Challenging Dogma


...Using social sciences to improve the practice of public health

Saturday, April 21, 2007

Return to Sender: How Abstinence Education and Campaigns Have Failed in Addressing the African-American Community – Italo M. Brown

In a society where HIV/AIDS and other sexually transmitted diseases are having a devastating impact on the health outcomes of people, there is a constant push by the public health community to seek courses of action and intervene on the behalf of all humanity. Decade after decade, new strides are made and fresh ideas are shoveled through the gauntlet of efficacy—with hopes of reaching a new level of protection. Nearly 1.5 million Americans have been diagnosed with HIV, and sadly, the numbers continue to escalate (1). Yet, it is difficult to overlook that 13% of the total U.S. population accounted for approximately half of the new HIV/AIDS cases diagnosed in 2005 (2). The same 13% of America’s population has a rate of diagnosis that is at least 10 times greater than other classified groups (3). Unfortunately, the individuals who represent this particular thirteenth percentile are African-Americans. Although the cumulative total of prevalent AIDS cases in 2005 for both the majority (White) and the African-American ethnicities is estimated at 400,000, a greater proportion of blacks are contracting this potentially-fatal disease (3).

As the African-American culture continues to evolve into a more diverse yet intricate mosaic and its influence continues to impact the world, one can only ponder why the health outcomes of this group continue to lead in the negative category. The apparent rise in HIV/AIDS cases among African-Americans has, however, triggered some directed public health response; interventions such as needle-exchange programs and condom promotion/education have been implemented in the Black community, yielding marginally positive results. Yet, one intervention tactic has been abandoned as a probable mechanism to lower the incidence of HIV/AIDS in this group. Abstinence campaigns and abstinence educational initiatives are among the myriad of public health strategies implemented worldwide, in efforts to combat this pandemic. Its traditional appeal is ornately fortified with orthodox religious values, generally making it an effective mode of HIV/AIDS prevention in the United States. Under the Bush Administration, over 100 grantees have been awarded funding to initiate abstinence-only education services in communities across the nation (4). Since 2001, approximately $200 million dollars of the national budget have been allocated to abstinence-only efforts in America each year (4). However, from a social and behavioral standpoint, one could argue that the abstinence campaign is biased, and thus has a null effect on the Black community. The use of abstinence education and abstinence campaigns has failed in the Black community for a number reasons orbiting around the inherent inability to accurately assess this dynamic and unique social structure. First, the educational platform and campaign substance is “framed” in such a way that it alienates black people from the concept of abstinence; the community cannot readily identify with the materials or mode of transmission. Secondly, the actual concept of “abstinence” (abstaining from sex, indefinitely) is rather unrealistic, with respect to social dynamics established within the black community; the lack of “self-efficacy” in abstinence campaigns transforms the idealized goal into something of a joke. Finally, given that subjective norms exert an outward influence on personal behavior, educational campaigns for abstinence fail to identify and address subjective norms that are unique to the African-American culture, making behavior change highly unlikely.

The Abstinence Clearinghouse is considered one of the foremost advocates of the abstinence campaign. In conjunction with other organizations whom share similar public health aims, the National Abstinence Clearinghouse seeks to prevent sexual risk behaviors among youth that result in HIV/AIDS and other STDs” (5). However, if one were to visit this non-profit organization’s website, the first visual image seen would be a picture with a 20-something year old White woman in the foreground and a distinguishably young, White man in the middleground (6). This observation surfaces the existing paradox between HIV/AIDS intervention and target audiences; with African-Americans leading all ethnic groups in incident cases of the virus, one would expect such prevention campaigning to at least show the faces of the population at highest risk. Perhaps this dynamic alludes to a potential reason why abstinence campaigning in the Black community yields non-responsiveness, and frankly, is not a factor in changing outcomes. In social science, the theory of “Framing” describes the process or manner by which an idea is packaged, which in turn, influences the way that idea is perceived (7). Abstinence campaigns are failing among African-Americans because the idea of abstaining has been poorly framed. These campaigns and educational materials tend to appeal to white middle-high income, moderately religious suburban teens, an audience hardly comparable to the “high risk” black community. Maybe supporters and initiators of abstinence campaigning are oblivious to the fact that their message is inherently biased (faces on the literature and on the site do not reflect the target population adequately) and subconsciously wedges Blacks and the thought of abstinence further apart.

Research has shown that when youth identify with the characters or possess similarities with the images being depicted to them, behavior change is more likely to occur (8). By failing to connect the African-American youth with the message of abstinence through appropriate framing, educators and supporters have warranted an adverse affect. In other words, it is more likely that a Black teenager feels alienated by this message, or more importantly, that this message doesn’t even apply to him (think, “Well, no one in it looks like me, so it must not be speaking to me”). The countercurrent emotions adopted by youth in the “high-risk” population only strengthen the dissociation between Blacks and abstinence, and ultimately continue yield no reducing effect on incident cases.

As stated earlier, the African-American community is dynamic and filled with intrinsic complexity. It is interesting however why no one has drawn attention to the poor efficacy of this particular facet of HIV/AIDS prevention in this community, a facet which is readily engaged and that, if intervention was successful, would prove more cost-efficient. To combat the rapid rise in cases among African-Americans seen in the past two decades, public health aficionados collectively implemented practical ideas to reduce the risk of contracting the virus—i.e. community-based needle-exchange programs (reducing the risk among IV drug users) and condom-education centers and services. The consistent theme in both of these types of high-risk group interventions is that the programs were rather doable; neither program emphasizes complete cessation of the behavior, just merely making reasonable augmentations to personal habits. According to A. Bandura, the concept of “self-efficacy” is an essential element in influencing behavioral changes (9). Adapted from the social cognitive theory, self-efficacy is described as the “belief that one has the capabilities to execute the courses of actions required to manage prospective situations”(10). When assessing the effect of abstinence campaigns in the black community, it can be argued that little attention is given to this notion of self-efficacy; put simply, African-Americans do not consider abstaining from sex as a plausible goal. Abstinence campaigns and education initiatives have failed to address the impracticality of its aims, especially as it relates to the black community. For example, research in public school systems (via questionnaire) has shown that urban youth and minorities are more likely to engage in sexual activity (2). According to the 2005 Youth Risk Behavior Surveillance Survey System (YRBSS), 68% of black student respondents reported ever having sex, whereas 43% of white respondents and 51% of Hispanic respondents reported the same (11). Also, black student respondents lead in reports of having sex with 4 or more persons, 28% compared to 16% and 11% for Hispanic and whites respectively (11). Given this knowledge, coupled with the prudent facts solidifying the absence of “sufficient” abstinence education in those settings, it is clear that self-efficacy is not being considered as a pathway through which this preventative behavior can be expressed. Moreover, when one analyzes the compound effect of poor framing and the lack of an approach which considers self-efficacy, the reason why black youths do not abstain from sex sticks out like the proverbial sore thumb. In other words, African-American youths take abstinence as comic relief, provided that the message does not address them and the idea of abstinence is ridiculous to them. As the public health community continues to spearhead efforts to reduce the incidence of HIV/AIDS using abstinence education as a medium, it might prove beneficial to incorporate a level of practicality to inadvertently encourage people to attempt.

Research has indicated that ethnic communities possess a highly developed social infrastructure completely independent of common American society (12). In the African-American construct, it is socially acceptable to engage in sexual activities at a young age; in fact, one might even go as far as to say it is applauded, rewarded, and encouraged. Sexual behavior is positively reinforced in the community through various media: the music listened to, the visual images relayed via urban culture, interpersonal interactions, male-female social dynamics. All of these factors contribute to what is known as subjective social norms. Under the theory of reasoned action, it is believed that a particular behavior is manifested through intentions, which are a function of attitudes toward and surrounding the behavior, as well as the influence of subjective norms in one’s environment (13). Abstinence campaigns have taken subjective norms into account in the “general” population, but have failed to do so at the level of the African-American community. For example, some campaigns under Title V Section 510 funding have identified the parent-child connection as a probable indicator of how well abstinence messages are received (14). Many of the programs encourage parents to be “actively engaged in the program”, and to “attend focus sessions with their child” (14). Yet, in the black community, single-parent households have evolved into a social norm, and this norm exerts a certain influence on the lives of black youth. Therefore, this type of approach may prove ineffective on the premise that a subjective social norm has an impact on the target population. A research study by M. Bazargan for the Research Centers in minority Institutions showed that of the cross-sectional study participants (Los Angeles County High School Students), African-Americans were more likely to report higher levels of perceived peer pressure, lower levels of behavioral and refusal skills for avoiding sexual activity, and a more positive attitude towards sex—all of which were leading indicators for lowered likelihood to remain sexually inactive (15). If one were to take implications such as these into account, it could be concluded that subjective social norms clearly govern the lives of African-American youth, making them more susceptible to societal vices. So as a result, the minor effect that current abstinence education has on the Black population is further diminished due to the seemingly overwhelming presence of subjective norms.

Although one might argue that the startling increase in HIV/AIDS within the black community should carry enough shock value to alter personal intentions, it is clear that when weighed against nonconforming, fitting in and being accepted by societal standards wins out more often than not. To further illustrate, in The Persuasion Handbook, by author J. Dillard, it is noted that the influence of a subjective norm is weighted; in other words, the relative level of importance that the target individual places on the normative influence can sway that individual to do or not do a particular behavior (16). Advocates of abstinence-only education have overlooked the heavy importance that Black youths place on cultural norms. Everything from the way one dresses, to the music listened to, and the words used in day-to-day conversation are impacted by subjective norms in the Black community. So with the target age bracket being so impressionable and relying on intrasocially-accepted behaviors to validate their being, one would find it rather appalling that intelligible public health persons do not fully adopt this model in abstinence education. By failing to attack the subjective norms solidified in the black community, abstinence advocates are increasing their workload, decreasing their efficiency, and virtually attempting to ice-skate uphill.

In conclusion, abstinence campaigns and educational efforts, on the whole, have proven marginally effective. However, these messages have been so poorly addressed, that a group of distinctive, considerably at-risk people have become immune to its intent. The current frame that abstinence campaigns use provides African-Americans with a distorted view of the intervention, making it seem exclusive rather than all-inclusive. The current approach to promoting abstinence doesn’t reinforce self-efficacy, leading members of the African-American community to view the idea of abstinence as improbable, a complete farce, and a waste of one’s time. Finally, the current methodology of abstinence campaigning doesn’t factor in subjective social norms unique to the African-American culture, and thus, many attempts have been blindly misguided. If public health practitioners and abstinence advocates wish to battle HIV/AIDS wielding abstinence campaigning and education as a viable weapon, attention to the aforementioned gaps would undoubtedly yield better results.

References:

1. Centers for Disease Control and Prevention. MMWR 2006. http://www.cdc.gov/
2. Mengers, Patti. Talk focuses on HIV/AIDS in black community. Delcotimes Newspaper. 2007.
3. Centers for Disease Control and Prevention.
HIV/AIDS Surveillance Report: HIV Infection and AIDS in the United States and Dependent Areas, 2005. http://www.cdc.gov
4. The Office of Management and Budget. “Supporting a Compassionate Society”. FY06 Budget Priorities. White House Website.
http://www.whitehouse.gov/omb/budget/fy2006/compassion.html
5. The Abstinence Clearinghouse Website. Cooperative Agreement with the Centers for Disease Control. Abstinence Clearinghouse. Sioux Falls, SD. http://www.abstinencepartners.net/
6. The Abstinence Clearinghouse Website. Main Page. Abstinence Clearinghouse. Sioux Falls, SD. http://www.abstinence.net/
7. Dorfman, Lori, Lawarnce Wallack and Katie Woodruff. “More than a message: Framing Public Health Advocacy to Change Corporate Practices.” Accessed March 2007.
8. Maibach, E. and Parrott, R.L. “Reaching Young Audiences: Developmental Considerations in Designing Health Messages” by Austin, Erica. Designing Health Messages: Approaches from Communication Theory and Public Health Practice. SAGE Publications, Inc. Thousand Oaks, CA. 1995.
9. Bandura, A. (2001). Social cognitive theory: An agentic perspective. Annual Review of Psychology, 52, 1-26.
10. Wikipedia. Self-efficacy. Wikimedia Foundation Inc.
http://en.wikipedia.org/wiki/Self_efficacy.
11. Centers for Disease Control and Prevention. Youth Risk Behaviors Surveillance – United States, 2005. Surveillance Summaries, June 9, 2006. MMWR 2006.
http://www.cdc.gov/HealthyYouth/yrbs/
12. Kivisto, Pete. Americans All: Race and Ethnic Relations in Historical, Structural, and Comparative Perspectives. Second Ed. 2005.
13. Wikipedia. Theory of Reasoned Action. Wikimedia Foundation Inc.
http://en.wikipedia.org/wiki/Labeling_theory.
14. Devaney, Barbara. The Evaluation of Abstinence Education Programs Funded Under Title V Section 510: Interim Report. Mathematica Policy Research, Inc. Apr. 2005.
15. Bazargan, Mohsen. West, Kimberly. Correlates of the Intention to Remain Sexually Inactive Among Underserved Hispanic and African American High School Students Journal of School Health 2006. 76 (1), 25–32.
16. Dillard, James P. Pfau, Michael. The Persuasion Handbook: Developments in Theory and Practice. SAGE Publications, Inc. Thousand Oaks, CA. 2002.
17. Chua, Kao-Ping. “Introduction to Framing.” Accessed March 2007 .
18. Martindale, Don. The American Social Structure: Historical Antecedents And Contemporary Analysis. Appleton-Century-Crofts. New York, NY. 1960.

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