Tuesday, December 19, 2006

Homophobia, Stigmatization and the AIDS Epidemic: A Psychosocial Critique of a Public Health Intervention Failure - Stephanie E. Baker

Although the rate of HIV infection had declined in the United States between the mid-1980s and the mid-1990s, evidence now suggests that the number of HIV cases, mainly due to high risk sexual practices, is on the rise (CDC. Increases in HIV diagnoses, MMWR, 2003). The current HIV epidemic disproportionately affects men who have sex with men (MSM) by afflicting nearly half a million MSM in the United States alone, a startling figure which represents nearly half of all people living with HIV and 70% of all HIV infected male adults and adolescents (CDC HIV/AIDS fact sheet: HIV/AIDS among men who have sex with men. July, 2006). One way in which public health has responded to this epidemic, through sectors ranging from governmental agencies to religious advocacy groups, is through the implementation of a “use a condom every time” intervention. Given the dire, bleak state of the epidemic, wrought with rising statistics, it is clear that this behavioral change initiative has not been successful in alleviating the problem. Explaining this public health failure using reasons such as “AIDS burnout,” which results from years of exposure to prevention messages and safer sex practices (Ostrow, D.G., Fox, K., et al., 2004), is overly simplistic and could very well lead to an abandonment of the effort to help this at-risk population. Given that public health’s main goal is to promote health, prevent disease and prolong life through organized societal efforts, it is clear that a new approach is now necessary to intervene effectively in the problem. Both in content and delivery, the public health message to “use a condom every time” to reduce the spread of HIV/AIDS through high risk sexual behavior among homosexual men has been ineffective not only through individualizing the problem, but more so, in failing to address the fundamental psychosocial effects of homophobia and stigmatization in society.

One reason why the public health intervention of “Use a condom every time” is failing to reduce high-risk sexual behavior and the spread of HIV/AIDS among homosexuals is due to the message’s emphasis on individual- level risk elimination rather than on fundamental, more deeply routed societal factors. By focusing on total risk elimination rather than a more reasonable and attainable risk reduction strategy, the message lays out unrealistic goals and essentially sets the stage for the individual to fail (Siegel, 2004). If a homosexual has already engaged in sex without using a condom, the moment he hears this message, he views himself as a failure who has already put himself at great risk for HIV or AIDS. The homosexual recipient of this message adopts the fatalistic attitude that he has nothing more to lose and thereby continues to engage in high risk sexual practices. A facet of communication theory that the message to use a condom every time does not uphold is that the message must not cause harm or be offensive to the audience by blaming the victim (McGuire, 2001). By responding to the question of “What do I do if I think I am infected with HIV?” with “Remember, you must have engaged in behaviors that place you at risk for HIV infection…. those behaviors include unprotected sexual intercourse with an infected person,” not only reiterates the point that contracting the disease is the victim’s fault, but also could be perceived as having a parental tone of disappointment and condescension (“Learn about Safer Sex,” http://members.aol.com/gayjews/safer.html). In addition, stating such an obvious fact about sex and condom use is an insult to a homosexual’s intelligence, as most all are certainly aware of the dangers unsafe sex poses. Even more detrimental than insulting homosexuals on an intellectual and emotional level, using the individual-level message to use a condom every time runs the serious risk of blaming the victim, which thereby clouds the more powerful issues of homophobia and stigmatization which need to be addressed. The underlying factors of homophobia and stigmatization in influencing high risk sexual behavior wouldn’t even cross one’s mind after reading intervention materials such as the CDC HIV/AIDS Fact Sheet (2006), which lists solely individual level factors such as “complex sexual decision making, seeking sex partners on the internet, and failure to practice safer sex,” as reasons for the current increase in unprotected anal intercourse. When developing an effective public health intervention, it is important to remember that complicated behaviors are not always simple personal choices but rather are deeply intertwined within a person’s environment, making them difficult to change on one’s own accord. In order to be effective, public health messages must recognize and respond to the influence of a stigmatizing social environment on the behavior of homosexual men and move away from focusing on the individual’s risk eliminating behaviors.

Communication theory (McGuire, 2001) has shown that utilizing a message that instills a sense of fear and dread in the audience has the exact opposite effect that it intends- it completely turns the recipient off, not only to hearing the message, but also to heading the content or advice contained within that message. The World Health Organization, which states as its main objective “the attainment of the highest possible level of health for all people,” induces this fear to a large extent not only through incessant repetition of the message to use a condom every time (eight times within a six page presentation), but also through the use of capital letters and bold font to strongly and forcefully drive the message home (http://w3.whosea.org/LinkFiles/Flip_chart_14_condoms.ppt.) Inducing fear without providing a way to alleviate such fear or anxiety could lead some homosexual men to engage in unprotected sex more frequently and more often than they would have prior to hearing this message. Admonishing a homosexual to use a condom every time could be perceived as a warning that his sexual partner could very well have HIV/AIDS already, so therefore wearing a condom each and every time for protection is an absolute necessity. In a public health message geared toward homosexual orthodox Jews, the very first sentence states, “Many people think that they won’t get AIDS, but anyone who in engages in sexual behavior with a person infected with HIV can get AIDS” (“Learn about Safer Sex,” http://members.aol.com/gayjews/safer.html). For some homosexuals, this statement could form the fatalistic mindset that the risk of contracting HIV is so great, that they are bound to contract the disease at some point in their life anyway, regardless of how much protection they use and how often they use it. In addition, by bluntly stating that there virtually is no way to tell if the person they are dating has been infected with HIV, and by highlighting the fact that even condom use isn’t fool proof (“…on rare occasions, they can break”), this message heightens the level of fear that it has already begun to convey and leaves the recipient hopeless and understandably confused. Perhaps if a message is conveyed that utilizes softer tactics and provides realistic information which alleviates, rather than induces, fear, the audience would be more apt to comply with the health protection strategies contained within it.

Although most individual level behavior models are not adequate in and of themselves in getting to the root, fundamental causes of public health problems, the Theory of Self-Efficacy (Bandura, 1970) could help to explain part of the failure of the “use a condom every time” message. According to the Theory of Self-efficacy (Bandura, 1970), the extent to which a person believes they can master or be successful a certain behavior, they will perform that behavior. The theory outlines two types of expectancies that exert strong influence over a behavior: perceived outcome expectancy, which states that a certain behavior will lead to a certain outcome, and perceived self efficacy expectancy, which states that one can successfully execute the behavior to bring about the outcome. Any individual, regardless of sexual orientation, could very well not believe or have faith that he is capable of using a condom during every single sexual encounter. Therefore, this person would have a very low level of self-efficacy, and hence, will not perform the behavior of wearing a condom. In addition, if a homosexual’s potential partner dislikes or refuses to engage in sexual interaction using a condom, one perceived outcome of such a behavior could be the lack of an outlet to fulfill a homosexual’s sense of love and belonging, which is often negated within the homophobic surrounding in which he lives. Given that this outcome is far from a desirable one, he knowingly does not engage in the behavior of wearing a condom. It is easy to understand how one wouldn’t heed such an unrealistic, unattainable message as “a condom can’t do you any good if you don’t have one when you need it, so have plenty around where you could have sex” given the fact that a person knows that he isn’t capable such a task (OrthoGays. “Learn about Safer Sex,” http://members.aol.com/gayjews/safer.html, www.OrthoGays.com). In reality, sex can occur in almost all locations, so exhorting someone to be sure they have plenty of condoms around for such times is impractical. By failing to be realistic and making extreme claims which few human beings, gay or straight, could achieve, the likelihood of the message to “use a condom every time” being successful in reducing high risk sexual behavior and HIV infection is minimal at best.

Relaying the message of “wear a condom every time” to homosexuals also could be perceived as making a negative value judgment against the homosexual lifestyle. By clearly outlining in a bullet point that one of the ways in which men who have sex with men (MSM) could prevent the contraction of HIV is to be in a long-term mutually monogamous relationship, the CDC HIV/AIDS Fact Sheet is actually suggesting that not enough homosexuals are involved in a committed, monogamous relationships, in which condom use every time isn’t as necessary or vital to prevent the spread of HIV/AIDS (CDC HIV/AIDS fact sheet, January, 2006). Surely, most everyone is aware that having intercourse with solely one person (who is HIV free) drastically reduces or even eliminates the risk infection, so by actually reiterating that piece of common knowledge on a fact sheet geared solely toward homosexual men could very well leave the recipients with feelings of worthlessness and devaluation by society. Similarly, stating that “If MSM choose to have sex outside a steady relationship, they should always use a condom… (and) should know their HIV status and that of their partner(s),” is a loaded statement that suggests or hypothesizes infidelity and the inability of homosexuals to hold down a stable relationship. As Odets points out, public health, most likely, would not be so free in delivering the same message to heterosexuals due to the fact that society respects the values that heterosexuals place on committed relationships (Odets, 1995). In addition, the message to use a condom every time takes away a homosexual’s informed judgment and the ability to make his own decisions, leaving him with a sense of lack of control, hopelessness and self-doubt. Interventions should give control back to the homosexuals so that they may make informed decisions for themselves, rather than being told from outsiders, who have little understanding what it’s like to be gay in today’s society, what they should or should not do. As one gay activist had powerfully noted regarding HIV prevention messages, “we have been ‘educated’ to death. Under the rubric of ‘safer-sex,’ and ‘HIV prevention,’ we've been told what to do and what not to do, shamed and guilted incessantly. We have been messaged and marketed a million times. We have been directed, instructed, commanded, suggested, harangued and manipulated -- all by people who believe that if you tell people repeatedly what to do or not to do with their sex, they will comply,” (Rofes, 1999). Given the fact that, in this day and age, the majority of homosexual men are well informed of the risks of unsafe sex, having any prevention message which fails to respect this knowledge will, as Adam foresees, “surely fall on deaf ears” (Adam, 2005). In fact, communication theory tells us that one of the criteria that needs to be met in order to develop a persuasive message is that the messenger is seen by the audience as a credible source of information (McGuire, 2001). Although homosexuals may acknowledge that the messenger is knowledgeable in its statistical and scientific information, the two components that comprise credibility- perceived honesty and similarity to the target audience- are not met within the homophobic society in which its is transmitted. It is evident that all individuals must be viewed within their prospective social context so that we in public health can begin to better understand the attitudes and emotions and powerful extenuating circumstances underlying such high risk behavior.

A critical reason why the public health intervention message of “use a condom every time” is currently failing to alleviate the problem of high risk sexual behavior and the spread of HIV/AIDS among the male homosexual population is due to the fact that the message is being conveyed within a homophobic society and ignores the negative psychosocial effects of homophobia and stigmatization of gay men that have a significant impact on problem. Studies have shown that growing up with anti-gay messages and derogatory jokes against gays leads to an internalization of such negative attitudes and results in high levels of psychological distress (D’Augelli & Hershberger, 1993). The presence of anxiety and depression, coupled with low self-esteem, may very well drive homosexuals to engage in self-destructive risky behavior with causal partners in an effort to help validate their attractiveness and self-worth, a validation which they don’t receive within a homophobic society. Homosexual respondents in a study by Stokes & Peterson (1998) emphasized disenfranchisement and hopelessness as reason for their high risk sexual behavior. Given that sex was a way to affirm that they are loved, valued and accepted, the respondents didn’t hesitate to act impulsively and unsafely. A desperate urge to feel needed, coupled with the hope of gaining love through a solid relationship, helped fuel their self-destructive behavior. When one thinks so low of himself, the message to wear a condom each and every time one engages in intimate sexual contact, understandably, wouldn’t hold much weight. Within a hostile, homophobic environment, homosexuals are deprived of the basic human needs of safety and security, love and belonging, and status or self-esteem (Maslow, 1943). In addition to denying homosexuals a sense of safety through the threat of verbal and physical violence and aggression, homophobia denies homosexuals emotionally-based relationships, the need to love and be loved, and to be accepted as a valuable part of the community. If a person is viewed in a negative light, as a homosexual very frequently is, he becomes increasingly susceptible to social anxieties, depression and loneliness, all of which rob him of this basic human needs of security. Even worse, the locations where homosexuals could seek belonging, such as the church and family, are often the very places where homosexuals are made to feel threatened, demeaned and demoralized the most. In one study, gay males indicated higher levels of self esteem and comfort with their sexual orientation if their parents were seen as approving of their sexual orientation and were important in their lives (Savin-Williams, 1995).

Both levels of self-esteem that Abraham Maslow (1943) outlines in his Hierarchy of Human Needs- the lower level comprising the need for respect from others, including positive recognition, attention and reputation, and the higher level consisting of the need for self-respect, including feelings of confidence, independence, and achievement- are also difficult for homosexuals to receive and maintain in today’s society. Low self-esteem and inferiority complexes, which ensue from a homophobic, stigmatizing society, were considered by Maslow to be at the root of most human psychological problems, such as depression. Because society doesn’t respect or value his lifestyle, a homosexual could very well begin to internalize those negative attitudes and feelings and develop self-loathing, which then leads to a search for respect and reassurance from others in order to validate oneself. When this validation isn’t received from outer societal outlets, but rather within the context of unprotected sexual relations, the vicious cycle continues. What’s worse, given that these needs are what Maslow has called deficiency needs, when a homosexual doesn’t receive them, he feels the need for them even more so. Studies have shown that unprotected anal intercourse is associated with high levels of depression and with low self-esteem and that there is clear progression from self-acceptance of homosexuality to increased self-esteem and decreased high risk sexual behaviors (Rotherman-Borus, Ried & Koopman, 1995, In: Stokes & Peterson, 286-287). Rather than leaving the message at “you need to use a condom every time you have sexual intercourse,” public health advocates should convey that they care about homosexuals as people and that they accept and value them for who they are (AVERT, http://www.avert.org/usecond.htm). Positive messages such as these would demonstrate that society wants what’s best for homosexuals and therefore would like them to engage in behaviors to protect their health and well-being. In addition, to maximize the effectiveness of the message, public health could transmit a more flexible, softer tactic that discounts the perceived benefits of the unhealthy practice of sex without a condom rather than solely focusing on negatively attacking the unhealthy behavior. For example, relaying the understanding that unsafe sex does not make someone desirable to their peers or is not the “cool,” or socially acceptable action to take, it could lessen its occurrence. By appealing to the values of the audience- values of love, acceptance and respect- the message is more likely to have a successful outcome. As one gay respondent in a Stokes & Peterson (1998) study aptly stated regarding the effort to decrease high risk sexual behavior among homosexuals, “If you can’t get them to improve on their own self-worth and help them to love themselves, it is a lost cause” (page 285). Lacking a sense of belonging and acceptance, along with adequate levels of self-esteem, the likelihood of a homosexual moving upwards on the hierarchy of human needs toward the human growth need of self-actualization and engaging in self health protection, especially through using a condom every time, is slim.

Homophobic attitudes within society create a “don’t ask don’t tell” atmosphere and very often set the stage for some homosexuals to engage in quick, secretive encounters which occur without protection. According to Labeling Theory (Becker, 1963), the labels applied to individuals influence their behavior. Those who are labeled in a certain way actually take on the characteristics of those labels and live up to them as a self-fulfilling prophecy. Through homophobic stigmatization, homosexuals are labeled as deviant, abnormal and highly promiscuous; therefore, a small subset of the gay community actually confirms, and helps to define, that label through frequent and unsafe causal encounters. Viewing themselves as morally at odds with those members of the rule abiding, normative, and homophobic society in which they live, these homosexuals see themselves as different from the mainstream and thereby feel they have little choice but to conform to the essential meaning of the judgment placed upon them. Focusing attention on the act of the individual by admonishing him to always wear a condom is clearly ineffective in intervening in this problem due to the fact that certain homosexuals, albeit a small sub-population, actually seek out these unsafe sexual encounters- the polar opposite effect that the message intends to bring about. “Barebackers,” men who seek out other men for unsafe sex, have been portrayed within the gay media as rebels who break away from their conformist peers (Suarez, T & Miller, J., 2001). Engaging in such self-deprecating and self-destructive behavior not only affirms the label that has been applied to the gay population by society, but also reveals that these men are actively seeking out attention, love and a sense of belonging, albeit in a fleeting and dangerous manner that ultimately will fail to nourish and sustain such needs. This reckless behavior, which essentially is a game of Russian roulette, displays just how low these men think of themselves and just how little self-worth they hold within them. As Green (1996) appropriately states, “...ignoring the role homophobia plays in the psychology of AIDS means ignoring an element of a disease at least as powerful as biology. If we care about health, there is little choice but to care about people’s feelings, too” (page 84). Rather than endorsing the message of “use a condom every time,” which essentially admonishes homosexual men to behave a specific, predetermined way within their intimate, personal relationships, public health should instead focus on expressing their care, concern and respect of the homosexual lifestyle. This strategy would hold great promise in creating a comfortable atmosphere that fosters open discussion rather than one that dismisses homosexuals as deviant and abnormal. Because the deviant behavior here is labeled as such by persons in positions of power, or our homophobic, masculinized society, the change that is warranted lies with altering society’s views, not with homosexual men’s actions. Perhaps if society’s moral indignation is replaced with tolerance and respect, the desired outcome of less unsafe sexual relations and an alleviation of the AIDS epidemic would be seen.

By shifting our attention away from the current proscriptive message to use a condom every time and toward the more proactive approach of addressing and combating homophobia, perhaps we in public health can begin to see a decline in the high risk sexual behavior and consequential HIV/AIDS epidemic among the homosexual population. One way in which public health could help to diminish or alleviate society’s homophobic attitudes and beliefs is through educational programs geared toward young children. By targeting people at a young age, a time in human development when one’s beliefs, attitudes and values are formed, and shifting the focus away from the dominant, heterosexual norm through an early introduction to alternative lifestyles, children will be much more likely to grow up viewing their homosexual peers with respect and acceptance rather than with disdain or degradation. Given that it is human nature to fear the unknown or that which is different, bringing the homosexual lifestyle to the forefront and shedding light on the fact that homosexuals share the same needs and values as their heterosexual counterparts would be an effective tactic in addressing the problem. Storybooks or television programs which portray healthy, loving relationships within families with homosexual parents could help debunk the negative stereotypes that permeate our society and break down the barriers to foster insightful discussion, both within the classroom and without. It is within this supportive, welcoming atmosphere that strides could be made not only in building up a homosexual’s self-esteem and sense of self-worth, which would help him to refrain from engaging in the unhealthy, self-destructive behavior of unsafe sex, but also in displaying to the greater community that homosexuals are no different than their heterosexual counterparts in their basic human needs for love, protection and respect. In fact, studies have shown that social support plays a prominent role in a gay man’s psychological well-being. It has been found that homosexuals who perceive themselves as having low social support are likely to be depressed and have lower levels of self-acceptance than those with high social support (Vincke & Bolton, 1994). Procuring the assistance of gay role models to invest in an educational, informational intervention would provide them with the confidence and self-respect they need to engage in healthier sexual practices which involve protection rather than destruction. Utilizing an opinion leader within the population to communicate these positive images is a tactic that holds a better chance of a message being accepted and embraced by the homosexual community, as it is known that the more similar in values the communicator is to the audience, the more likely the audience is relate to the communicator and, hence, the more likely they are to comply with the content of the message (Rogers, 1983). Just as homosexuals themselves have been successful in utilizing peer outreach tactics to reduce the rate of unsafe sex among their peers, so can we in public health be successful in reducing society’s homophobic attitudes (Keagles, Hayes & Coates, 1996). Creating a non-stigmatizing environment that provides social support and social networks could aid in the fight against the HIV/AIDS epidemic among MSM and serve as a protective barrier to a homosexual’s societal-induced vulnerability and consequential unsafe sexual practices.

It is clear that addressing the AIDS epidemic among homosexuals by utilizing an intervention which focuses solely on individual behavior modification distracts us, in public health, from seeing the deeper contributing issues of homophobia and stigmatization and their negative effects on homosexuals. Stigmatization and homophobia not only affect the perceptions and practices of individual homosexual men, they also hamper the provision of interventions that are effective, affirming, and tailored to meet the needs of the population (Valdiserri, RO; In Peterson & DiClemente, 2001). The public health message to “use a condom every time” exhorts gays to act safely in the present moment in order to maintain healthy selves for the future, but if life is perceived by them as not worth living in the here and now, the future is irrelevant. Although changing deeply entrenched homophobic attitudes and views is a daunting, difficult task at best, at least our effort to try to address them is a strong step in the right direction.


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Underneath the Red Dress: How the ‘Heart Truth’ Campaign Fails through its Rigid Design & Disregard for Social Science Variables-Susan Helwig Svencer

Since 2003 the National Heart, Lung, and Blood Institute (NHLBI), a division of the U.S. Department of Health and Human Services, has promoted women’s cardiovascular health through a campaign entitled the Heart Truth, with a red dress as its symbol (www.hearttruth.gov ). The campaign focuses on increasing awareness that heart disease is the number one killer of women as a means of inspiring women to take action and lead healthier lives. Studies published on the Heart Truth website note that awareness of heart disease has increased among women since the program’s inception, but that women have not changed their cardiovascular-related health behavior (1). As a fundraising campaign among wealthier, Caucasian women, it appears to be effective, but as a true intervention among all women, it fails for a number of reasons. The campaign’s message will not have a broad reach due to its disregard for sociocultural and economic variables, as demonstrated through its narrow choice of communication channels and the promotional materials content. In addition, the environmental and economic variables that may significantly affect a woman’s receptivity to and ability to act on the recommended behavior changes were also ignored when the campaign materials were developed. And lastly, the theoretical basis on which the campaign is designed assumes awareness equates to action and does not capitalize on women’s stated drivers of and barriers to improved cardiovascular health.

The first means by which the Heart Truth scope is limited is through its prohibitive advertisement placement Women of lower socioeconomic status are considerably less likely to be exposed to the Heart Truth promotional materials as a result of the use of communication channels inaccessible to many women. While many of the campaign materials will reach middle-to-upper class women, others will not come into contact with them, confounding the campaign’s focus on all women.
The hallmark, annual promotional event for the Heart Truth takes place at New York’s Fashion Week, creating collaboration between the campaign and what the Heart Truth’s public relations firm deems “an industry intrinsically tied to the target audience” (2). However, fashion week’s target audience is a small subpopulation of women - mainly Caucasian and upper class – and focusing on fashion as a means of promoting the campaign reinforces the exclusion of the lower class. Furthermore, several high-end brands with upper class association are the primary fashion week sponsors, including Mercedes-Benz, IMG Models, Swarovski, Inc., and Olympus (2). A connection to fashion as well as these brands may reach wealthier women and generate favorable press for the campaign, but less advantaged women will certainly not be exposed to the Heart Truth messages through these fashion-related events.
In addition, large scale advertisements depicting women in red couture or former first ladies dressed in red were placed in 22 US airports. By displaying advertisements in airports rather than in more common locales, the Heart Truth circumvents women of lower socioeconomic status who are less likely to pass through an airport. Air travel frequency is significantly lower in households earning less than $25,000 per year than others, and in total, only 7% of long-distance trips within the US are by air (3, 4). Cost is the most-cited obstacle to increased air travel, meaning women without the expendable income to fly will not see the advertisements.
Public service announcements (PSAs) were also placed in numerous print magazines. While some of these (Essence, People En Español, BabyTalk) boast a relatively ethnically and financially diverse readership, several others do not. With a median household income between $80 and 90K, InStyle and Real Simple, two other magazine featuring Heart Truth PSAs, target affluent readers (5, 6). And arguably anyone reading Health and Balance magazines, where Heart Truth PSAs also appeared, are already proactive about their health and are not the population most in need of the Heart Truth’s messages.
The reach of the Heart Truth message is further restricted because the primary means of disseminating information to women is through the NHLBI’s website. Caucasians are nearly twice as likely to have internet access at home as are Blacks or Hispanics (7), and the same pattern emerges when overall use of the internet is examined. However, internet use is related to more than race: it is highly correlated to income level, education, and geographic region (8), rendering the Heart Truth health information less accessible or even unattainable to a large proportion of women. Moreover, even if women do have internet access, reading health information online has been shown to have little effect on the frequency of physician visits and even on the depth of overall health knowledge of the reader (9).

On top of the exclusionary dissemination of campaign information, the second way the Heart Truth message is constrained is by its disregard for the sociocultural context in which women receive their messages. Even if women are exposed to the Heart Truth materials, the content is not adaptable or even accessible to a diverse population.
Despite a stated focus on Latinas and African American women, the campaign information directed to each of these groups are only marginally different from the materials designed for the broader female population. The only changes made to the Latina and African American specific materials are images of women from each group and statistics specific to each population. Stating that “heart disease is more prevalent among black women than white women” (10) or that “nearly two out of every three Latinas are overweight or obese, increasing their risk of heart disease” (11) is not only uninspiring, it outright ignores the culture nuances that may significantly affect the health behaviors (i.e. level of physical activity and a healthy diet) that led to these statistics and an increased risk of heart disease. For example, Hispanic and Black women’s low level of physical activity has been shown to be influenced by factors different than that of white women, including family health, perceived social norms, access to neighborhood resources and facilities, as well as cost and time (12, 13). And while levels of smoking remain the same for Black and White women, Black women gain substantially more weight after smoking cessation than do white women (14) – a critical factor in getting women to quit smoking not addressed by the Heart Truth. By using race as an individual level, categorical variable, the NHLBI has overlooked the complexities of health disparities that arise when cultural factors are considered.
Intra-racial distinctions are another crucial determinant of health behavior that is overlooked by the Heart Truth. The campaign takes a one size fits all approach to its content, assuming, for example, that all Hispanic women respond and act in a similar way. However, attitudes towards smoking cessation and weight loss have each been shown to vary considerably within the broad Hispanic population, in some cases even by level of acculturation (15). In addition, a recent study among Black women suggests that those with strong religious beliefs have more interest in and higher actual consumption of fruits and vegetables than those with weaker religious beliefs and behaviors (16). Yet the Heart Truth communication materials do not even acknowledge intra-racial differences exist, much less allow their messages to be tailored to subgroups.
The advertisements placed in airports mentioned earlier in this article featured either mannequins dressed in red couture dresses designed for the Heart Truth by 21 prominent fashion designers or US First Ladies dressed in red suits. These images are concerning for several reasons. Rather than motivate women to better heart health, the former may serve to alienate those who cannot afford the glamorous dresses nor have an occasion to wear them. The First Ladies featured in the latter may not be recognizable to a large proportion of women. While these advertisements are no longer displayed in airports, First Lady Laura Bush remains the primary spokeswoman for the Heart Truth campaign, a polarizing figure even among those who can identify her. As purported through McGuire’s Communication / Persuasion Matrix, the source of information strongly affects its reception (17). In this case, women who can identify with Laura Bush and/or women who wear couture are more likely to be persuaded by the message being delivered through these print advertisements than are those who do not relate to the messengers, once again alienating women of lower socioeconomic status and non-white women.
The Heart Truth strongly suggests women develop a healthy relationship with their physician to determine their risk of heart disease and to set goals for achieving heart health. Yet in the general US population, distrust of the healthcare system is high and closely linked to a worse self-reported health, even after adjusting for socioeconomic status and access to health care (18). This distrust and resulting decreased participation in the healthcare system also varies considerably by race and culture – a fact conveniently disregarded by the Heart Truth. Significant racial differences (Caucasian vs. Black) in the level of trust in medical care have also been found to exist (19). Many have cited Tuskegee as a clear determinant of this mistrust among the Black population (20), but differences are also likely due to historical and personal experiences that are broader than that (21). Black and Hispanic residents in the south Bronx have expressed a “deep and pervasive distrust of the health care system, exasperated by difficulties that patients experience in communicating with their providers” (22). Specific to cardiac procedures, Black patients have also been shown to prefer they build a solid relationship with their physician before agreeing to undergo surgery, yet they consistently feel the trust they so desire is absent. These patients also report they are often confused by the cardiovascular health information they do receive, which could be unintentionally fostering these feelings of mistrust (23). Misgivings and suspicion toward organized medicine must be addressed before women can be expected to develop a strong relationship with their physicians, per the Heart Truth’s recommendations.

In addition to the economic and cultural oversights that limit the Heart Truth’s reach, many of the campaign’s lifestyle recommendations discount potential environmental and socioeconomic barriers. The Heart Truth fundamentally oversimplifies these issues by emphasizing, “Protecting your heart can be as simple as taking a brisk walk, whipping up a good vegetable soup, or getting the support you need to maintain a health weight” (24). Women are told to “choose a diet low in saturated fat, trans fat, cholesterol, and moderate in total fat” (25) without being informed how to do so. The Heart Truth website does provide women with recipes for heart healthy food, yet many of these recipes contain ingredients that may be difficult for women of low income and in disadvantaged neighborhoods to obtain, much less afford (i.e. Dijon salmon, zucchini lasagna, and peach cobbler (26). Strong links between socioeconomic status and food purchasing decisions have been found, with those of lower socioeconomic status being less likely to buy high fiber, low fat, salt and sugar foods, as well as fruits and vegetables (27). When low income women are provided financial supplements for the purchase of produce, they come closer to meeting dietary guidelines, as one of the key impediments (cost) to their purchasing is eliminated (28). For all women to adopt heart healthy eating habits, an understanding of the obstacles preventing such lifestyle changes is paramount. Unfortunately, the Heart Truth does not acknowledge that any barriers other than a patient’s willingness to change play a role in health behavior.
Lastly, the Heart Truth campaign was developed under the assumption that all health behaviors are rational, such that basic awareness of women’s heart disease risk will inspire action. Coupling this erroneous postulation, seemingly derived from the Health Belief Model (HBM), with the Heart Truth’s disregard for women’s stated influences of their health behavior has rendered the intervention ineffective at improving women’s overall cardiovascular health.
The Heart Truth campaign appears to have been built on the (HBM), as its primary aim is to make women understand they are highly susceptible to heart disease and that contracting it will cause considerable harm. According to the HBM, internalizing this susceptibility and potential severity should cause women to see the benefit in a behavior (in this case eating healthier, exercising, and visiting their physician regularly to prevent heart disease) and therefore cause them to intend to adopt the behavior (29). Yet this model assumes that obstacles to performing a given health behavior are minimal. It also does not take into account how attitudes and beliefs may affect uptake of a behavior, and assumes that all health behaviors are rational. Because these factors – most notably the existence and impact of obstacles as well as variable attitudes towards health – are excluded from the Heart Truth’s design, its reach is significantly constrained. This, however, could be rectified by incorporating components of other health behavior models (Bandura’s notion of self-efficacy or the social factors and attitudes that comprise part of Azjen and Fishbein’s theory of reasoned action) (30) to address the obstacles women face in adopting behaviors beneficial to their cardiovascular health.
NHBLI surveys suggest awareness that heart disease is the number one killer of women has risen from 34% to 55% since 2000 (1), as well as that women do recognize the red dress as a national symbol of heart health (31). However, data also show that few behavior modifications have been made as a result of this increased awareness (32). Through several studies, women have cited numerous barriers to their taking preventive health measures. First among these is confusion in the media (1, 33). With conflicting information regarding the benefits of various diet changes and exercise regimens, are women supposed to accept the Heart Truth’s recommendations at face value? It is unfair and unrealistic to assume that they will. Caretaking responsibilities and family obligations are also commonly noted impediments to behavior change. And interestingly, women who do take action note that they do so for their family as opposed to for themselves. These attitudes reveal an important driver of health behavior that should be used as a motivator and as a means of helping women address many of the barriers they face. Unfortunately, the Heart Truth has ignored these data points because they are inhibited by the rigid, illogical structure of the HBM.

Through the Heart Truth campaign, the NHBLI has the opportunity to improve the cardiovascular health of considerably more women than it is currently affecting. By expanding its use of communication channels and rethinking its advertisement placement, the Heart Truth could more thoroughly expose women of lower socioeconomic status to its messages. Adjusting the content of promotional materials to take social and cultural as well as environmental and economic factors into account would make the messages and behavior modification recommendations more realistic and accessible to both women of color and disadvantaged women. Incorporating the factors women explicitly say affect their health behavior into the campaign, as well as acknowledging that obstacles to adopting a given health behavior do exist (potentially through the use of behavioral models beyond the HBM), would serve to make the intervention a powerful resource and means of affecting health behavior change. If these modifications can be made, the Heart Truth still has a chance to make a true impact and meet the goal of not only reminding women of the need to protect their heart, but also inspiring them to do so.

1 Getting the message: Heart Disease is the #1 Killer of Women. 2005. Available at: http://www.nhlbi.nih.gov/health/hearttruth/whatis/message.htm. Accessed October 22, 2006.
2 Ogilvy Public Relations Worldwide. Case Studies: the Heart Truth. DATE?. Available at: http://www.ogilvypr.com/case-studies/heart-truth.cfm. Accessed November 3, 2006.
3 U.S. Department of Transportation, Bureau of Transportation Statistics. 2001 National Household Travel Survey Data. Long Distance Passenger Travel. Available at: http://www.bts.gov/publications/transportation_statistics_annual_report/2004.Accessed October 29, 2006.
4 U.S. Department of Transportation, Bureau of Transportation Statistics. 2001 National Household Travel Survey Data. Long Distance Travel by Income, Gender, and Age. Available at: http://www.bts.gov/publications/transportation_statistics_annual_report/2004.
Accessed October 29, 2006.
5 Time, Inc. October 18, 2006. In Style secures its third consecutive readership increase. Available at: http://www.timeinc.com.au/news/IN_STYLE_News/10_8_2006_IN_STYLE_secures_its_third_consecutive_readership_increase.aspx. Accessed November 11, 2006.
6 Real Simple Media Kit. Spring 2006. Available at: http://www.realsimplerewards.com/rsn/mediakit/PDFs/RS06demos_0506.pdf. Accessed November 11, 2006.
7 US Census Bureau. Computer and Internet Use in the United States: 2003. Available at: http://www.census.gov/prod/2005pubs/p23-208.pdf. Accessed October 22, 2006.
8 National Telecommunications and Information Administration. US Department of Congress, July 1998. Falling Through the Net: Defining the Digital Divide. Available at: http://www.ntia.doc.gov/NTIAHOME/FTTN99/part2.html. Accessed, October 27, 2006.
9 Baker L, Wagner TH, Singer S, Bundorf MK. Use of the Internet and E-mail for Health Care Information. JAMA 2003 May; 289(18):2400-6.
10 U.S. Department of Health and Human Services. September 2003. The Heart Truth for African American Women: An Action Plan. Available at: http://www.nhlbi.nih.gov/health/hearttruth/material/factsheet_aa.pdf. Accessed October 22, 2006.
11 U.S. Department of Health and Human Services. September 2003. The Heart Truth for Latinas: An Action Plan. Available at: http://www.nhlbi.nih.gov/health/hearttruth/material/factsheet_latina.pdf. Accessed October 22, 2006.
12 Keller C, Fleury, J. Factors related to physical activity in Hispanic women. Journal of Cardiovascular Nursing 2006 Mar-Apr; 21(2):142-5.
13 Schrop SL, Pendleton BF, McCord G, Gil K, Stockton L, McNatt J, Gilchrist VJ. The medically underserved: who is likely to exercise and why? Journal of Health Care for the Poor and Underserved 2006 May; 17(2):276-89.
14 Sanchez-Johnsen LA. Smoking cessation, obesity and weight concerns in black women: a call to action for culturally competent interventions. Journal of the National Medical Association 2005 Dec; 97(12):1630-8.
15 Kerner JF, Breen N, Tefft MC, Silsby J. Tobacco use among multi-ethnic Latino populations. Ethnicity & Disease 1998; 8(2):167-83.
16 Holt CL, Haire-Joshu DL, Lukwago SN, Lewellyn LA, Kreuter MW. The role of religiousity in dietary beliefs and behaviors among urban African American women. Cancer Control 2005 Nov;12 Suppl 2:84-90.
17 McGuire WJ. Input and Output Variables Currently Promising for Constructing Persuasive Communications. In R. E. Rice & C. K. Atkin (Eds), Public Communication Campaigns (3rd ed., pp. 22–48). Newbury Park, CA: Sage Publications.
18 Armstrong K, Rose A, Peters N, Long JA, McMurphy S, Shea JA. Distrust of the health care system and self-report health in the United States. Journal of General Internal Medicine 2006 Apr; 21(4):292-7.
19 Boulware LE, Cooper LA, Ratner LE, LaVeist TA, Powe NR. Race and trust in the health care system. Public Health Reports 2003 Jul-Aug; 118(4):358-65.
20 White, RM. Misinformation and misbeliefs in the Tuskegee Study of Untreated Syphilis fuel mistrust in the healthcare system. Journal of the National Medical Association 2005 Nov; 97(11):1566-73.
21 Brandon DT, Isaac LA, LaVeist TA. The legacy of Tuskegee and trust in medical care: is Tuskegee responsible for race differences in mistrust of medical care? Journal of the National medical Association 2005 Jul; 97(7):951-6.
22 Kaplan SA, Calman NS, Golub M, Davis JH, Ruddock C, Billings J. Racial and ethnic disparities in health: a view from the South Bronx. Journal of Health Care for the Poor and Underserved 2006 Feb; 7(1):116-27.
23 Collins TC, Clark JA, Petersen LA, Kressin NR. Racial differences in how patients perceive physician communication regarding cardiac testing. Medical Care 2002 Jan;40(1 Suppl):I27-34.
24 What Are the Risk Factors for Heart Disease? 2003. Available at: http://www.nhlbi.nih.gov/health/hearttruth/lower/risks.htm. Accessed October 22, 2003.
25 Tips for Heart Health. 2003. Available at: http://www.nhlbi.nih.gov/health/hearttruth/lower/tips_hearthealth.htm. Accessed October 22, 2006.
26 When Delicious Meets Nutritious: Recipes for Heart Health. January 2005. Available at: http://www.nhlbi.nih.gov/health/hearttruth/material/factsheet_recipes.pdf. Accessed October 22, 2006.
27 Turrell G, Hewitt B, Patterson C, Oldenburg B, Gould T. Socioeconomic differences in food purchasing behavior and suggested implications for diet-related health promotion. Journal of Human Nutrition and Dietetics 2002, Oct; 15(5):355-64.
28 Herman DR, Harrion GG, Jenks E. Choice made by low-income women provided with an economic supplement for fresh fruit and vegetable purchase. Journal of American Dietetic Association 2006, May; 106(5):740-4.
29 Rosenstock IM. Historical origins of the health belief model. Health Education Monographs 1974; 2:328-335.
30 Salazar MK. Comparison of four behavioral theories. American Association of Occupational Health Nurses Journal 1991; 39:128-135.
31 Harris Interactive. One in Four U.S. Women Recognize the Red Dress as the National Symbol for Women and Heart Disease Awareness. January 2005 Commissioned by WomenHeart: the National Coalition for Women with Heart Disease. Available at: http://www.nhlbi.nih.gov/health/hearttruth/whatis/reddress_recognized.htm. Accessed October 22, 2006.
32 Lifetime Women’s Pulse Poll. New Lifetime Poll Shows More Than Half of Women Know Heart Disease is their #1 Killer, Yet Only One in Three Believe They are Personally At Risk. Released February 1, 2006. Available at: http://www.nhlbi.nih.gov/health/hearttruth/press/risk_awareness.htm. Accessed Octoer 22, 2006.
33 Mosca L., Mochari H, Christian A, Berra K, Taubert K, Mills T, Burdick KA, Simpson SL. National study of women's awareness, preventive, and barriers to cardiovascular health. Circulation 2006 Jan 31; 113(4):525-34.

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.


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HIV Over 50: Stigma leading to insufficiency of prevention-Jessica B. Castronovo

Over the past 25 years, HIV/AIDS has been affecting many aspects of society at astonishing rates. Public health practitioners (doctors, policy makers, educators, etc) in all spheres of influence have been working hard to put together comprehensive and effectual prevention efforts targeting those at risk for HIV/AIDS infection. Unfortunately these care providers have focused on small groups that are considered at risk due to their lifestyle (IV drug users, men who have sex with men etc). Many of these efforts have been considered successful. In their haste to address this very important issue of HIV/AIDS prevention, stigma has prevented practitioners from even identifying people over the age of fifty as a group at risk.

Older adults are living in a society where they are stigmatized because of their age. It is thought by much of society, and often themselves, that older adults are not vital, pleasure seeking individuals. As a result, older adults are not viewed as at risk for a HIV/AIDS, which is often considered a disease of the young and/or risk courting. The stigma of being older, combined with the stigma of the behaviors which put one at risk for HIV/AIDS infection are placing older adults at great and unnecessary risk of infection. Further more, Public Health has failed older adults in the realm of HIV/AIDS prevention. In many of the spheres that impact an individual’s life, where the various types of Public Health practitioners can intervene, there is scarce education, acceptance and care. In this paper I will outline and explore the failures of Public Health utilizing the Social Ecological Model, which draws the spheres of influence in a person’s life, going from the broad world of state and federal policy down to the individual interactions a person has. All spheres are places in which Public Health can intervene with prevention efforts-and often it is done, with other populations-but older adults are failed in multiple spheres.

The US Centers for Disease Control and Prevention (CDC, 2003a) estimate that the number of adults over the age of 55 living with HIV/AIDS in the United States increased by at least 107% from 1998-2002. This is a larger increase then any other adult age group. Between 10% and as high as 18% of people living with HIV/AIDS are over the age of fifty and 25% of these cases are in persons over the age of 60 (Feldman, 1994). It can also be assumed that there is actually a higher rate of HIV/AIDS in the older adult population then the statistics reflect, but they have not been tested. Elderly have been found to be less likely to be tested the any other group (Doup, 1994; Feldman, 1994; Jones, 1999). In contrast, the rate of infection of children age 5 and younger is less then 1% of the AIDS cases (CDC, 1998). The level of perception of risk does not coincide with these statistics on infection, the CDC Behavioral Risk Factor Surveillance System, 2000 Survey reveal that among adult respondents age 55-64, 81% reported no risk for HIV and 15.1% reported a low chance of getting HIV (CDC, 2003a).

From the data, it is clear that HIV/AIDS infection is a real issue among older adults and in turn the responsibility of Public Health practitioners.

Societal Sphere of Failure
Social Structure, Policy and Systems are the broadest and largest level of influence when discussing the prevention of a disease from a public health standpoint. These influences may have been local, state or federal policies regulating prevention and care efforts. Overall very little has been done at the societal level to dispel society’s ageist views about older adults and their risk of HIV/AIDS.

When one thinks of HIV prevention campaigns, the most popular methods address the need to use condoms or clean needles. What is also apparent in these campaigns is a younger population is being targeted. There is usually flashy writing and young innocent or confused, attractive looking people making safer sex look enticing. Older adults have been left out of most HIV/AIDS prevention campaigns, including the brochure driven ones. Only 14 states in the United States have print information about HIV/AIDS geared specifically towards older adults (Apreal, et al, 2004). Nancy Oreal, et al also call into question the quality of the printed prevention efforts reaching the intended audience. The availability does not appear widespread or in multiple languages. The exclusive use of print material also leaves out the group of older adults who are illiterate. With the factor of illiteracy comes increased chance of poverty, substance abuse and depression-all increased risk factors for HIV/AIDS.

The lack of literature available has been found to be insufficent in fundamental ways. The focus of the literature geared toward older adults was primarily education. It usually included a list of facts pertaining to older adults higher risk factors for HIV/AIDS. States did include in their literature aimed at older adults myths and stereotypes around HIV/AIDS, basic facts about HIV/AIDS and basic STD prevention strategies (i.e. condom use). There was no mention of physiological aging factors, which have been linked to decreased immune systems; vaginal wall thinning and less vaginal lubrication may increase the risk of HIV in sexually active older women (Zablotsky, 1998). The mere fact that the ads and pamphlets do not generally include older adults perpetuates the normative myths surrounding older adults and their risk for HIV. Our society continues to believe that older adults do not engage in behaviors that put them at risk, which is not true. “An increasingly high percentage of newly identified AIDS cases in older adults are due to HIV transmission through risky sexual behaviors (Maes & Louis, 2003, ” especially male-to-male sexual contact (Strombeck &Levy, 1998). “Despite the dominant stereotypes of an ‘asexual older person’, studies on sexual activity among older adults showed that a high percentage (81.5%) of subjects over age 50 were involved in one or more sexual relationships (Inelmen, et al, 2005).”

Studies have been done to document the lack of impact Public Health prevention campaigns have had on the older adult community. The majority of people over the age of 50 with AIDS reported that they had not received very much information on prevention. When they did report receiving information about HIV/AIDS, it was through the mass media. In a focus group in New York City, older adults over the age of 50 relayed that they did not perceive HIV/AIDS prevention messages as targeted towards them. (Klein, et al, 2001). According to researchers Schable et al,1996 “…older women with heterosexually acquired HIV are less likely to have used a condom before their HIV diagnosis and less likely to have been tested for HIV.” when compared with older groups of women. This is a living example of the need for a condom use message not reaching an at risk population, whether it be not identifying with the issues of risk or not even getting the message of the importance of condom use. Older adults were raised to use condoms as birth control, making post-menopause pregnancy no longer a concern, and an issue that getting addressed. They are instead applying this condom use message to their children and grandchildren, not themselves.

Institutional Sphere of Failure
The medical community is a strong partner when it comes to addressing prevention and treatment of diseases. It is often relied upon to be a place of formal and informal rules and regulations. These are thought of as safety nets to teach people about disease and its prevention or treatment. The main line of defense in the medical community is thought to be the Primary Care Physician (PCP). In the area of HIV/AIDS education, prevention and treatment the PCP has fallen dangerously short.

At the heart of this failure is the issue that PCP’s buy into the ageist myths of older age equaling celibacy and sobriety (Engle, 1998). It remains easy for the PCP to ignore HIV/AIDS as an issue because elements of aging mimic symptoms of HIV/AIDS. Common symptoms of HIV/AIDS that can be attributed to aging are memory loss, loss of muscle tone and fatigue. Some studies show that “…over 90% of those 50 years and older have never had an HIV test (Maes & Louis, 2003).”

The result of ageist views of many PCP’s is a “don’t ask, don’t tell” standard of care around the subject of behaviors that would put an older adult at risk for HIV/AIDS. This can lead to serious consequences. As stated previously in this paper, the number of adults over the age of 55 living with HIV/AIDS increased by 107% from 1998-2002. This is the largest increase of all adult age groups (CDC, 2003a).

It is not to say that PCP’s do not discuss sexuality with their patients. There has been a large increase in the use of and acceptance of sexual enhancement drugs. The introduction of this class of drugs has increased the sexual potency of men and frequency of sexual intercourse. This increase in prescribing appears to have correlated with “an increasingly high percentage of newly identified AIDS cases in older adults “…due to HIV transmission through risky sexual behaviors (Maes & Louis, 2003)”. When paired with the hands off approach PCP’s have had of truly addressing older adult sexuality it can be dangerous. Additionally there does not appear to be a protocol that is followed for pairing education about HIV/AIDS with the prescribing of sexual potency medications.

In regards to the societal sphere’s potential interaction with the PCP’s, there is no current standard public health outreach to the medical community that serves to enhance awareness of older adults as an at risk population for HIV/AIDS. As an example, among PCP’s, there is no push to have the doctors ask a series of risk factor questions during the patient’s medical visit. In contrast, adolescents and young adults are asked standard questions about their sexual behavior and drug use-risk factors that are significant in both young and old.

Individual Sphere Failure
The most pointed and specific level of influence is the individual. This is where prevention efforts incorporate health behavior theory in order for people to change their behaviors. There have been very few interventions that have been implemented to target the older adult and their risk of HIV/AIDS. Among efforts that have been made to target older adults all are lacking in key elements that have made prevention efforts with other groups viable. Studies have shown that HIV/AIDS prevention efforts that teach sexual negotiation skills and increase availability of condoms improve self-efficacy, which is a key element to changing behavior. If an individual believes in a behavior or intervention and feel they can do it then they are more likely to follow through with that healthier behavior.

The theory of reasoned action is a particularly useful and informative way to identify effective intervention programs. In a study done by Jemmott & Jemmott (1991) surveying young black women, those who registered more favorable attitudes toward condoms and those who perceived subjective norms more supportive of condom use reported firmer intentions to use condoms in the next three months. Key behavioral beliefs are related to attitudes centered on the adverse effects of condom use on sexual enjoyment. Key normative influences were respondents' sexual partners and mothers. However, women's own attitudes were a stronger determinant of intentions to use condoms than were their perceptions of normative influences, particularly among women with above average AIDS knowledge. These results suggest that the theory of reasoned action provides a potentially useful conceptual framework for interventions to change a key AIDS risk behavior among women. In turn it can be expanded to other groups who have been stigmatized and disempowered (such as older adults).

In terms of research to establish effective prevention methods, very little HIV research has explored the channels and methods of communication that are more frequently used by, acceptable to, or effective with older people. The biological, psychological and social issues of people over the age of 50 need to be taken into account when developing a prevention program.

Current prevention strategies for older adults are more centered around providing information (safer sex, the etiology of HIV and modes of transmission). An example of this method is the Senior HIV Intervention Project (SHIP) originally located in the Dade, Broward and Palm Beach Counties of Florida. SHIP started in 1997 by the Department of Public Health in response to the dramatic increase in HIV/AIDS among the elders of Dade, Boward and Palm Beach Counties. It was recently discontinued in Palm Beach County due to the person running the program becoming too elderly to do so. There is one Educational Coordinator overseeing the program in Broward and Dade Counties. It is integrated with general HIV/AIDS prevention for all populations. This is a program which trains older adult peer educators to present educational and safer sex seminars at retirement communities, focusing on the etiology of HIV and modes of transmission and the importance of knowing one’s HIV status by testing. Trained AIDS educators meet with health care professionals and aging service workers to help them understand the risks posed to older adults by HIV. This is done in small group meetings (Agate, et al, 2003). While a step in the right direction, this program, along with others that are similar in Chicago, IL and Baltimore, MD, is missing a key element that would cause change on the individual level. While basic education is important, it can be shown repeatedly in public health that simply knowing about something does not guarantee that an individual will translate it into their daily lives. There is no emphasis on the concrete issues that put individuals at risk such as condom availability and sexual negotiation skills. Attacking HIV/AIDS prevention with emphasis on self-efficacy with development of personal attitudes towards condoms, discussing their partner’s status and making decisions based upon the information provided. Simply teaching how to put a condom on and how to ask a partner what their sexual history paired well with the education that SHIP and other programs like it would be the start to a better prevention model.

In discussions with the Educational Coordinator, she did acknowledge this deficit and has been trying to remedy this by offering the prevention education focusing on sexual negotiation and condom use to all ages. Unfortunately she has found that older adults have not been actively participating in these educational sessions. She did acknowledge that this is an issue, but has little funding to expand her programming to be more age and culturally sensitive.

It does not appear that much research has been done on whether the intervention of SHIP has made a real difference in people’s lives. What has been measured after exposure to SHIP and other programs like it are the participant’s level of knowledge about HIV/AIDS. There is no discussion about attitudes towards prevention techniques such as using the condom they are told will prevent HIV and negotiating the use of this condom. There was also no data available on rates of infection after exposure to the program. Incidences of HIV/AIDS have also increased in Dade, Broward and Palm Beach County since the introduction of this prevention program.

In conclusion, HIV/AIDS prevention has failed older adults in many spheres of influence in their lives. On a Systems level prevention efforts are obviously directed towards the young, IV drug users and men who have sex with men. On the organizational level, it is the medical community, captained by PCP’s where HIV/AIDS is rarely discussed with older adults and sexual potency medications are prescribed with little safer sex discussion. In the individual sphere, HIV/AIDS prevention methods are missing as a largely important part of prevention efforts-giving individuals life skills to deal with situations where they could be put at greater risk for HIV exposure. It is well documented in research done on prevention programs and programs aimed at changing people’s behavior that the most important determinant of the impact of a prevention effort is change in important attitudes translated into people’s true actions. There does not appear to be sufficient data to determine if the small prevention efforts have made a true impact, but with their emphasis on education and exclusion of theoretically supported necessary elements such as sexual negotiation and condom availability, they are failing older adults. Public Health must take responsibility for the increase in the HIV infection rate of older adults that is known (i.e. those who have been tested) and for the fact that the data in general on this issue is paltry and then change accordingly.

Agate, L.L, Mullins, J.M., Prudent, E.S & Liberti, T.M. (2003) Strategies for Researching Retirement Communities and Aging Social Networks: HIV/AIDS Prevention Activities Among Seniors in South Florida. JAIDS: Journal of Acquired Immune Deficiency Syndromes, 33 (2): S238-S242.

Centers for Disease Control and Prevention (1998). CDC: Basic Statistic-Cumulative Cases-United States, 2000.

Centers for Disease Control and Prevention. (2003a). Cases of HIV Infection and AIDS in the United States, 2002: Table 10. Estimated numbers of persons living with AIDS by year, and selected characteristics, 1998-2002-United Sates. HIV/AIDS surveillance report edition, 14 (2). Atlanta, GA: Centers for Disease Control and Prevention, U.S. Department of Health and Human Services.

Coon, David W. , et al. (2003) Designing Effective HIV/AIDS Social and Behavioral Interventions for the Population of Those Age 50 and Older: Interventions and Research Methods for Use with Older Populations. JAIDS: Journal of Acquired Immune Deficiency Syndrome: 33(2): S194-S205.

Doup, Liz. The Aging of AIDS. Miami Herald: August 28, 1994; Section J; page 1; Column 1.

Engle, Laura. Old AIDS: Body Positive; 11:1. (www.bodypositive.com/bp/jan98/old_aids.html)

Feldman, Mitchell. (1994) Sex, AIDS and the Elderly. Archives of Internal Medicine:15:1, p19.

Gonzalez, Edith. Educational Coordinator of Boward and Dade County Senior HIV Intervention Program, Boward County Department of Public Health. Interview 12/7/2006.

Guiding Principles of the Florida HIV/AIDS and Aging Task Force. (amhserver.fmhi.usf.edu/shapre/HAATF-GuidingPrinciples2000.html)

www.hivoverfifty.org/tip.html (Obtained 11/12/2006).

Inelman, E. M. , et al. (2005) HIV/AIDS in older adults: A Case Report and Literature Review. Geriatrics, September: 26-30.

Jemmott, L.S. & Jemmott, J.B. 3rd . (1991). Applying the theory of reasoned action to AIDS risk behavior: condom use among black women. Nursing Research, 40(4):228-34.

Klein, S.J., et al (2001). Age-Appropriate HIV Prevention Messages for Older Adults: Finding from Focus Groups in New York State. Journal Public Health Management, 7(3): 11-18.

Maes, C.A. & Louis, M. (2003). Knowledge of AIDS, Perceived Risk of AIDS, and At-Risk Sexual Behaviors Among Older Adults. Journal of the American Academy of Nurse Practitioners, 15(11): 509-516.

Medicaid and HIV/AIDS Fact Sheet. Published by AIDS Action. (www.the body.com/aac/Medicaid.html).

Orel, N.A., Wright, J.M & Wagner, J. (2004). Scarcity of HIV/AIDS Risk-Reduction Materials Targeting the Needs of Older Adults Among State Departments of Public Health. The Gerontologist, 44 (5): 693-696.

Schable, B., Chu, S.Y. & Diaz, T. (1996) Characteristics of women 50 years or older with heterosexually acquired AIDS. American Journal of Public Health, 86 (11): 1616-1618.

Sormanti, M., Wu, E., El-Bassel, N. (2004) Considering HIV Risk and Intimate Partner Violence Among Older Women of Color: A Descriptive Analysis. Women and Health, 39 (1): 45-63.

Stall, R & Cantania, J (1994). AIDS Risk Behaviors Among Late Middle-aged and Elderly Americans. Archives of Internal Medicine, 154: 57-163.

Strombeck, R. (1998). Educational Strategies and Interventions Targeting Adults Age 50 and Older For HIV/AIDS Prevention. Research on Aging. 20(6): 23-28.

Monday, December 18, 2006

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


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.


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.

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

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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.

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