveyfacts) There needs to be a large-scale campaign to educate the population and reduce the stigma such as the World Psychiatric Association’s International Programme to Fight the Stigma and Discrimination towards schizophrenia. (Open) This campaign should be about educating society about mental illness and fighting the associated stigma and discrimination of all mental illnesses, not just schizophrenia.

To change culture, the entire population must receive accurate information about mental illness and the seriousness of mental health. The public health system has to study how best to reach different subpopulations within our society and find ways to combat the stigma. Educating society about mental illness will decrease the prejudice and ignorance towards the mentally ill. If mental illness received as much publication as other diseases or even dangerous habits such as smoking, the general public’s negative attitude would change towards the mentally ill. Resources such as presentations, the media, celebrity experiences, posters, ads, newspapers, magazines and in the classroom must be utilized to reach out to the greater population.

One way to reach the general public is through our many avenues of communication and technology that exist today. Each day mass media bombards us with images and messages from the moment we get up in the morning until we drift off to sleep each night. Television for example, can be a positive method to create worldwide awareness. Popular programs such as 60 Minutes, Dateline, sitcoms and the general news should use the fact that they are broadcasting on national television (or even internationally) and use that time to educate the public. By interviewing professionals and the general public about their experiences with mental illness others might be able to understand and learn that they or someone they know needs treatment. Knowledge and information about where to seek treatment would open the door for individuals who need a starting point. Mike Wallace of 60 Minutes is a perfect example of a celebrity who has discussed his experiences with clinical depression and treatment on television and today leads an accomplished life. (NMHA) His message to the world makes people realize that they too could lead a fulfilling life by seeking treatment.

For those who do not watch or own a television other means of teaching the public about mental illness should be emphasized. The public health system needs to promote the importance of mental health and also to teach that mental health disorders are similar to any other disease. Standards need to be established to ensure that accurate and positive information is publicized. Another possibility would be establishing and promoting more advice hotlines, so individuals would have the opportunity to speak with a professional about mental illness. By creating a safe environment for individuals to obtain more information hopefully more will seek help for themselves, family, or friends. The public health system should also educate students about mental illness. Today many children see mental health professionals for a multitude of reasons such as learning disabilities, family issues, peer pressure, attention deficit disorder and attention deficit hyperactivity disorder. Those that do see a mental health professional often feel segregated due to fear of rejection from their peers. However, given positive information about mental health students will learn how to deal with their thoughts and feelings and as a result will therefore gain self confidence. Children must also learn to use and understand the meaning of the correct terminology so they will not label others as crazy, unstable or unusual. Not only will this have a positive impact on their experience at school and their education but also opening them up to treating other individuals equally.

Public health also must educate and train health professionals to clearly diagnose patients. The numerous cultures that exist within the United States are an important dynamic that health care professionals need to focus on in the management of the mentally ill. The need for education and training in cultural competence is essential in order to clearly diagnose and treat patients. (Link) Health professionals need to be aware of the effects of culture and ethnicity particularly in the field of psychiatry since symptoms of mental illness are diagnosed from verbal and nonverbal cues, eye contact and facial expression of the patient. (Vedantam) Due to the difference in cultures, simple facial responses have different meanings, for example for some cultures eye contact is a sign of disrespect. Failing to acknowledge the many differences in cultures that exist not only discourage the mentally ill from seeking help due to fear of misinterpretation but also correlates with the stigma.

Public health officials need to create a uniform policy for both mental and physical health services and the corresponding insurance coverage. This policy should include equality for coinsurance, deductibles, and day and visit limitations and maximum out of pocket caps. (Bossolo) The mentally ill would more apt to seek treatment if insurance coverage and policies for mental health benefits were equivalent to those of infectious and chronic diseases. Mental illness is a disease that requires immediate action and treatment as in any other illness.

The stigma of mental illness began long ago and has not only increased but has become an inherent part of our culture. Negative terminology and labeling that results from discrimination has delayed many individuals and their families from seeking medical and psychiatric care. When you consider the medical advances public health has made in the treatment of infectious and chronic diseases, mental illness has actually progressed very slowly. The stigma associated with this disease has limited the access to care. Although there have been several mental health commissions, policies and procedures created to help the mentally ill these initiatives do not begin to compare to the advances in other biological, physical and environmental illnesses. (WebMD) Going forward public health needs to focus on not only the treatment of the population of the mentally ill, but also work to eliminate the stigma of mental illness. Public health needs to wage an aggressive war to combat the lack of education, knowledge, and prejudice against mental illness.

Bibiolography:

Mental Illness and the Family: Stigma: Building Awareness And Understanding About Mental Illness. National Mental Health Association. Retrieved October 17th, 2006 from, http://www.apa.org/releases/insurance.html

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Pols, Dr. Han. September 1, 2003. History of Psychiatry. Retrieved October 27th, 2006 from, http://www.usyd.edu.au/hps/course2003/3010.html

Link, B. G. PhD, Phelan, J. C. PhD, Bresnahan, M., MPH, Stueve, A., PhD, and Pescosolido, B. A., PhD. Public Conceptions of Mental Illness: Labels, Causes, Dangerousness, and Social Distance. SB780 Course Reader. September 1999. Vol. 89, No. 9. Page 111.

Bethlem Royal Hospital. last modified November 16, 2006. Wikipedia Encyclopedia. Retrieved Nov 3, 2006 from, http://en.wikipedia.org/wiki/Bethlem_Royal_Hospital.

Obesity Consult Center. Tufts-New England Medical Center. Homepage. Retrieved on December 1, 2006 from, http://www.obesityconsult.org/

ABC, Inc. “Crumbs”, About the show. Retreived on November 16, 2006 from, http://abc.go.com/primetime/crumbs/about.html

NMHA Requests That ABC Immediately Pull Crumbs from Broadcast. National Mental Health Association. Retreived on November 16, 2006 from, http://www1.nmha.org/newsroom/stigma/crumbs.cfm

National Mental Health Association Fact Sheet: Mental Illness. National Mental Health Association. Retreived on November 18, 2006 from, www.nmha.org/infoctr/factsheets/14.cfm

American Psychiatric Association. April 25, 2006. American Psychiatric Survey, Fact Sheet: Consumer Survey on Mental Health. Retrieved October 27th, 2006 from, http://healthyminds.org/multimedia/2006consumersurveyfacts.pdf

Open the Doors. Information on the Global Program. Retrieved on December 3, 2006 from, http://www.openthedoors.com/english/01_01.html

Vedantam, Shankar. MIND AND CULTURE: Psychiatry's Missing Diagnosis Racial Disparities Found in Pinpointing Mental Illness. Washington Post. Tuesday, June 28, 2005; Page A01. Retreived on November 20, 2006 from, http://www.washingtonpost.com/wp-dyn/content/article/2005/06/27/AR2005062701496.html

WebMD, Mental Health: Causes of Mental Illness, Medically reviewed by Cynthia Haines, MD, July 2005. Retreived on November 30, 2006 from, http://www.webmd.com/The National Health and Medical Research Council of Australia. 2001. Mental Illness: The Facts. Mental Health Matters. http://www.mental-health-matters.com/articles/print.php?artID=656

Blast from the Past: Bringing Back Community Involvement and Positive Messages in Safer-Sex Interventions among Gay Men - Gadi Niram

Introduction

The advent of the HIV epidemic among gay men in the 1980s led to strong efforts among gay men to combat HIV infection through the practice of safer sex. These efforts were tremendously successful, and infection rates “dropped precipitously” from the mid 1980s through the early 1990s. (Hammond, 2000). However, as the first generation of men living in the era of HIV have gotten older, the rates of infection among men who have sex with men have climbed, roughly tripling from 4822 new cases in 1993 to 14,819 new cases in 2005. (Centers for Disease Control, 1983-2005).

As the rates of infection have risen, the formerly positive (normative-reeducative) approach taken by those seeking to promote safer sexual practices among gay men has also undergone a drastic change. Early messages were positive in their tone. They recognized men’s need for sexual contact, showed condom use as a pleasurable activity, and addressed the target audience peer-to-peer and man-to-man. Unfortunately, these successful early approaches have largely been abandoned. While recent research has suggested that either a “shocking” (power-coercive) approach (Dahl et al., 2003) or a “rational and direct” (rational-empirical) approach (Marchand & Filiatrault, 2002) would be most effective, this paper will argue, using samples of both early and recent safer-sex messages, that given the fact that such rational or negative ads have predominated during a concomitant rise in HIV infection rates, it is time to consider a return to the earlier strategy of positively-framed HIV prevention messages, delivered from within the target community.

The Role of Human Needs

The early, normative-reeducative safer-sex messages demonstrated a clear understanding of Abraham Maslow’s hierarchy of human needs. Maslow recognized sex itself as a basic human need (Maslow, 1943), a recognition reflected in the early advertisements reviewed below. In these early campaigns, sex is portrayed as pleasurable with and because of—not despite—the use of condoms. “Love and affection, as well as their possible expression in sexuality” warned Maslow, “are generally looked upon with ambivalence and are customarily hedged about with many restrictions and inhibitions.” (Maslow, 1943) The early safer-sex ads recognize Maslow’s observations, and show the sexual needs of the target audience as something inherent to their being, and not as an aberrant behavior to be indulged in only under prescribed circumstances.

The early safer-sex ads also incorporate Maslow’s recognition of higher-order human needs, such as acceptance and self esteem. (Maslow, 1943) They treat the targeted men with respect, and as valued, competent adults. In contrast, the more recent ads reviewed adopt a scolding, coercive tone, fail to support men’s self-esteem as human beings with human needs, and treat them as fundamentally incompetent and in need of supervision in order to care for themselves.

The Power of Positive Messages

Safer-sex messages to gay men in the late 1980s and early 1990s came largely from gay community organizations, and not from public health organizations or practitioners from outside the gay world. The messages represented an in-group perspective, rather than making an appeal from authority. Further, they portrayed—even promoted—sex as a normal, expected behavior among the target audience, and highlighted the pleasure that could be had while still protecting oneself against infection. A 1984 poster shows a naked pair of interracial gay sex partners alongside the caption, “YOU CAN HAVE FUN (and be safe, too)” (San Francisco AIDS Foundation, 1984). A 1990 poster took the message a step further, shifting safer sex from merely being an activity to being a part of a person’s identity. Showing an attractive, shirtless man, the 1990 poster’s caption read, “BE A RUBBERMAN—USE A CONDOM EVERY TIME” (San Francisco AIDS Foundation, 1990). The message: someone who always uses condoms can be sexually desirable, and if you want to be with this “rubberman” you might consider being a rubberman, too.

A 1990 poster, part of a campaign called “red hot + blue”, says it directly: “safe sex is hot sex” (King Cole Inc., 1990). Two naked men are shown in what is clearly a pleasurable embrace. Slogans, including the above, frame the photograph. “USE A CONDOM EVERY TIME”, says the caption, certainly a realistic goal when the result is potentially the pleasurable encounter depicted. (Interestingly, the poster’s Spanish caption translates to “TAKE CARE OF YOURSELF, USE CONDOMS!” with no mention of using them every time. The comparison of English- and Spanish-language messages is beyond the scope of this paper.)

Fear and negativity

The early safer-sex posters carried simple, direct messages that relied on positive images of sex. The posters’ messages used images of the pleasure that could be had in a safer sexual encounter to promote condom use as an inherent component of sexual pleasure rather than as a condition to be fulfilled in order to make the sexual act acceptable. Compare to these earlier messages three more-recent advertisements aimed at preventing the spread of HIV in gay men. A 2001 poster (San Francisco AIDS Foundation, 2001) portrays an unsafe sex act between two men who, from the perspective of preventing HIV transmission, have already failed. In the accompanying caption, each man makes assumptions about the other’s HIV status, based on what he knows about the other man from earlier social encounters, the negative partner assuming he is not at risk of contracting HIV and the positive partner assuming he is not at risk of newly infecting someone. The campaign avoids completely the topic of condom use for protection and instead pleads with its audience to discuss HIV status with their partners before engaging in what it assumes will be unprotected sex. The campaign would appear to have given up, or at least considerably lowered its definition for success among its target audience. This weary advertisement not only promotes risky behavior, but it also subtly promotes the idea that past failure is permanent failure, obviating the need to further concern oneself with matters of health during sex.

A 2003 poster from an Irish organization has the familiar photograph of attractive men, but a radically different tone to its text (Southern Gay Men's Health Project (Ireland), 2003). It adopts the power-coercive tone of a scolding mother whose words carry an implicit assumption of failure: “If you want to be HIV positive”, the caption begins, “you can”:

1. Fuck without a condom
2. Assume everyone you have sex with is HIV negative
3. Assume it will never happen to you

“HIV infections,” it concludes, “are on the increase in young gay men.” The message is both fatalistic and discouraging, almost daring the target audience to violate its tenets. While this and the previous message are from gay or largely-gay organizations, they fail to adopt the in-group perspective of the earlier safer-sex campaigns.

The State of New York, in a 2005 campaign, also denies its target audience a sense of potential safety. “Age won’t protect you from AIDS” says the poster showing a well-dressed older man sitting in front of his birthday cake (New York State Department of Health, 2005). After the poster presents some alarming statistics, there comes this warning: “HIV prevention is a lifelong job.” The individual is told by a judgmental outsider that he has a job to do, with potentially lethal consequences should he fail.

The Limits of Fear

Given the respective changes in HIV infection rates during the reign of each approach, the normative-re-educative safer sex strategy used in the late 1980s and early 1990s would appear to be more effective than the currently recommended rational-empirical and power-coercive strategies used to communicate the benefits of a safer-sex and condom use. Focusing on the positive, communicating from within the target group, and designing messages to resonate primally rather than cognitively may allow future safer-sex campaigns to achieve the success of their predecessors.

Social psychologist Stephen J. Blumberg notes that:

increasing fear and anxiety [in HIV prevention messages] can have unintended consequences. The self-protective behaviors that are stimulated by fear may be fashioned to reduce directly the anxiety itself rather than the risk of contracting the disease (Blumberg, 2000).

Blumberg cites Morris and Swann, who demonstrated that when shown a fear-based HIV-prevention film,

sexually active college students (but not abstainers) reported reduced perceptions of risk for HIV infection, reduced interest in additional information about AIDS, reduced desire to be a peer AIDS educator, and reduced memory for AIDS-relevant information from the film. (Morris & Swann, 1996)

Morris and Swann’s experiment shows that if a fear-based message does not provide a realistic method of countering the risk it presents, the likelihood of these counterproductive behaviors increases (Devos-Comby & Salovey, 2002). Some HIV-prevention messages, including the aforementioned State of New York message targeting older men, fail to present any method of countering risk, or present only the option of abstinence (Ibid). Abstinence is an outstanding method of avoiding sexually-transmitted disease risk, including the risk of HIV, but abstinence is an expression of an existing value, induced by deep personal beliefs (Holman & Harding, 1996). For those people who do not hold abstinent values, an abstinent approach ignores Maslow’s characterization of sex as a basic human need, either physiologically or as an expression of love and affection. (Maslow, 1943) An advertisement or brief film is unlikely to induce sexually abstinent values in a sexually-active target audience, and a fear-based abstinence argument may have an effect opposite of what is desired. The weaknesses of today’s fear-based appeals are compounded by the fact that they very often originate or appear to originate from an authority figure or group external to the target of the prevention appeal.

The Appeal of Community

Community-based appeals have proven effective not only in the early HIV prevention campaigns, but also in communicating other public health messages. When disseminating information about a toxic chemical hazard, community members, including

unofficial local opinion leaders, the media (local and national), and networks of relatives and neighbors […] may have as much credibility with the public as official messengers. In fact, they often enjoy greater credibility (Fessenden-Raden et al., 1987).

A 1999 community-based project to increase mammography among African-American women discovered that when mammography was introduced essentially as a community value through the women’s churches, the participants “significantly increased…their practice of breast self-examination and mammography…compared with the women in the control [group] (Irwin et al., 1999).” The personal experiences of breast cancer survivors, presented to church members after worship as a regular church activity, helped dispel doubts the women had about the ability to cure cancer, and led them in greater numbers to seek medical approaches to dealing with cancer risk (Ibid).

Similarly, the message that gay men should use a condom every time they have sex can be effective (as it was in the past), but not when presented as a judgement by an authority figure external to the target population or as a goal that becomes useless after even a single failure to comply. Instead, as was done in early anti-HIV campaigns, condom use should be presented as an exciting, erotic option, suggested by a member of one’s desired or potential sex-partner pool.

Conclusion

In the late 1980’s and early 1990’s the gay sexual icon of the day was the ACT-UP kid. Clad in jeans, a t-shirt with a safer-sex message, and often sporting a necklace of freedom rings, a set of rainbow-colored rings that symbolized gay pride, these young gay disciples of the AIDS Coalition to Unleash Power conveyed a simple message: They were attractive, and they were potential sexual partners, but they would not engage in sex without the use of a condom.

The late 80s to early 90s was a period of remarkable success for safer-sex messages, as measured by decreasing HIV infection rates; indeed for the ACT-UP kids, the message crossed over from a health message to an essential component of their identity and even their fashion choices. Today, when HIV infection rates are rising, and safer-sex messages are failing to resonate with their target audiences and induce them toward safer sexual behavior, it is essential to reexamine the early period of anti-HIV campaigns and draw lessons on how to repeat that success today.

Among homosexually active men, HIV is perceived as less of a threat than it once was because therapies have improved, men communicate less with their partners about the risks involved in their sexual congresses, and community norms have shifted such that unsafe sex is no longer unacceptable (Morin et al., 2003). Shifting the public health message back to a sex-positive, community-based approach that makes safer sex once again a communal value is an important step in reversing the increase in new HIV infections. As author Douglas Crimp opines,

…AIDS will not be prevented by psychic damage to teenagers caused by ads on TV. It will only be stopped by respecting and celebrating their pleasure in sex by telling them exactly what they need and want to know in order to maintain that pleasure (Crimp, 1987).

Works Cited

Blumberg, S. J. (2000). Guarding against threatening HIV prevention messages: An information-processing model. Health Education and Behavior, 27(6), 780-795.

Centers for Disease Control. (1983-2005). HIV/AIDS surveillance reports.

Crimp, D. (1987). How to have promiscuity in an epidemic. October, 43(AIDS: Cultural Analysis/Cultural Activism), 237-271.

Dahl, D. W., Frankenberger, K. D., & Machanda, R. V. (2003). Does it pay to shock? Reactions to shocking and nonshocking advertising content among university students. Journal of Advertising Research(September 2003), 268-280.

Devos-Comby, L., & Salovey, P. (2002). Applying persuasion strategies to alter HIV-relevant thoughts and behavior. Review of General Psychology, 6(3), 287-304.

Fessenden-Raden, J., Fitchen, J. M., & Heath, J. S. (1987). Providing risk information in communities: Factors influencing what is heard and accepted. Science, Technology, & Human Valued, 12(3 & 4), 94-101.

Hammond, T. (2000). U.S. AIDS cases, deaths, and HIV infections appear stable: Center for the Advancement of Health.

Holman, T. B., & Harding, J. R. (1996). The teaching of nonmarital sexual abstinence and members' sexual attitudes and behaviors: The case of latter-day saints. Review of Religious Research, 38(1), 51-60.

Irwin, D. O., Spatz, T. S., Stotts, R. C., & Hollenberg, J. A. (1999). Increasing mammography practice by african american women. Cancer Practice, 7(2), 78-85.

King Cole Inc. (1990). Safe sex is hot sex.

Marchand, J., & Filiatrault, P. (2002). AIDS prevention advertising: Different message strategies for different communication objectives. International Journal of Nonprofit and Voluntary Sector Marketing, 7(3), 271-287.

Maslow, A. H. (1943). A theory of human motivation. Psychological Review, 50(4), 370-396.

Morin, S. F., Vernon, K., Harcourt, J. J., Steward, W. T., Volk, J., Riess, T. H., et al. (2003). Why HIV infections have increased among men who have sex with men and what to do about it: Findings from california focus groups. AIDS and Behavior, 7(4), 353-362.

Morris, K. A., & Swann, W. B., Jr. (1996). Denial and the AIDS crisis: On wishing away the threat of AIDS. In S. Oskamp & S. Thompson (Eds.), Safer sex in the 90's understanding and preventing HIV risk behavior. New York: Sage.

New York State Department of Health. (2005). Age won't protect you from AIDS.

San Francisco AIDS Foundation. (1984). You can have fun (and be safe, too).

San Francisco AIDS Foundation. (1990). Be a rubberman.

San Francisco AIDS Foundation. (2001). How do you know what you know? Phase 2.

Southern Gay Men's Health Project (Ireland). (2003). If you want to be HIV positive.

Exacerbating the Problem: Our Failure to Embrace Mental Health is Hindering Acceptance, Increasing Stigma, and Reducing Access - Justin Nyborn

“A clear and complete insight into the nature of madness, a correct and distinct conception of what constitutes the difference between the sane and the insane has, as far as I know, not been found.” -Schopenhauer, The World as Will and Idea (as cited in Barlow & Durand, 2000).

Introduction

Open a scholarly journal or the health section of any newspaper in the U.S. and find a collection of highly debated and controversial health topics. The media uses its power of persuasion to dictate trendy and controversial topics and therefore has a powerful influence over the public health opinion of public health issues. Public health practitioners, themselves, the media’s source of public health information, have failed to focus on critical issues in public health. For instance, there are numerous interventions in public health aiming to prevent and treat chronic or infectious disease, but very little is being done to prevent mental illness. In the media, we hear and read about public health wars on drugs, tobacco, and obesity, but we never hear about a war on depression, schizophrenia, or bipolar disorder. We are currently not embracing mental illness with the same vigor and deserving attention as physical disorders. 22% of the U.S adult population has one or more diagnosable mental disorder in a given year and 10 million children in the US have a mental disorder that causes some level of impairment (MMWR, 2005). With numbers as high as these, it is clear that mental health must not be ignored, and further, public health practitioners must scrutinize why mental illnesses have not effectively been treated. Although organizations like the CDC, the nation’s premier public health agency, have begun to address and allocate funding for mental health with its public awareness campaign World Mental Health Day and its collaboration with the World Federation for Mental Health to address stigma, their efforts are secondary compared to their efforts in preventing and treating chronic physical diseases (MMWR, 2005).

Additionally, the failure of public health practitioners to treat mental illness also reflects their inability to treat physical diseases. The mentally ill tend to have higher rates of “all cause” morality (Osborn, 2001). In accordance, it is suggested that individuals with depression and psychosis such as schizophrenia have higher risk for cardiovascular disease (MMWR, 2005; Osborn, 2001). Individual health behaviors such as substance abuse, tobacco abuse, physical inactivity and increased rates of suicide are also correlated with mental illness (MMWR, 2005; Osborn, 2001). Pubic health practitioners spend time and resources searching for causes and treating these physical health conditions, but they ignore a large portion of the population that is at risk for these harmful health behaviors or illnesses.

The failure of public health to embrace mental health has resulted in negative consequences for individuals with a mental illness. The mentally ill feel a lack of acceptance by society and there is a stigma attached to mental illness, which has resulted in discrimination in these individuals (Corrigan, 2004; Barlow & Durand, 2000; Byrne, 2000). This lack of acceptance and discrimination has exacerbated the mental health problem and reduced the access to treatment in the population. Research by authors such as Kessler et al. (2003) have suggested that although there has been an increase in treatment of the mentally ill in the last decade, most mentally ill patients still do not receive treatment. Social and behavioral sciences such as education and psychology are necessary to explain why the failure of public health practitioners to embrace mental health is enhancing stigma associated with mental illness, hindering acceptance of mentally ill individuals, and creating barriers to accessing treatment which is making the problem worse.

Failure to Embrace Mental Health Hinders Acceptance of Individuals with Mental Illness

How does the failure to embrace mental health contribute to lack of acceptance?

Part of the problem with the failure to embrace mental illness is the fact that the public does not visualize themselves in the shoes of the mentally ill. The general public is not accurately informed of the daily struggles, obstacles, or level of functioning in these individuals. Public health practitioners need to further observe these individuals and take the time to understand their feelings and struggles that cause them to engage in negative behaviors or withdraw from society.

The theories of humanist psychologists Carl Rogers and Abraham Maslow explain the behavioral consequences when human beings feel a lack of acceptance. Their theories emphasize human needs one must satisfy to become a whole and adjusted individual (Carver & Scheier, 2000). Rogers believed that there is potential healthy growth in every living creature called self-actualization if there are no strong opposing influences inhibiting one’s potential. If one can maintain self-actualization, it enhances the self towards congruence and minimizes disorganization or incongruence (Carver & Scheier, 2000). This theory encompasses the belief that all individuals have the need for “positive regard”, or love, friendship, and support of others. (Carver & Scheier, 2000). Abraham Maslow elaborated on Rogers’s ideas to form his theory of the hierarchy of needs. The theory implies that all humans have a hierarchy of needs beginning at the most basic level of physiological needs such as food, air, and water leading to the need for self-actualization as the highest level of needs (Carver & Scheir, 2000). Similar to Roger’s positive regard, the third level of the hierarchy is love and belongingness including companionship and acceptance from others. If individuals fail to master the need for love and belongingness, they can’t reach the self-actualizing level of acceptance of self and others and this can result in a breakdown of the unity of self or anxiety.

Although the theories of Rogers and Maslow are merely conceptual and fail to explain all aspects of behavior or behavioral intentions, they both reinforce the idea that acceptance, love, and support from others are crucial for individuals to live healthy and well-adjusted lives. If the mentally ill can’t find love and acceptance or “positive regard”, they are left with only satisfying the most basic needs. Therefore, the failure of public health to embrace mental health contributes to a lack of acceptance, which prevents mentally ill individuals from living healthy lives with strong social support systems.

How does lack of acceptance contribute to decreased access to treatment?

The lack of acceptance of mentally ill individuals has led to barriers for these individuals to access medical care (Kessler et al., 2005; Druss & Rosenheck, 1998; Druss et al., 1998). Druss and Rosenheck (1998) found that the rates of those uninsured or having a primary care provider were the same between those with and without a mental illness, but those with a mental illness were twice as likely to report being denied insurance because of preexisting condition or having stayed in their job for fear of losing their health benefits. Thus, many mentally ill individuals feel they are denied insurance because of their condition. If individuals with a mental illness are unable to obtain love and acceptance, it is logical that they will fail to take the initiative to access medical care. If these individuals felt more fulfilled, congruent, and like equal members of society (i.e. more at ease at their place of employment), they may feel more comfortable and trusting accessing the medical health system. Although researching the access to medical care is of paramount importance, it does not explain why mental health is not embraced. We must first understand the contextual risk factors for why mentally ill individuals continue to engage in what society labels as irrational behavior. If mentally ill individuals feel accepted without a low self-esteem or self-worth, they may be more willing to access care with trust.

Failure to Embrace Mental Health Enhances Stigma Among Individuals with Mental Illness

How does the failure to embrace mental health contribute to increased stigma associated with mental illness?

The failure of public health to embrace mental health has contributed to discrimination and stigma of the mentally ill by their family members and friends, which is largely a reflection of how mental illness is portrayed through mediums such as the media. This continued discrimination is a reflection of the failure by public health practitioners to educate the public. Each culture and society has “norms” or rules of expected or proper behavior (Myers, 2002). These norms are a reflection of how we have been raised and socialized as members of society. Along with social norms is often labeling which leads to stigma and stigma results in stereotypes and often prejudice. The public views mental illness as sign of weakness (Corrigan, 2004). If society creates the label that the mentally ill are weak, it is easy for these individuals to internalize this message and behave according to the norm. In other words, once individuals are labeled, they may identify with the negativity associated with the label (Barlow & Durand, 2000). Human beings should never be affiliated with labels such as “dangerous”, “worthless”, or “dirty”. In order to embrace the mentally ill, public health practitioners must analyze how we can alter our negative social norms.

The failure of public health to embrace mental health has also led to increased stigma from friends and family of the mentally ill. As a result, these individuals feel alienated with a reduced social support networks (Byrne, 2000). Therefore, there is a public stigma of mental illness, which can perpetuate a self-stigma. Public health practitioners have failed to reach the families of the mentally ill to understand how they are torn by the social norms cast by society and their feelings for their loved ones. How are less informed members of society going to change their opinions of mental illness if family members and friends of individuals with a mental illness often feel ashamed of their loved ones? Education will be necessary to erase labels and stereotypes and change social norms.

What is the primary source for mental illness information? Media attention and portrayal of mental illness is largely responsible for why the world has adopted negative associations with the mentally ill and why public health practitioners have not embraced it. Walh (2003) found that in newspapers, the most common source of information about the mentally ill, the numbers of negative stories greatly outnumbered the positive stories. Other research discovered that mentally ill individuals are typically portrayed as violent, a seductress, maniac, or narcissistic parasite (Hyler et al., 1991; Diefenbach, 1996). It is undeniable that the media has extreme power and influence over the opinions of society and for many individuals, television and magazines are their only resources of gaining insight about public health information. The research of public health practitioners is where the media extracts their information. Therefore, the media has a great responsibility to alter their portrayal of the mentally ill as weak and dangerous. Public health practitioners must provide the media with anti-stigma research and effective modes of positively viewing the mentally ill, which they have failed to do. If we can’t change the prejudice and negative behavior of society, we can’t positively change the behavior in mentally ill individuals.

How does increased stigma of mental illness contribute to decreased access to treatment?

As a result of the stigma and discrimination attached to mental illness, the mentally ill often choose not access medical care treatment. Due to negative labels, many mentally ill individuals choose to lead lives of secrecy. Both the public stigma and resulting discrimination (i.e. “I don’t want to work with them”) and self-stigma (i.e. low self esteem, low self-efficacy, shame) contribute to the mentally ill avoiding treatment (Corrigan, 2004).

In order to increase the comfort of the mentally ill to access treatment, public health practitioners need to focus on the positive aspects that mentally ill individuals can contribute to society. Although research is controversial and results are mixed, studies suggest there is a link between mental illness and creativity (Waddell, 1998; Andreasen, 1987). The media and public health practitioners have failed to reach Americans with this message. What about the people with mental illnesses who work for the government, teach at universities, or have won humanitarian prizes? We need to change our outlook and cognitive schema by erasing misconception of mental illness and educate individuals that mentally ill individuals should not be thought of as violent, dangerous, and inferior members of society. By continuing to portray the mentally ill in a negative light, we are only continuing to support the misconception of this stigmatized population and preventing them from seeking treatment.

Increased stigma and decreased treatment are also a reflection of the failure of public health practitioners to educate society about mental illness (Byrne, 2000; Corrigan, 2004). Students should learn about the discrimination of mental illness from youth. If kids or adolescents are not taught the truth about mental illness, their only perceptions are created and distorted through the media. Public health practitioners need to institute the need for education and information about mental illness, so from youth, children and adolescents can obtain a realistic perspective of mental illness. If society is well educated about mental illness it could reduce stigma, and reducing stigma may increase the number of mentally ill individuals willing to access treatment (Corrigan, 2004).

Conclusion

Not to dismiss the importance of focusing public health on physical disease, but the society’s ignorance of mental health and the neglect of public practitioners to address mental health because of the stigma and negative views of society is unacceptable. As human beings, we have lost a sense of altruism and with our neglect of the mentally ill; we have chosen to keep them alienated and labeled inferior simply because society fails to re-shape the image of mental illness. Research focuses on individual risks such as access to mental health care, understanding the brain processes of the mentally ill, or analyzing specific disorders. Although, these are all extremely important contributions to understanding mental health, the problem exists on a much larger scale. The failure of public health to embrace mental health has contributed to the stigma and lack of acceptance associated with mentally ill individuals which results in barriers to necessary treatment. Therefore, public health is exacerbating the mental health crisis by failing to embrace it.

First, we must embrace the individuals who have these disorders. We need to reach out to them and attempt to understand their feelings. They deserve the belongingness and support to feel like integrated and competent individuals. Public health practitioners need to immerse themselves into the community to observe these individuals and learn how they live, what they feel, and why their behaviors prevent them from living healthy lives. Then we can have a better understanding in order to successfully educate society and realistically and positively portray these individuals. We must change the negative attitudes and behaviors of society. We must re-define our social norms for the mentally ill and advocate this change with a positive portrayal through the media. Public practitioners should change their focus on individual risk factors of mental illness and start viewing it as a problem that must encompass social sciences in order to promote health initiatives and efficient and effective intervention strategies. Improving access to mental health will help individuals to seek to healthier lifestyles, but we have to analyze why these individuals choose not to access the care even when they possess the means.

Public health needs to change at the structural level. Health departments should have divisions specifically for mental health awareness and prevention. We must look at improvement of the mental health crisis as societal problem with environmental factors. These divisions can specifically monitor the barriers to improving the health of the mentally ill at the societal level, not just at the individual level. It would be the responsibility of these divisions to educate society on the truth about mental illness and help erase stigma and negative labeling. With structural divisions like this in place working effortlessly to improve mental health at the societal level with the same drive as chronic physical or infectious diseases, we can begin the war on mental illness.

The mentally ill have the right to live healthy lives. Although public health practitioners have their work cut out for them, change is not beyond our reach. However, if public health practitioners continue to fail to embrace public health, a large portion of society will remain stigmatized and unhealthy, which affects the overall health of society.

References

Andreasen, N. C. (1987). Creativity and mental illness: prevalence rates in writers and their first-degree relatives. American Journal of Psychiatry, 144, 1288-1292.

Barlow, D. H., & Durand, V. M. (2002). Abnormal Psychology. (3rd. ed.). California:
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Byrne, P. (2000). Stigma of mental illness and ways of diminishing it, Advances in Psychiatric Treatment, 6, 65-72.

Carver, C. S. & Scheier, M. F. (2000). Perspectives on personality. (4th ed.). Boston: Allyn and Bacon.

Centers for Disease Control and Prevention. (2005). The role of public health in mental health promotion. (MMWR, 24, 841-842). Washington, DC: U.S. Government Printing Office.

Corrigan, P. (2004). How stigma interferes with mental health care, American Psychological Association, 7, 614-625.

Diefenbach, D. L. (1998). The portrayal of mental illness on prime-time television. Journal of Community Psychology, 25, 289-302.

Druss, B. G. & Rosenheck, R. A. (1998). Mental disorders and access to medical care in the United States. American Journal of Psychiatry, 155, 1775-1777.

Druss, B. G., Harris, M.A. Jr,, & Bruce, M. L. (1998). Physical health, depressive symptoms, and managed care enrolment. American Journal of Psychiatry, 155, 878-882.

Hyler, S. E., Gabbard, G. O., & Schneider, I. (1991). Homicidal maniacs and narcissistic parasites: Stigmatization of mentally ill persons in the movies. American Psychiatric Association, 42, 1044-1048.

Kessler, R. C., Demler, O., Frank, R. G., Olfson, M., Pincus, H. A., Walters, E. E., Wang, P., Wells, K. B., & Zaslavsky, A. M. (2005). Prevalence and treatment of mental disorders, 1990 to 2003. The New England Journal of Medicine, 352, 2515-2523.

Myers, D. (2002). Social psychology. (7th ed.). Boston: McGraw-Hill.

Osborn, D. P. J. (2001). The poor health of people with mental illness. Western Journal of Medicine, 175, 329-332.

Wahl, O. F. (2003). News media portrayal of mental illness. American Behavioral Sciences, 46, 1594-1600

Waddell, C. (1998). Creativity and mental illness: Is there are link? Canadian Journal of Psychiatry, 43, 166-172.

The Role of Cultural Health Beliefs in Public Health Practice: What the Health Belief Model Isn’t Telling Us– Jessica J. Harvill

Introduction

The topic for the December 2004 volume of the American Journal of Public Health was “Health Disparities: The Importance of Culture and Health Communication” (Thomas, 2004). In the Editor’s Choice opening section, Stephen B. Thomas, PhD, from the Centre for Minority Health at the Graduate School of Public Health from the University of Pittsburgh decries “Efforts to eliminate health disparities must be informed by the influence of culture on the attitudes, beliefs, and practices of not only minority populations but also public health policymakers and the health professionals responsible for the delivery of medical services and public health interventions designed to close the health gap” (Thomas, 2004). And yet, despite this impassioned cry for consideration to be given to cultural health beliefs and the medical practices that arise from those beliefs there has still been little consideration given to the role of culture and of acculturation when it comes to actually designing public health theoretical models (Abraido-Lanza, 2006). Instead, models of health behaviour such as the Health Belief Model (HBM) remain the cornerstone of public health theory.

I challenge that the Health Belief Model does not give enough cultural consideration to public health practices and interventions. In addition, the HBM does not give enough credence to traditional medical and alternative medical practices that 34% of the adults in the United States currently utilize (Astin, 1998). Rather, it focuses on aspects of health promotion such as “perceived susceptibility”, “perceived severity”, and “perceived benefits” (Rothman, 2006), totally disregarding the fact that in surveys about traditional and alternative medicine usage, most respondents reply that they use those therapies over traditional medical ones because they feel more comfortable with the alternative therapies, and can have more control to personalize their therapies (Park, 2002), reasons that can not be placed within the categories of health determination found in the HBM.

In a 1998 study on the relationship between traditional/alternative treatment use and medical treatments, it was found that “negative attitude towards or experiences with conventional medicine were not predictive of alternative health care use” (Astin, 1998) and that “the majority of alternative medicine users appear to be doing so not so much as a result of being dissatisfied with conventional medicine but largely because they find these health care alternatives to be more congruent with their own values, beliefs and philosophical orientations towards health and life” (Astin, 1998). This implies that people are not turning to alternative medical interventions as a desired alternative to western medical treatments, but instead are using them in a combined, hopefully complimentary fashion. This holistic health paradigm does not have a place in the HBM and similar public health theories, and that fact is providing a disservice to ethnic minorities and traditional medical practitioners, as well as to the public health professionals that are attempting to serve them. As seen in the three case examinations below, the HBM does not do enough to legitimately consider alternative health beliefs, especially those related to traditional and alternative medical practices. It is up to current and upcoming public health professionals to acknowledge and consider these limitations, and to work on designing a new theory of health behaviour that better suites the needs of all the people that those in the public health profession serve.

Case 1: Health Beliefs and Home Remedies Among African Americans
In a 2004 study, Becker et al. found that 70% of African Americans reported at their family had utilized home remedies at some point (Becker et al., 2004). Further observation found that home remedies and self-care “develop[ed] throughout the life course, and that such behaviour varies according to an individual’s group affiliation in habits, beliefs, and practices that constitute a cultural way of life” (Becker et al., 2004). Yet, despite these figures, the HBM gives no consideration to these home remedies and they role they play in the overall health paradigm of many African Americans.

Another example of this can be found in analyses of the cultural dimensions of high blood pressure in African Americans. On average, African American males have higher arterial blood pressure than whites, even adjusting for age, socioeconomic status, and access to healthcare (Dressler and Bindon, 2000). Yet, despite these numbers, most public health interventions geared towards African Americans focus on the same behaviour changes as interventions gears towards other primary ethnic groups found in the US. These interventions continue to focus solely on biological aspects of health, such as diet and exercise, without considering crucial cultural aspects, such as the fact that the role of extended family and social support is much more important in African American communities than generally found in white communities with similar socioeconomic backgrounds (Dressler and Bindon, 2000). Anthropological studies on health consequences and cultural consonance in African American communities have shown that “the degree to which an individual is able to approximate in his or her own behaviour the cultural models for the domains of lifestyle and social support” (Dressler and Bindon, 2000) is directly correlated to improvements in overall cardiovascular health, as measured by blood pressure. These cultural factors, independent of the more medically-driven interventions often found in public health, have been shown to help improve health in a demographic that has been continuously shown to be under-served by the public health and medical communities. And yet, public health theories such as the HBM still do not allow for fact that health can be directly correlated to cultural factors, as well as to biologic ones.


Case 2: Traditional Health Beliefs and Ethnomedicine among the Hmong
Like many eastern societies, the Hmong place a particular emphasis on familial relationships. Family groups are generally large with the oldest man serving as the head of the patrilineal/patrilocal household (a wife will change her allegiance to her husband’s male ancestors). In the term of medical care, the patient and immediate family will all have a say, but the final decision for both diagnosis and treatment will come from the head of the household (Rairdan and Higgs, 1992). This group dynamic of medical decision making is an integral part of many Hmong families, but it is something that is given little consideration to in the HBM, which puts great stock in the idea of ‘self-efficacy’, or the belief that an individual must have a belief in their own capabilities in order to institute behavioural changes (Rothman, 2006). In a culture which places greater emphasis on the importance of the group, or family, than the individual, a theory of health behaviour that focuses on the individual and the individual’s ability to motivate him or herself would not effectively communicate desired health behaviours to the target individual.

Another factor which can affect the applicability of aspects of the health belief model such as perceived susceptibility and cues to action is the differences in communication found between the west and traditional Hmong culture. For many Hmong, respect is an important sociocultural factor and age, education and authority all define how Hmong interact with each other and with public health workers. Communication should be formal, and any sense of informality or casual attitude is considered very rude, especially if the person to whom one is conversing is elderly (Raridan, 1992). This can cause complications in communication because it is also considered very impolite to disagree with someone, especially if they are of higher status then yourself. This often results in a positive response to any query or question. For example, is it possible that when asked a question such as “do you think you are likely to contract this disease” or “do you regularly visit a physician for health check-ups” it would be culturally appropriate for a Hmong to reply in the affirmative. Unlike western communication norms this positive response is not considered agreement, but rather acknowledgement that they have heard what was being communicated (Rairdan and Higgs, 1992). A public health worker without knowledge of the cultural implications of these responses may believe that they have managed to engage the Hmong person in a health promotion program, when in fact they were just acknowledging that the public health worker was speaking to them.

The conduction of invasive medical tests, especially those that involve the collection of body fluids, are also a major point of conflict between Hmong patients and western medical practitioners. Hmong beliefs state that there is a finite level of blood available, and that if any is extracted from the body it can never be replaced (Fadiman, 1997, Raridan, 1992, Westmeyer, 1988). Because of this, excessive or unnecessary medical tests should be avoided if at all possible. Many Hmong living in the United States have had enough interactions with western medicine to adapt to their practices, and most will consent to a blood draw if necessary. It is important that the purpose for each test and how that purpose relates to the immediate physical symptoms be explained to the patient in order to obtain consent for the blood or fluid draw. This belief is such an integral part of some Hmong’s spiritual and personal beliefs that it would be culturally incompetent and ethically wrong for a public health professional to dismiss them as irrational or inconsequential to public health practice. Instead, against health belief model’s notion of perceived barriers, public health practitioners should focus on health communication models that allow for cultural flexibility and conservative determination of invasive medical practices. For example, if working on a program for early diabetes detection, the emphasis should be on working with the healthcare providers to draw the minimum amount of blood necessary for accurate testing and work on developing programs of clear communication telling exactly how much blood will be drawn and for what purposes the drawn blood will be used, more than on dissuading Hmong believers that their cultural considerations don’t have a role in the western healthcare system.

By not acknowledging the important role of culture of medicine, the HBM is missing many of these important considerations that public health providers should be aware of when designing, implementing, and evaluating public health interventions. Utilizing a public health policy that takes into consideration cultural competency, ethnomedical practices, and that accepts variations in health culture is a public health approach which can be vital to improving health disparities seen amongst many ethnic minority groups in the US. The lack of consideration given to these points of views in conventional public health theory is not only a disservice to the population that we as public health workers are trying to serve, but harmful to us as a profession by promoting a legacy of arrogance and insensitivity.

Case 3: Health Culture and Treatment Compliance Among Vietnamese Refugees
Like recent Hmong immigrant, many Vietnamese new to the United States and other Western countries find themselves operating within an entirely different health paradigm than they are used to. Key differences in health interpretations between many recent Vietnamese immigrants and the western public health community can include the cultural interpretation of diseases and therapies as ‘hot’ or ‘cold’, the role of family members in encouraging or discouraging initiation of and compliance with western medical care (like the Hmong, most if not all decisions will ultimately be made by the head of the household, and not necessarily the patient or targeted person), and the community perception of the disease and/or treatment (Ito, 1999).

These key differences in the perception of health and wellness can make it difficult for public health officials to not only communicate their own health goals, but to understand the current health practices of the population that they are wishing to intervene in. One public health study on TB beliefs among recent Vietnamese immigrants concluded that there was little or no use of traditional medicine for the disease (Carey et al. 1997), but did not take into consideration that it would have been considered very rude to mention any traditional medicines that were being used to treat the illness to a western healthcare worker. In this case, the absence of reference to traditional or alternative treatments does not necessarily negate their absence, but as the investigator was working within the health belief model, these types of considerations did not enter into their investigation or intervention strategy.

Although the use of competent medical translators can provide basic information on tuberculosis transmission and infections for those who need it, social and cultural views of disease further complicate the issue. However, where the health belief model might block these cultural views as perceived barriers that need to be changed, a culturally sensitive interpretation shows how a competent public health professional can work within the health belief systems of the Vietnamese population to design and implement programs that can communicate the importance of using and adhering to western treatment regimes, while at the same time allowing for traditional treatments that meet other physical, mental, and cultural needs of the target population.

Discussion
As seen in Case 1, too often when public health professional think of alternative and traditional medicine, they do not consider the cultural implications of the healthcare treatments. Instead they focus on scaring, threatening, and blackmailing people into participating in specific health behaviours within the western medical paradigm. Theories such as the HBM consider culture only as an avenue of communication to help ‘convince’ people with alternative belief systems to participate in the health behaviour that they are promoting, without exploring other, more culturally sensitive methods, of achieving the same health behaviour. This approach is seen not only when dealing with groups that are recent immigrants to the US, but in groups that have a long history within the US and a high level of acculturalization, such as African Americans.

The United States currently has a population of approximately 200,000 Hmong people, primarily concentrated in several dozen communities across the country (Fadiman, 1997). As with many groups, minority ethnic people immigrate to new countries and they bring their traditional ways of life with them, including cultural traditions, kin relationships and medical practices. As seen in Case 2, in the case of the Hmong these traditional beliefs vary, in some cases greatly, from the western norm, and there can be a steep learning curve of acculturation especially for individuals who immigrate to western countries in adulthood. These cultural factors can have a large influence on health behaviour and “acculturation may affect health behaviours as a consequence of coping responses to discrimination and poverty: loss of social networks; exposure to different models of health behaviour, and changes in identity, behavioural; and chances in identity, behavioural prescriptions, beliefs, values, or norms” (Abriado-Lanza, 2006). By examining these traditional health practices in comparison to western medical practices and common public health interventions, it is possible to explore how certain aspects of the HBM fail to give proper consideration to culturally imperative health practices and how this lack of consideration results in health disparities amongst immigrant communities.
The notion of perceived susceptibility, or of whether or not an individual feels like they are likely to get a disease, is one of the key concepts of the Health Belief Model (Rothman, 2006). An example of this was found in Case 3 and its examination of perceptions of tuberculosis in recent Vietnamese immigrants. A common illustration of this concept is the statement ‘I’m not gay, so why should I worry about HIV?’ In a case such as this, the traditional intervention would be the development of an education program which explains the many methods of HIV transmission, and how all people who engage in ‘risky behaviours’ have the potential to get the disease, not just those who are gay, or who are junkies. Although this is a good start, when dealing with sociocultural beliefs and interpretation of health and disease, lack of education is not the issue. Instead, it is the “health culture or sociocultural context in which the patient is immersed and how it affects his or her interpretations of the origins and meanings of disease and decisions about compliance or non-compliance with medical treatments” (Ito, 1999) that has the greatest influence on perceived susceptibility.

As all three cases show, the HBM is negligent in a vital area of public health practice: the role of culture on health and healthcare. Instead of relying on the HBM’s narrow views of health and health communication, public health practitioners need to being developing and implementing public health theories and approaches that consider a more holistic approach to health, disease, and communication: approaches that give culture the consideration that it deserves.

Conclusions
Changing US demographics lend need to public health theories that broaden the HBM to incorporate other, non-traditional cultural medical approaches. Although individual public health practitioners have called to integrate cultural sensitivity and public health practice, there has been very little reflection of this call seen in public health theory. Old standbys such as the Health Belief Model continue to disregard the high level of usage of traditional and alternative health practices in the communities which it is supposed to be serving, encouraging public health professionals to develop attitudes where the goal is to communicate around traditional health beliefs, rather than work with those beliefs to develop a holistic health paradigm for ethnic minorities and other people who do not totally ascribe to the western healthcare system. As the three cases examined above show, the health belief model and similar theories are not serving the health needs of, and is even alienating, large chunks of the American public. It is up to public health professionals to research, develop, test, and implement culturally considerate theories of public health belief.

Works Cited

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Astin, John A. Why Patients Use Alternative Medicine: Results of a National Study. JAMA 1998;279(19):1548-1553.

Becker, Gay, Rahima Jan Gates, and Edwina Newsom Self-Care Among Chronically Ill African Americas: Culture, Health Disparities, and Health Insurance Status. AJPH 2004; 94(12): 2066-2073.

Bodeker, Gerard and Fredi Kronenberg A Public Health Agenda for Traditional, Complementary, and Alternative Medicine. AJPH 2002; 92(10): 1582-1591.

Carey, James W, Margaret J. Oxtoby, Lien Pham Nguyen, Von Hunh, Mark Morgan, and Marva Jeffery Tuberculosis Beliefs Among Recent Vietnamese Refugees in New York State. Public Health Reports 1997; 112:66-72.

Dressler, William W. and James R. Bindon The Health Concequences of Cultural Consonance: Cultural Dimenions of Lifestyle, Social Support, and Arterial Blood Pressure in an African American Community. Am Anthropologist 2000; 102(2): 244-260.

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The Failure of the Dietary Guidelines to Promote the Health of a Culturally Diverse America: An Abandonment of Social Science Principles-Rebecca Bokat

The Dietary Guidelines for Americans were first published in 1980 following the Senate Select Committee on Nutrition and Human Needs Dietary Goals, in order to combat the increased incidence of overweight, obesity, and chronic diseases that were the result of a poor diet and sedentary lifestyle (1). Despite the establishment and periodic revision of the Dietary Guidelines for Americans, the prevalence of obesity has doubled over the past three decades and continues to increase in the United States (2). Obesity is costly to society because it is associated with chronic diseases including cardiovascular disease, type II diabetes, hypertension, stroke, dyslipidemia, osteoarthritis, selected cancers, gallbladder disease, sleep-breathing disorders, musculoskeletal disorders, and all-cause mortality (3). The rate of obesity in the United States follows a socioeconomic gradient, such that the burden of disease falls disproportionately on people with limited resources, racial and ethnic minorities, and the poor (3). The goals of the Dietary Guidelines to promote the health of Americans and to reduce their risk for major chronic diseases has not been realized because the Guidelines rely solely on scientific evidence and fail to take into account basic behavioral and social science principals. In order to design an effective strategy to combat the obesity epidemic and meet the needs of a multicultural and dynamic population, the cultural, economic, and social differences among Americans must be taken into account.

The homogenous approach to nutrition recommendations reflected by the Dietary Guidelines for Americans fails to take into account the increasingly heterogeneous US population. Census data demonstrate an increase in diverse racial and ethnic groups in the United States from approximately one-fourth to one-third of the population, and this trend is expected to continue, such that by the year 2030, minority groups will account for forty percent of the total population (3). Given that African Americans are the second largest ethnic minority group in the country and that this population has a higher prevalence of obesity and weight-related diseases than the general US population, extensive research has been conducted on the eating practices of African Americans. Research has indicated that the dietary habits, food choices, and cooking methods unique to African Americans evolved from a long history of slavery, persecution, and segregation (5). The slaves who were brought to the US combined their West African cooking methods with those of the British, Spanish, and Native American techniques to produce a distinctive African American cuisine known as ‘soul food’ (5). Soul food emphasizes fried, roasted, and boiled food dishes using primarily chicken with the skin left intact, pork, pork fat, organ meats, sweet potatoes, corn, and green leafy vegetables (4). As a result of the high intake of deep fried foods, eating chicken with the skin, not trimming fats from meat, seasoning vegetables with fat and meat, and reusing oils, fats and grease to flavor foods, the traditional African American diet tends to be low in fiber, high in sodium, nitrates, sugar, fat and/or cholesterol (5). These dietary practices continue to persist despite their health implications because long-term beliefs, attitudes, and behaviors among the African American community have been handed down across generations. Subsequently, healthful eating is viewed as an abandonment of tradition and culture and is perceived as conforming to the dominant culture. Mexican Americans are a second minority group that is becoming a fast growing segment of the American population, and like African Americans, dietary practices and nutrition related behaviors are culturally defined and established early in life. A collaborative research study conducted by the CDC’s Division of Nutrition and Physical Activity found that the dietary practices typical of Mexican American families included eating traditional Mexican food that is high in fat and starch and low in vegetables (6). This study also discovered that young African Americans and Mexican Americans have different perceptions about healthy and unhealthy weight compared with whites (6). Specifically, a person who is overweight is considered to be well-nourished or “full figured” in the African American and Mexican American cultures. The Dietary Guidelines for Americans are not culturally relevant or sensitive to the dietary practices and food-related behaviors of the diversity of ethnic and racial minorities that represent large segments of the American population. The Dietary Guidelines, which are based on the medical model and view food as being therapeutically valuable, isolate food from the cultural context of eating and therefore has limited effectiveness with many minority groups.

The Dietary Guidelines for Americans 2005 recommends nine servings per day of a variety fruits and vegetables and three cups of reduced fat or fat-free milk or other dairy products for the reference 2,000 calorie level (7). However, the Guidelines do not take into account the limited availability and high cost of fruits, vegetables, and reduced fat dairy products and the greater availability and lower costs of high-fat foods in impoverished urban neighborhoods. These low income neighborhoods have a disproportionately higher number of racial and ethnic minority populations, particularly Hispanic and non-Hispanic blacks (8). The limited access and higher cost of healthier foods in poorer urban neighborhoods is a direct result of the migration of supermarkets to the suburbs, leaving low-income shoppers who do not have access to private transportation at the mercy of high priced convenience stores and local grocery stores (5). Convenience stores, also known as bodegas, and local grocery stores that serve poorer inner city neighborhoods have limited inventories and usually do not stock large amounts of perishable foods (5). In the Bedford-Stuyvesant neighborhood of Brooklyn, only 21 percent of the bodegas offered apples, oranges and bananas; leafy green vegetables were found in only 6 percent of the bodegas; and only one in three bodegas sold reduced-fat milk (9). A study that tracked the availability of diet soda, low-fat or fat-free milk, high-fiber bread, fresh fruit and fresh vegetables in food stores in East Harlem and the Upper East Side found that stores on the Upper East Side were more than three times as likely than the stores in East Harlem to stock all five of the aforementioned items, despite the fact that East Harlem had more than twice as many food stores per capita as the Upper East Side (10). East Harlem is around 90 percent Hispanic and black (10). Even if healthy food is available in these types of neighborhoods, local convenience and grocery stores often charge more for it than supermarkets (9). In the Bedford-Stuyvesant neighborhood of Brooklyn, the average cost of a gallon of milk was 79 cents higher in the Bodega than in a supermarket (9). Although there is limited access to healthier food options in most of these low-income neighborhoods, there is a greater availability of inexpensive, high-fat foods. A recent geographical analysis determined that predominantly black neighborhoods have 2.4 fast-food restaurants per square mile, compared to 1.5 such restaurants in predominantly white neighborhoods (3). On Third Avenue in East Harlem, a banner outside McDonald’s advertises a $1 menu, while down the street a KFC sign boasts that you can “Feed Your Family for Under $4 each (10)”. Foods that are energy-dense and highly palatable, like fast-food and potato chips, sodas, and doughnuts available at bodegas, are associated with diminished feelings of satiety and the over consumption of fats and sweets, leading to increased energy intakes (3). Research focusing on the availability and cost of foods in impoverished urban neighborhoods has concluded that neighborhood differences may account in part for health disparities that have a dietary component (5).

The Dietary Guidelines for Americans blindly assumes that provided with nutrition information, consumers will make the appropriate changes in their eating habits and lifestyles. The DGAs view individual level behavior change separate from the social context of eating, which research has shown influences all aspects of eating patterns. Social connections satisfy one of the fundamental human needs of belonging identified by psychologist Abraham Maslow in his Hierarchy of Needs (11). Humans need to feel belonging and acceptance whether it comes from large social groups or small social connections (11). Individuals have a need to belong to a social group and eating certain foods from one’s cultural group is a way of staying connected to that group. Research through focus group interviews has shown that minority groups, particularly African-American and Hispanic populations, report that eating healthfully is perceived as giving up part of their cultural heritage and trying to conform to the dominant culture (5). Individuals may consciously or unconsciously participate in culturally defined eating patterns in order to maintain group identity (5). A resident of Spanish Harlem was quoted as saying that people in his neighborhood “associate diet as unhealthy. If you’re dieting, then you’re sick. You look at people on the streets, they’re heavy. That’s the way we grow up here (10)”. Despite the resident’s family history of diabetes, he added that people in his community “love eating trash…we grew up eating McDonald’s and I still find myself eating candy and chocolate cake (10).” He also added that the members of his community have “cultural differences…for a guy to eat a salad, he’s a wimp. The women can’t be chumps either. A woman can eat a salad but has to eat it on the low. She has to do it quiet. They make fun of you: What are you, a rabbit (10)?”

It is evident from the obesity epidemic that is currently plaguing the nation that the Dietary Guidelines for Americans are an ineffective public health intervention. Not only are the Guidelines not reaching large segments of the American population, particularly low income ethnic minorities, but the Guidelines are not applicable and practical in the real-life setting of these people’s lives. The biomedical orientation of the Guidelines limit their effectiveness with lower-income minority groups because they isolate eating behaviors from the cultural, economic, and social context in which eating patterns are developed, maintained, and passed down. The individual-level nutrition recommendations made by the Guidelines developed for the general population are not culturally relevant or specific to many minority groups residing in poor inner city neighborhoods. The Guidelines expect these population groups to practice dietary patterns that are contrary to the foods available and the dietary practices followed in their environment. An effective public health intervention to reduce obesity and the risk of chronic diseases must take these cultural, economic, and social differences into consideration; otherwise the impact of the obesity epidemic will continue to disproportionately affect people with limited resources, racial and ethnic minorities, and the poor.

References

1. Mahan, L.K., & Escott-Stump, S. (2004). Krause’s Food, Nutrition, & Diet Therapy (11th ed.). Philadelphia: Saunders.
2. Zhang, Q. & Wang, Y. (2004). Trends in the Association between Obesity and Socioeconomic Status in U.S. Adults: 1971 to 2000. Obesity Research, 12(10), 1622-1632.
3. Boyle, M.A., & Holben, D.H. (2006). Community Nutrition in Action (4th ed.) Belmont: Thomson Wadsworth.
4. Airhihenbuwa, C.O., & Kumanyika, S. (1996). Cultural Aspects of African American Eating Patterns. Ethnicity & Health, 1(3), 245-263.
5. James, D. (2004). Factors Influencing Food Choices, Dietary Intake, and Nutrition-Related Attitudes among African Americans: Application of a Culturally Sensitive Model. Ethnicity & Health, 9(4), 349-367.
6. Centers for Disease Control (2000). Executive Summary: Healthy Weight, Physical Activity, and Nutrition: Focus Group Research with African American, Mexican American, and White Youth. DNPA Physical Activity and Nutrition Adolescent Initiative.
7. U.S. Department of Health and Human Services and U.S. Department of Agriculture. Dietary Guidelines for Americans, 2005. 6th Edition, Washington, DC: U.S. Government Printing Office, January 2005.
8. Townsend, M.S. (2006). Obesity in Low-Income Communities: Prevalence, Effects, a Place to Begin. Journal of the American Dietetic Association, 106(1), 34-36.
9. Santora, M. (2006, January 20). New York Pushing Better Diet in Poorer Neighborhoods. New York Times.
10. Kleinfield, NR (2006, January 10). Living at the Epicenter of Diabetes, Defiance, and Despair. New York Times.
11. Maslow’s Hierarchy of Needs. Wikipedia: The Free Encyclopedia. Retrieved November 11, 2006, from http://en.wikipedia.org/wiki/maslow’s_hierarchy_of_needs

Abstinence is best? How this country’s ignorance to basic social science principles is ultimately endangering sexual health of youth - Melanie Steeves

Swedish teens are having sex. French and English teens are having sex. Canadian teens are having sex and not so far away… American teens are having sex! This is something we know and something we study, but not something, it would seem, that we, as a nation, are willing to accept. Instead of having open and honest discussions with the adolescents in the country around sex and reproductive care, as most other nations do, the policy in the United States has increasingly been to preach abstinence and pretend the phenomena does not exist. In fact, while there are 3 federal programs dedicated to funding abstinence-only education, there is not one program funded federally that promotes comprehensive sex education policies. (Dailard, 2002)
In terms of statistics, the United States performs poorly on all measures of adolescent sexual health when compared to other developed countries around the world. Teens are disproportionately affected by sexually transmitted infections (STIs). While adolescents aged 15-24 account for 25% of the sexually active population in the United States, nearly half of new STIs occur among this same age group. Teen pregnancy and abortion rates in this country are far higher than those in other nations as well. (Alan Guttmacher Institute fact sheet, http://www.guttmacher.org/pubs/fb_ATSRH.html).

Research has shown that teens are having sex regardless of the type of sex education they receive and that they greatly benefit from having the necessary information to negotiate a healthy and safe sexual relationship. (Kirby, 2001) This essay accepts and supports that view, and moreover, intends to review specific social science principles to illustrate why an abstinence-only approach, when combined with adolescence, may be a recipe for disaster.

Rebellion and establishing a sense of self

Adolescence is a period of physical and mental growth. It is a time when teenagers must navigate their way through the mastery of many developmental tasks. According to the Psychological Basis of Psychiatry, these tasks include establishing a defined sense of self, developing peer groups, cultivating autonomy and separation from family, and preparing for intimate relationships. (Thambirajah, 2005) In fact, Erik Erikson’s theory of psychosocial development postulates that the central goal of adolescence is to establish a defined ego identity. (Thambirajah, 2005) Rebellion is a natural part of this development. Teens push against authority and their parents as a way of establishing their autonomy and their own sense of self. Smoking, ignoring curfews and parental rules, and acting out in school are all ways that teenagers assert their independence.

By teaching abstinence-only sex education and discouraging adolescents from having sex, we may be creating an area where teens can rebel against authority and assert their independence. Adolescents may come to see sex as a forbidden fruit and therefore be more likely to engage in sex acts. If instead, we had frank conversations about sex, they may be less likely to see out sex as a form of rebellion. If sex were normalized in the home and in schools, teens would have no means to push against authority in this area. Instead, they would be able to partake in intimate relationship when they were ready, with the tools and self-efficacy needed to engage in a healthy sexual interaction.

Creating cognitive dissonance

Cognitive dissonance is simply defined as the inner tension one feels when one holds two conflicting viewpoints, or when one’s behavior does not match one’s inner morals or beliefs. The theory suggests that an individual will alter their beliefs or behavior to relieve this inner tension, sometimes by irrational means. (Thambirarajah, 2005)

As an example, in a Florida study concerning the impacts of cognitive dissonance, adolescents were put into two groups and read preventative, public health messages that either totally opposed consuming an alcohol-like substance or recommended using moderation in consumption. Half of the subjects then tried the product while the other half performed a random task. The two messages had the same effect amongst the teens who had not tried the product. Interestingly though, participants receiving the abstinence message who also tried the product expressed stronger intentions to use the product than did those who had received the message urging moderation, perhaps to alleviate some of their feelings of inner tension over the conflicting message and their subsequent behavior. (Albarracin, 2003)

Keeping this study in mind, students involved in abstinence-only sex education classes who already have sex may forgo barrier methods such as condoms, to help relieve the cognitive dissonance they feel. That is, because they have been taught they should not have sex, they may deny to themselves that what they are engaging in is a sexual act and they may believe that they, therefore, do not need protection. Comprehensive sex education, on the other hand, acknowledges that teens may be having sex and aims to provide the tools necessary to engage in healthy and safe sexual relationships thus alleviating any threat for cognitive dissonance.

Influence of peer groups

Adolescence is a time when young people are forming their self-concepts largely through their peer groups and experiences. They tend to define themselves in relation to the company they keep, their clique, gang, sports team, etc. Peers operate as guides through an individual’s social world; peers provide the information, rules, and emotional support teens need to separate from their families and move toward independence. (Thambirajah, 2005) As we continue to push abstinence on teens we must realize that we may be alienating many groups of teens and hence, countless numbers of the teenagers we are trying to protect.
As we increase the number of programs geared towards abstinence-only sex education, we need to understand that this message essentially excludes a huge number of adolescents and peer groups. Most teenagers will have sex before they leave high school, an estimated 7 in 10 teens to be exact. (Guttmacher, 2006) Those adolescents who have already had sex will not see how an abstinence-only message applies to them. Additionally, those teens who have not had sex, but who belong to a peer group where sexual experience is normalized will most likely tune out the teachings. Also, the gay and lesbian community may not identify with the wait-until-marriage message, as they are not permitted to marry in nearly all states, and therefore believe that the idea to abstain does not apply to them.

By teaching such a black and white form of sexuality education we are alienating an estimated 70% adolescents. The message of abstinence-only sex education competes with the standards and expectations of many peer groups. In disregarding the influence that peer groups have on adolescents, we are ignoring a huge segment of the teen population and thusly not providing them with the appropriate information about their sexual health. Perhaps if we geared our safe sex messages around the standards and goals of peer groups we would have an easier time reaching out to all adolescents. By engaging student groups in their health rather than dictating appropriate forms of behavior, we could better involve all teens in their reproductive well being.

Conclusion

We know from international research that abstinence-only education may not be the best way to equip the adolescents of this country with the tools they need to protect themselves and negotiate intimate relationships. Rarely, however, do we consider why this approach may not succeed in terms of social science theories and principles. This paper was intended to illustrate how and why our reliance on abstinence has failed to improve the reproductive health of out nation’s adolescent population. The author used basic psychological principles-- cognitive dissonance, adolescents’ reliance on peer groups and adolescent development of self concept-- to highlight the potential shortcomings of our current approach and to suggest methods we could employ to work more effectively with adolescents regarding their sexual health.

References

Dailard C, Abstinence promotion and teen family planning: the misguided drive for equal funding, The Guttmacher Report on Public Policy, 2002, 5(1):1-3.

Guttmacher. Facts on American teens’ sexual and reproductive health. Alan Guttmacher Institute Website, 2006. Retrieved 11/6/06. http://www.guttmacher.org/pubs/fb_ATSRH.html

Kirby D, Emerging Answers: Research Findings on Programs to Reduce Teen Pregnancy, Washington, DC: National Campaign to Prevent Teen Pregnancy, 2001.

Thambirajah MS. Psychological Basis of Psychiatry. Elsevier Limited. 2005, 222-224, 305-311.

Albarracin D, Cohen JB, Kumkale GT. When communications collide with recipients’ actions: effects of post-message behavior on intentions to follow the message recommendations. Personality & Social Psychology Bulletin, 2003, 29(7):834-45.