Fear-Based Campaigns: The Way Forward or Backward?
Fear-based HIV campaigns were popular in the early years of the HIV epidemic -- they typically used scary imagery, such as tombstones, to alert the population to the dangers of HIV/AIDS. Fear-based HIV campaigns have resurfaced with the "It's Never Just HIV" campaign initiated by the New York City Department of Health. This campaign has dramatically divided HIV activists. But do fear-based campaigns work?
"It's Never Just HIV"
What Is Everyone Talking About?
Using graphic imagery and foreboding music and voiceover, the "It's Never Just HIV" campaign video warns that HIV can lead to osteoporosis (bone loss), dementia and anal cancer, even if someone is taking treatment. It closes with the words: "Stay HIV free. Always use a condom." This campaign, aimed at the city's Black and Hispanic young gay men and other men who have sex with men (MSM), was released in December 2010 by the New York City Department of Health, on YouTube and television. The video was accompanied by subway posters and an educational brochure available through community groups and service organizations.
The "It's Never Just HIV" campaign set off a barrage of commentary from AIDS activists and organizations, with arguments for and against the campaign.
Those who support the campaign believe that there is complacency surrounding HIV and that it is time to remind people of the consequences of HIV infection; it is not something solved by simply popping a pill a day. One of the most vocal supporters was activist Larry Kramer, a writer and founder of ACT UP (AIDS Coalition to Unleash Power) who said: "This ad is honest and true and scary, all of which it should be. HIV is scary and all attempts to curtail it via lily-livered nicey-nicey "prevention" tactics have failed."1
Those who are critical of the campaign, including New York's Gay Men's Health Crisis (GMHC) and the Gay and Lesbian Alliance Against Defamation (GLAAD), believe that it stigmatizes both people living with HIV and gay and bisexual men -- particularly Black and Hispanic gay men -- and creates more fear of the virus. Marjorie Hill, GMHC's Chief Executive Officer said: "We know from our longstanding HIV prevention work that portraying gay and bisexual men as dispensing diseases is counterproductive. Studies have shown that using scare tactics is not effective. Including gay men's input, while recognizing their strength and resiliency, in the creation of HIV prevention education is effective. Gay men are part of the prevention solution, not the problem."2
Another concern voiced by opponents of the campaign is that it may negatively affect people living with HIV, especially those recently diagnosed, who may feel that if all these bad things are going to happen, why bother taking treatment.3
Why Was the Campaign Developed?
The campaign was developed as a response to the increasing number of HIV infections in young Black and Hispanic MSM in New York City. There are approximately 4,000 new HIV infections in New York City every year. Seven out of 10 new diagnoses in New York City MSM are in African-American and Hispanic men.4 Although the number of new diagnoses in older men is declining (down from 1,190 in 2001 to 830 in 2009), the number in men under 30 has increased (up from 489 in 2001 to 747 in 2009).4
People from the Health Department also wanted to counter advertising from drug companies, which gives the impression that living with HIV is not a big deal.
Initially, the New York City Health Department asked gay and bisexual men to review a variety of marketing approaches that could encourage men to reduce their risks for getting HIV and complement existing prevention measures. The outcome was that these men urged the Health Department to use a hard-hitting strategy similar to that of anti-smoking campaigns.5
The chosen strategy, which aims to provoke fear, shows young men what they are risking when they have unprotected sex and tells them to reduce their risk for HIV infection by using condoms. Bone loss, dementia and anal cancer were chosen as just three of the conditions to highlight that can result from chronic HIV infection. The Health Department focus-tested the campaign with gay and bisexual men and found that "the response was very positive."5
What Is the Rationale Behind a Fear-Based Approach?
Fear-based campaigns use a scary image or message (for example, a picture of lung cancer on a cigarette package or the testimonial of a victim who lost a loved one to drunk driving) in an attempt to frighten people. It is thought that this fear will make people change their behaviour (for example, stop smoking or not to drive when drunk) to avoid the feared outcome. In addition to the scary image, the message usually contains information on how to avoid the negative consequence.
What Is the Evidence?
Are Fear-Based Campaigns Effective?
Much research has been conducted to investigate whether or not fear-based campaigns are effective. The best way to look at these results is through a meta-analysis, which synthesizes the outcomes from all the studies that have been done on a similar topic. This provides a more robust answer to the question of whether something (in this case, fear-based campaigns) is effective.
The largest meta-analysis conducted to date combined results from 98 studies that looked at different types of behavioural outcomes of fear-based campaigns -- such as drinking and driving, anti-smoking and safer sex campaigns. According to the results of this meta-analysis, fear-based campaigns do produce a small but statistically significant change in people's attitudes and behaviours. The authors noted that "fear appears to have a relatively weak but reliable effect on attitudes, intentions and behaviours."6
However, much of this research has limitations: Many of these studies were conducted in university labs with students. Research in the lab does not mimic what typically happens in the real world. For example, in a lab setting, someone cannot choose to avoid looking at the messages whereas in the real world, this can and does happen. Also, the students used as research subjects in these experiments may not reflect the target audience of the campaign. Would the target audience respond the same way? Finally, most of the research conducted to date evaluates the short-term outcomes of fear-based campaigns (typically, after three to six months). This means that we don't know if the reported behaviour changes continued beyond this limited timeframe.
Are HIV Fear-Based Campaigns Effective?
A 2005 meta-analysis of fear-based HIV prevention campaigns found that the strategy of appealing to people's fears did not work.7 This analysis synthesized the results of 194 studies that evaluated HIV prevention interventions aimed primarily at promoting condom use. The meta-analysis found that the most effective HIV prevention interventions:
However, this meta-analysis found that fear-based approaches did not increase rates of condom use and that such strategies were the least effective. Surprisingly, it found that fear-based approaches may be associated with decreases in condom use.
Why Might Fear-Based HIV Campaigns Not Work?
There are many possible reasons why fear-based campaigns are not effective at promoting condom use.
Some experts have suggested that fear-based campaigns generally work only on people who don't already know about the seriousness of the threat.8 It may be that most people are now so informed about HIV that a fear-based approach won't work anymore.
It may be that fear-based campaigns can work to promote the uptake of certain HIV prevention behaviours but not others. Although current research has found no evidence of an increase in condom use after an HIV fear-based campaign, a fear-based campaign could perhaps have an effect on other protective behaviours, such as abstinence. More research is needed to test this hypothesis.
Fear-based messaging does not take into account the "messy" environments in which decisions take place. Sexual encounters occur in a context that can be influenced by extraneous factors -- such as drug use, coercion or violence -- which can impact a person's ability to make informed choices. This can strongly influence whether someone can make the choices needed to protect themselves.
In some situations, fear-based campaigns can produce the opposite effect of what was intended. Such campaigns have been found to provoke two simultaneous, opposing reactions:6,9,10 on the one hand, a positive response -- the tendency to adopt the recommended behaviour; on the other hand, a negative response, or a defense mechanism, which results in not adopting the recommended behaviour. More specifically, a fear-based message may evoke the following defensive mechanisms:
Denial -- If people believe that the harmful consequence is unlikely or impossible, they may discount or deny the information and the relevance of the message.10-12
Othering -- "Othering" occurs when the target audience thinks that the message is not directed at them but at some other group.11 For example, older gay men may rationalize that the target audience is younger gay men. When "othering" occurs, people do not heed the message or change their behaviour.
Ridiculing -- Ridiculing occurs when a person thinks the message is absurd and, consequently, does not heed its message.
Minimizing -- Minimizing occurs when people think that the negative outcome is exaggerated and therefore don't respond to the message. For example, younger people are more likely to not have a sense of their own mortality; this may lead them to minimize the message.
Avoidance -- People may avoid the message altogether.11 People don't necessarily want their views challenged and may therefore avoid the messages -- by flipping the page, changing the channel or simply tuning out.
This article was provided by Canadian AIDS Treatment Information Exchange. It is a part of the publication Prevention in Focus: Spotlight on Programming and Research. Visit CATIE's Web site to find out more about their activities, publications and services.
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