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ABSTRACT
An Exploration of the Social, Political, Religious, and Economic Constraints to
the Implementation of an Effective AIDS Prevention Program
Until a cure for AIDS is found, prevention is the key, but health
communication research states that effective AIDS/HIV prevention programs have
not been implemented. Researchers and AIDS prevention program coordinators agree
about what constitutes an effective AIDS prevention program. However, both
groups discussed various obstacles to the implementation of such programs. This
study found that the obstacles that are the most prevalent spring from the
conservative movement that has been sweeping the nation since the 1980s.
Constraints to AIDS Prevention Programs
An Exploration of the Social, Political, Religious, and Economic Constraints to
the Implementation of an Effective AIDS Prevention Program
PURPOSE
Despite the recent reports in the media that the number of AIDS deaths fell 13%
in the first six months of 1996, the number of AIDS/HIV-related cases in the
United States continues to rise at an alarming rate. Since 1981, the amount of
reported AIDS cases in the United States has climbed up to 581,429 (CDC
Surveillance Report, Dec. 1996). In the United States alone, the disease has
become the leading cause of death for all Americans ages 25-44. Furthermore,
AIDS is the third leading cause of death for women. In 1996, women made up 20%
of new cases.
It is evident prevention is the key, but health communication research states
that effective AIDS/HIV prevention programs have not been implemented in the
United States. However, most of this research was developed during the first
decade of the disease. As the second decade of the AIDS/HIV epidemic in the
United States comes to a close, it is important to examine whether or not the
social, political, religious, and economic constraints that plagued AIDS
prevention programs during the first decade of the disease still exist.
The purpose of this study is to explore the problems and opportunities program
planners encounter with the implementation of effective AIDS/HIV prevention
programs.
Significance
Much of the existing research about AIDS prevention and education focuses on
both what is effective and the fact that individuals are not changing their
risky behaviors (e.g. many studies discuss how college students continue to have
unprotected sex). If health communication researchers know what would make
individuals change their behavior, why do individuals continue to engage in
risky behavior? Existing research has not addressed this paradox adequately.
Perhaps AIDS prevention program planners are aware of the research that
discusses what is effective. Perhaps they know from their own experience what
will make people change their behavior. However, constraints may be preventing
these AIDS education planners from developing the kinds of programs that are
effective. If these program planners can ascertain and understand the obstacles
they face, they can design strategies to overcome them. This study will help
identify the obstacles to AIDS prevention with the goal of determining what
avenues should be taken to implement the kinds of effective programs health
communication researchers recommend. Furthermore, this study should help to
establish a new focus of health communication research -- how to overcome the
obstacles to effective AIDS prevention programs.
LITERATURE REVIEW
Because a cure for AIDS may never be found, prevention is the only way to stop
the spread the disease (Freimuth, Hammond, Edgar & Monahan, 1990; Maibach, Kreps
& Bonaguro, 1993; Westmoreland, 1987). The most effective prevention tools are
public education programs that teach people how to avoid transmission of the
disease (Flora & Maibach, 1990; Freimuth et al., 1990; Westmoreland, 1987).
Since AIDS/HIV first was identified, educational programs have been designed to
inform the public about the disease.
Surveys of adolescents, drug users, prostitutes, college students, and the
general population demonstrate these groups have fairly accurate information
about how AIDS/HIV is transmitted and how to protect themselves (Freimuth, 1992;
Freimuth et al., 1990; Freudenberg, 1994; Turner, Miller & Moses, 1989). The
increased level of knowledge about AIDS constitutes a triumph for AIDS education
(Freudenberg, 1994). Although AIDS/HIV programs have contributed significantly
to the increase in the American public's knowledge of the disease, these
programs have not been universally effective in changing people's behavior
(Becker & Joseph, 1988; DeJong & Winsten, 1992; Edgar et al., 1989; Freimuth et
al., 1990; Freudenberg, 1994; Tones, 1986). One repeated finding is that
accurate information is not by itself a predictor of behavior change (Becker &
Joseph 1988; Turner, Miller & Moses 1989).
For example, several studies show that although the American Association for
World Health (1996) recently found that condom use among adolescents increased
from 46% to 56%, a significant number of adolescents and college students still
are not protecting themselves from AIDS/HIV consistently (Becker & Joseph, 1988;
Sheer & Cline, 1994; DiClemente, Boyer & Morales, 1988; Turner, Miller & Moses,
1989). Although homosexual men have shown the most significant changes in sexual
behavior (some studies show as much as 90% of urban gay men have made some
changes in their sexual behavior, such as using a condom), many men who have sex
with men do not practice safe sex regularly. They may use condoms more, have
unprotected anal sex less, and have fewer sexual partners, but only a small
minority always follow safer sex guidelines (Becker & Joseph, 1988; Turner,
Miller & Moses, 1989). DesJarlais and Friedman of the New York State Division of
Substance Abuse Services (1988) found that more than half of the IV drug users
who have participated in studies have made some changes in their risk behavior
related to AIDS, such as getting off drugs or using clean needles more. However,
less than half of the IV drug users have changed their sexual behavior. Fewer
practice these changes consistently.
These examples demonstrate that gains in factual knowledge often do not lead to
health-protective changes in sexual behavior. Effective AIDS educational
programs must motivate, as well as inform. So programs must help target
audiences recognize their HIV risk, convey appropriate strategies for minimizing
risk, and motivate audiences to implement these strategies (Atkin, 1981; Kreps &
Maibach, 1991; Rubinson & Alles, 1984; Tones, 1986). Although the purpose of
this paper is to examine the obstacles to the implementation of effective AIDS
prevention programs, first it is important to examine what researchers say
constitute effective AIDS prevention programs.
Researchers' Recommendations for AIDS/HIV Prevention Programs
Besides abstinence, condom use is the best protection against sexually
transmitted AIDS (DeJong & Winsten, 1992). To be more effective, programs should
address the psychological barriers that impede greater use of condoms,
demonstrate the immediate personal benefits that condom use might bring, and
teach interpersonal skills necessary to introduce their use in a sexual
relationship (DeJong & Winsten, 1992). DeJong and Winsten (1992) said promotion
efforts should show "a new normative consensus in favor of condom use" (p. 266).
If advertising and other promotions show teenagers that condoms have a
widespread acceptance among both women and men, they are more likely to use
condoms themselves.
The mass media, especially television, are the best vehicles for disseminating
prevention messages because the mass media reach large numbers of people quickly
(Freimuth, 1992; Signorielli, 1993). Although the mass media are not expected to
shoulder the responsibility of educating people about AIDS, the media can
provide the information necessary for people and institutions to make informed
decisions on both an individual and public level (Netters, 1992).
Solomon (1989) found the most consistent advice for developing effective health
messages is to target messages to specific groups in the audience rather than
attempting to create messages appropriate for a general audience. Because the
individuals who are at greatest risk for AIDS/HIV are diverse, both culturally
and behaviorally, campaign planners cannot develop a general set of effective
campaign messages that will work equally well with all audiences (Ratzan, 1993).
So these different programs must establish different objectives, use various
communication strategies, and have separate measures of success based on the
type of target audience (Rugg et al., 1990, p. 83). Campaign planners must
"consider the nature of the health risk, the specific target audience, and the
behavior change they wish to encourage the target audience to adopt" (Flay &
Burton, 1990, p. 131).
Furthermore, in addition to targeting populations who engage in high-risk
behaviors, such as homosexuals and IV drug users, AIDS/HIV communication
programs should be "designed to discourage others who currently do not engage in
risky behavior from adopting behaviors that would put them at risk" (Maibach,
Kreps & Bonaguro, 1993, p. 16). For example, AIDS/HIV prevention programs need
to target teenagers to prevent "the initiation of high-risk behavior" (Maibach,
Kreps & Bonaguro, 1993, p. 16).
Advocates for safe sex education and condom provision to youths and adolescents
argue that they do not necessarily approve of youths having sex so early.
However, they realize that large numbers of young people are sexually active but
remain ignorant about the consequences of their behavior (Jonsen & Stryker,
1993). These advocates say adolescents are going to have sex regardless of
warnings from authorities, and not providing safer sex education or condoms to
young people places them at risk of HIV infection. These advocates call for the
provision of age-appropriate sex education that includes information about
homosexuality, modes of HIV transmission and methods of prevention, as well as
the provision of condoms without either mandatory counseling or parental consent
(Jonsen & Stryker, 1993).
Metts and Fitzpatrick (1992) suggested sexual communication competence be
taught in schools because students have little or no information about effective
communication techniques for enacting information-seeking episodes that lead
smoothly to and through protected sex. Adelman (1992) said sex education needs
to combine cognitive, affective, and behavioral learning that encourages various
ways to initiate discussion of safe sex with a potential partner. Because
scripting or improvising "sex talk" may be difficult and awkward, Adelman (1992)
suggested teachers discuss protective techniques that can encourage discussion
about safe sex.
Maibach et al. (1993) said because AIDS prevention programs concern "personal,
habitual, and often taboo topics such as sexual practices and illegal drug use,"
discussing these topics can be challenging and difficult (p. 17). So, although
these researchers' strategies and suggestions for more effective programs have
existed for several years, many constraints prevent such programs from being
implemented. These campaign ideas often are met with some form of opposition.
Obstacles to Researchers' Recommendations for AIDS/HIV Prevention Programs
Condom programs have been criticized for promoting sexual promiscuity rather
than having a vital role in preventing the spread of HIV (Ratzan, 1993). Condom
use is morally unacceptable to large numbers of people who oppose contraception,
so program planners have been hesitant to include the promotion of condoms in
their programs (DeJong & Winsten, 1992). They fear, correctly, that they will
not receive adequate media attention or government support if they do.
The U.S. broadcast media do not want to alienate large segments of the mass
audience or endure the political or economic pressure that would ensue if they
are used to communicate the specific information that is necessary for
motivating condom use or other safe sex behavior (Montgomery, 1989). In 1992,
some local affiliates accepted condom advertising, but the major networks did
not. However, a 1987 poll showed 60% of U.S. adults were in favor of
contraceptive advertising, while 37% were not (Louis Harris & Associates Inc,
1987). Furthermore, when former Surgeon General Koop and others called for
increased condom use to stall the AIDS epidemic, support for contraceptive
advertising increased to 74% of those polled (Louis Harris and Associates Inc.,
1987). Although these statistics should have convinced the television networks
to air contraceptive advertising, a small, highly vocal group still opposed such
ads, so the networks hesitated (DeJong & Winsten, 1992).
The concerns of national broadcasters have influenced the way AIDS prevention
public service programs have dealt with the issue of condom use and safe sex
behavior (DeJong & Winsten, 1992). Even in 1988, this reticence meant condom use
could not be suggested in television or radio public service announcements as an
AIDS prevention method. Also, various AIDS programs often were obscured by the
media frenzy over objections to the candid and precise language and visual
representations used by other groups (Ratzan, 1993). Television networks would
not accept advertising for contraceptives until 1991 and refused to run some
PSAs about AIDS that included condoms.
Freimuth et al. (1990) said AIDS requires discussing sensitive issues such as
explicit sexuality and death and dying, but the target audiences for many AIDS
prevention messages are small and stigmatized groups (such as homosexuals and IV
drug users), who are not in the mainstream of normal television programming. So
the researchers were not surprised from the results of a content analysis they
conducted that found the majority of the PSAs about AIDS (69%) did not address
specific risk behaviors. For example, although in 1988 the CDC reported that 63%
of AIDS cases have been transmitted by unprotected homosexual behavior, only one
of the messages analyzed was targeted to audiences engaging in this high-risk
behavior.
The inconsistency between choice of target audience and discussion of high-risk
behaviors "reflects the difficulty of using a mass medium to reach small
stigmatized groups" (Freimuth et al., 1990, p. 776). Members of the target
audiences such as homosexuals and intravenous drug users often engage in
behaviors foreign to traditional target audiences. Messages intended for these
groups that are broadcast on a mass medium also will reach many other audiences
who may be offended by the content or whose prejudices about these groups might
be reinforced by the messages (Freimuth et al., 1990). So although early
communication programs that were developed by and for homosexual men included
explicit descriptions and illustrations of safe sex techniques, programs
developed for the general public or broader audiences were much less explicit
and rarely mentioned condom use or sexual transmission (Brown, Waszak &
Walsh-Childers, 1989).
There has been a continuous conflict over the role of education about safer sex
and condom distribution programs in preventing HIV transmission, especially when
the programs have been designed for school-age people. Although there has been
strong resistance in the national government to condom education for people of
all ages (Jonsen & Stryker, 1993), Freudenberg (1994) has found that public
opinion polls show strong support for government-supported AIDS education. As
early as 1985, a national poll showed 74% of the respondents supported
production and distribution of explicit safer sex educational materials.
However, despite broad public support for AIDS and sex education in schools,
development and implementation of these programs repeatedly have been blocked by
a vocal minority of religious leaders and conservatives (Freudenberg, 1994).
Opponents of safer sex education and the provision of condoms argue that the
control of sexuality of young people properly belongs with parents and religious
institutions, which emphasize chastity before marriage and fidelity afterward
(Jonsen & Stryker, 1993). This group argues that safer sex education threatens
these goals and appears to condone sexual experimentation (Jonsen & Stryker,
1993).
These religious groups have been successful in enforcing their approach to AIDS
education. For example, in 1986 when condom provision in the public senior high
schools in New York City was proposed, an active coalition of religious groups,
led by the Archdioceses of New York and Brooklyn, persuaded the school board to
reject the proposal (Jonsen & Stryker, 1993). In New York City, a film on AIDS
for high school students was withheld for more than a year because it did not
stress abstinence sufficiently. School programs often are unable to use clear
and explicit language that would help young people protect themselves
(Freudenberg, 1994).
All of these obstacles to the campaign strategies and suggestions of health
communication researchers exemplify the extreme negative impact a small but
vocal group of moralists have had on the implementation of effective AIDS
prevention programs. Now only political action and leadership will secure an
appropriate scientific and humane response to this disease because "politics
permeates every aspect of prevention, research, and treatment" (Krieger &
Appleman, 1994, p. 24). However, the choices a government makes to control any
epidemic such as AIDS depend not only upon general social attitudes toward those
afflicted but also, even more importantly, upon the economic and political
agenda of the ruling power at the time when the epidemic strikes (Krieger &
Appleman, 1994).
So the reason AIDS has provoked a genuine policy crisis is that it has forced
the U.S. government to choose between its duty to defend the existing moral
order and its obligation to protect the nation's health: either it could appease
the right wing and endanger the public's health or it could follow the
scientific recommendations and offend political sentiment among vocal groups
(Krieger & Appleman, 1994). In the United States, when the epidemic first
struck, the government chose the first option - it catered to the New Right,
which was gaining popularity. The country did so at the expense of the disease's
first victims.
The U.S. Government Responds to AIDS
Pressure from conservatives in America has been "effective in preventing the
federal government from assuming the leading role in educating the public about
AIDS," and for several years no coherent national policy was developed, and no
strategy for educating the public ever was articulated (Silverman, 1992, p.
351). Health communication and political experts have blamed the Reagan
administration and the New Right for the slow response to the disease (Hombs,
1992; Krieger & Appleman, 1994; Silverman, 1992; Westmoreland, 1987).
President Reagan did not discuss AIDS in any of his State of the Union
addresses (Silverman, 1992). The first time Reagan formally mentioned AIDS was
at a September 1985 press conference, four years after AIDS first appeared. He
said the U.S. public did not need to panic because AIDS remained confined to the
homosexual and intravenous drug user populations (Krieger & Appleman, 1994).
When he finally mentioned the subject again in May 1987, he used a major portion
of his discussion to endorse mandatory testing of individuals, in contradiction
to the recommendations of his head of public health, Surgeon General C. Everett
Koop. Furthermore, no effort was made to place the Surgeon General or any other
expert in charge of the AIDS fight.
Many researchers speculate that AIDS did not reach the top of the political
agenda because the disease initially struck groups traditionally stigmatized in
American society -- homosexuals and intravenous drug users (Krieger & Appleman,
1994). Westmoreland (1987) said the federal government did not want to be seen
or perceived as "condoning" homosexuality. "Politicians easily could dismiss the
urgency of the problem because initially it seemed to be an isolated situation
only affecting a small and relatively disenfranchised segment of society"
(Silverman, 1992, p. 353).
The administration took this stance despite recommendations from the National
Academy of Sciences, which called for a sexually explicit, frank educational
campaign geared toward both the population at large and high risk groups
(Committee on A National Strategy for AIDS of the Institute of Medicine, 1986).
However, although other countries were implementing such risk-reduction
programs,[1] the Reagan administration stonewalled such efforts and encouraged
lower levels of government to do the same (Krieger & Appleman, 1994).
In addition to ignoring the problem, the Reagan administration made it
difficult for AIDS prevention efforts to receive funding. The Reagan
administration engaged in a massive military buildup financed by large
reductions in social spending (Krieger & Appleman, 1994). In the fiscal year
1981 the National Institutes of Health spent $3,225 per death on AIDS and $8,991
in FY 1982. Interestingly, toxic shock syndrome was solved by FY 1982, but NIH
spent $36,100 per death on it that year (Hombs, 1992 ). In 1982 and 1983, nearly
95% of all federal research money for AIDS came from funds already allocated to
other important health research projects (Oakland Tribune, 1985). In 1985, only
5% of the federal budget for AIDS went to education (Krieger & Appleman, 1994).
When Congress proposed raising the education allocation to 20% ($68 million) in
the 1986 budget, the Reagan administration sought to cut this amount by a third
(New York Times, 1986). In 1990, President Bush said he was not convinced
spending more money on AIDS would have any additional effect in curbing the
epidemic (New York Times, 1990). Funding seemed even more limited for at-risk
groups. In 1985 the Office of Technology Assessment of the U.S. Congress wrote,
"So far, efforts to prevent AIDS through education have received minimal
funding, especially efforts targeted at groups at highest risk" (Bayer & Kirp,
1992, p. 33). For example, gay and bisexual men accounted for 88% of all AIDS
cases in California in 1991, but only 5% of the state's prevention money went to
that group (Coates, 1996).
Krieger and Appleman (1994) said the U.S. government's response to AIDS cannot
be "understood apart from the New Right's emergence as a powerful political
force and its influence on the Reagan administration (p.15). The New Right used
the AIDS crisis as a "political godsend" (Krieger & Appleman, 1994, p. 17). The
AIDS crisis gave the New Right a fresh reason to reaffirm its stance against
homosexuals, intravenous drug users, and promiscuity (Krieger & Appleman, 1994).
For example, Patrick Buchanan, Reagan's arch right-wing adviser, characterized
AIDS as nature's revenge for unnatural sex: "the poor homosexuals, they have
declared war upon nature, and now nature is exacting an awful retribution"
(Krieger & Appleman, 1994, p. 17). The New Right and the nation's conservatives
used religion as a means to oppose prevention efforts.
The important influence of religion in American social life also has played a
crucial role in shaping and limiting the content of AIDS prevention efforts
(Bayer & Kirp, 1992). Religious fundamentalists have used their influence to
restrict the implementation of effective programs. Many religious groups have
interpreted the AIDS epidemic in the light of their beliefs and teachings
(Jonsen & Stryker, 1993). Religious values have been cited as a rationale for
efforts to stop such crucial policies as frank and effective prevention
education (Hombs, 1992).
During the first decade of the disease, the United States was marked by
economic recession and cutbacks at all levels of government, so health
communicators had the task of educating the public about AIDS with fewer and
fewer resources at their disposal (Ratzan, 1993). Instead of helping health
communicators implement effective AIDS prevention programs, the nation's leaders
opted to preach the age-old appeal to "just say no" and to recommend abstinence,
rather than execute a realistic effort to develop strategies that would educate
the public on how to lessen their risk of contracting AIDS (Ratzan, 1993).
Although some researchers have blamed the Reagan and Bush administrations,
as well as the Religious Right, for most of the obstacles to more effective AIDS
prevention programs, the current government has had the opportunity to learn
from past governments' examples. Since President Bill Clinton has been in
office, funding for AIDS programs has increased dramatically. The major health
policy makers in the Clinton administration consistently have recognized AIDS as
one of the most serious national health problems (Quam, 1992). In December 1995
Clinton met with AIDS experts from across the nation to discuss the status of
the epidemic and tactics to deal with the disease (AIDS Policy and Law, 1995).
However, that same year Republicans took over Congress, and there has been
considerable apprehension by AIDS prevention and education advocates that some
of the important funding that Clinton supported now will decrease significantly
(Hodel, 1995). So AIDS prevention advocates have started to target
"small-town-bred, small-town-value Congressional Republicans and conservative
Democrats" to try and "win over the new majority in Congress on the issue of
HIV/AIDS funding" (Barnes, 1995, p. 31). However, no extensive research has been
conducted to determine whether obstacles experienced by AIDS campaign planners
previously still exist today and if they do, why.
So, this study examined the current social, political, religious, and economic
barriers to the implementation of effective AIDS prevention programs.
METHODOLOGY
Advantages of Qualitative Research
Because so little research has explored the constraints that affect the
implementation of effective AIDS prevention programs, a qualitative methodology
is appropriate because it allows for a more in-depth analysis of the research
problem. Health communication researchers discussed some of the obstacles to
the development of AIDS education and prevention programs in the first decade
of the disease. However, AIDS prevention and education program planners have
not been asked to address these issues. It is essential to ask them to discuss
the obstacles because they continue to face these obstacles daily.
If health communication researchers wish to help program planners overcome the
obstacles to the implementation of effective AIDS prevention programs, they
first need to understand the barriers program planners encounter. As Lindlof
said, "Qualitative inquirers strive to understand their objects of interest"
(1995, p. 9).
By contrast, a quantitative measure analysis would not be as useful because
quantitative research is designed to "isolate and define categories as
precisely as possible before the study is undertaken, and then to determine,
again with great precision, the relationship between them" (McCracken, 1988, p.
16). However, this study is designed to go beyond just defining the categories.
And furthermore, many of these responses can't be placed into distinct
categories. So, like all qualitative research this study will try to:
make sense of what goes on, to reach out for understanding or an
explanation beyond the limits of what can be explained with the
degree of certainty usually associated with [numerical] analysis
(Wolcott, 1994, p. 10-11).
Qualitative research allows the researcher to look for "patterns of
interrelationships between many categories rather than the sharply delineated
relationship between a limited set of them," according to McCracken (1994,
p.16). Given the complexity of the various obstacles to prevention efforts,
exploring many interrelated factors is necessary before realistic
recommendations can be made.
In-depth interviews were used to collect the data because "in-depth interviews
permit you to examine a particular research question in an open-ended fashion"
(Broom & Dozier, 1990, p. 42). Furthermore, interviews "give us the opportunity
to step into the mind of another person, to see and experience the world as
they do themselves" (McCracken 1988, p.9). The interviews conducted were
"active interviews," which Holstein and Gubrium (1995) argued reject the
quantitative standpoint that interviews can and should be objective. Instead,
as Holstein and Gubrium (1995) said each interview is unique and creates a
special meaning between the interviewer and the interviewee; thus each
interview situation is inherently subjective.
Furthermore, Lindlof (1995) argued that the interview is not an "objective
report of thoughts, findings or things out in the world" (p.165). The interview
is constantly under development. The participants add, remove, and change
details and information as the interview unfolds (Holstein & Gubrium, 1995).
The researcher then must interpret the response "within the entire matrix of
information about the interview event and the research problem" (Lindlof 1995,
p. 166). Instead of trying to prove a set of hypotheses based on a theory, this
method provided rich data that gives deep insight into the development of more
effective AIDS prevention programs.
Methodology
Because Florida has one of the highest rates of HIV infection in the United
States, and AIDS is the number one killer of nonwhite women ages 15-44 in
Florida (North Central Florida AIDS Network Brochure), Florida AIDS prevention
and education coordinators were selected for the study. Using a snowball
sampling strategy (Broom & Dozier, 1990), the researcher used contacts in one,
medium-sized community in Florida to identify AIDS prevention professionals.
The Florida AIDS Hotline provided names of all 16 district AIDS coordinators,
who then were contacted to provide the names of organizations and individuals
in their area responsible for AIDS prevention services. More than 40 people
were contacted. Ultimately, 20 interviews were conducted with individuals on
all levels who were responsible for the creation and implementation of local
and state AIDS prevention programs. Of the 20 interviewees, 12 were female and
eight were male.
Each interview lasted about 30 minutes. Face-to-face interviews were conducted
with four of the individuals, and telephone interviews were used for the
others. All interviews were audio taped and then transcribed verbatim. Because
of the nature of study, the interviewees were told that they would not be
identified by name or other distinguishable traits in the report of the
findings.
The interviewees then were asked open-ended questions about problems and
opportunities they have experienced in implementing effective AIDS prevention
programs. Additional background information also was collected.
Data Analysis
Information from the interviews was analyzed for emerging themes and
perspectives by two independent coders. The coders used the constant
comparative method, which is an inductive process in which dominant trends and
divergent opinions are analyzed and formulated into various categories and
perspectives (Lindlof, 1995). Each coder then developed a list of independently
defined emergent themes and perspectives, and then the coders analyzed the
lists to determine any inconsistencies. No significant discrepancies were
uncovered.
Additionally, to ensure validity, member checks were performed with five of
the 20 interviewees. Member checks are "opportunities for the researcher to
test hypotheses, concepts, interpretations, or explanations with members of the
local culture he or she is studying" (Lindlof, 1995, p. 240). These five
respondents were asked to confirm that the themes and perspectives that emerged
from the research did represent and embody their attitudes, beliefs,
experience, and outlook appropriately. All five respondents affirmed that the
categories uncovered were valid.
Once the member checks were conducted, a descriptive analysis was used to make
generalizations about what the interviewees said, as well as to compare and
contrast where the opinions, observations, and comments diverged. Conclusions
and recommendations then were offered.
FINDINGS
The answers to the research question involved numerous, varying themes and
perspectives. However, before addressing the question, it is important to
provide some background information about the participants.
Profile of the Participants
Nine interviewees were from various nonprofit AIDS service organizations from
South Florida to the Panhandle. Seven of the interviewees were employed at
county health departments. Two of the interviewees coordinated AIDS education
and prevention at local universities. Finally, two were AIDS educators for
nonprofit social services agencies. The amount of experience these interviewees
had with AIDS prevention and education ranged from just four months to 14 years.
In both the AIDS service organizations and the county health departments, the
target audiences varied with almost every respondent. Target audiences included
gay teenagers, homosexual men of color, substance abusers, migrant workers,
health-care professionals, teenagers, youth, and minorities. Obviously, the
target audience of both university AIDS prevention programs was college
students.
The goals of the various programs ranged from an increase in one-to-one
community outreach to an increase in sensitivity and compassion toward those
already infected. Other goals included an increase in outreach to at-risk
populations, a decrease in the risk behaviors that lead to HIV transmission, and
an increase in the adoption of safe sex practices. Despite the wide range of
programs these coordinators developed, the bottom line goal and mission remained
the same: stop the transmission of HIV.
Constraints
This research question produced numerous and diverse responses, but several
pervasive themes could be identified and many perspectives overlapped. The
biggest obstacles identified were: difficulty getting into the schools, which
incorporated social, political and religious barriers, lack of funding, power of
religious influence, lack of political action, denial among target groups,
resistance from the audience and new drug is creating a false sense of hope.
Difficulty Getting Into the Schools
"The schools are the only places we've any real problems," said one AIDS
prevention coordinator. This educator is not alone -- the most often cited
obstacle was not being able to get into the schools to do AIDS education and
prevention programs. These educators said their programs meet resistance in the
school system because the educators often want to teach more than just
abstinence -- they want the students who are having sex to use condoms. However,
they can't get into the schools to accomplish this goal. As one interviewee
said:
One of things they (the school boards) don't want us to talk
about is condoms. There is no way you can do an effective program
without talking about condoms. You need to talk about all
possibilities, and so when you hamper one particular aspect of it, we
are not able to do what would work.
Respondents said the reason they cannot get into the schools is because they
face opposition from the Religious Right, conservative politicians on the school
boards, as well as vocal parents in the community who are opposed to AIDS
prevention education. One prevention coordinator used the following example to
discuss these barriers in her area. She said after she and her AIDS prevention
team spoke at a high school, they were scheduled to do a similar program at the
middle school, but the principal told them after they did the high school
presentation that they were not allowed back because they discussed condom use.
She said the school would not allow them to use the word despite the fact that
the middle school had about 20 pregnant students. "We saw them clearly. .
.obviously sex was happening," she said. "The school personnel will then say
that it's the parents (that don't want condom education), and they have told us
that it is the ones that scream and shout the loudest."
She then explained that the teachers at the school were begging for the
organization to come speak:
They know what's going on. They hear these kids talking. They
are frightened of it all . . . they want us to tell the facts, but
one parent or a couple of parents don't want it and the programs
don't go, and the research I've seen on parents when you actually
poll them is the majority of them said they want sex education in the
schools - more than 50% [want explicit AIDS education] always [in]
the studies I see. Yet they still don't happen . . . and it's because
of those who scream and shout the loudest get heard.
Many of the educators blamed the Christian Coalition for having the doors shut
to them in the schools. "We are unable to go into the schools in this county and
in our outlying counties because of the Christian Coalition," said one
prevention coordinator. Another interviewee said they can't get into the schools
because of "the very big, Christian fundamentalists' power over the people that
make decisions here."
Another educator for a social services agency said the school board has been
difficult because the people in the city she lives in are very religious. "It's
the Bible Belt. The First Baptist Church is a real big stronghold here," she
said. She then explained what happened recently when some new members who were
part of an organization similar to the Christian Coalition recently joined an
AIDS planning council in her area. "They totally derailed our prevention effort
with this Christian Coalition bullshit," she said. "These five people are now
speaking for two counties." She explained that the only prevention method this
group wants to discuss with school-age children and nonmarried adults is
abstinence. "They do not [want] condoms distributed, and that's not aimed at
school children -- that's for the total population of their county," she said.
"They made our whole prevention plan be changed." She said that although her
organization does teach abstinence, that method is not an option for some of the
members of her target audience:
That's not the only tool. There are people who are just going to
totally turn off if that's what you talk about. You have to be
realistic with people. I always liken it to a carpenter -- he can't
just use the hammer as his only tool. That's a tool, but how much
carpentry can you do with just a hammer by itself? You have to have a
broad spectrum of things and ways of reaching people.
Another prevention coordinator said some religions say that to use a condom is
a sin, which creates a tremendous barrier for her outreach workers:
When we try to tell someone who's grown up their entire lives
with that message being sent to them and then we come and try to tell
them to use a condom, it will save your life,. . . .they get this
major conflict. It's like they are saying, "That's a sin -- I might
go to hell for doing something like that." So we've really created a
huge conflict there.
Some of the AIDS education and prevention coordinators blame the community and
some small groups of vocal parents who are part of a conservative movement that
is gaining increasing influence in communities in Florida. Furthermore, the
respondents said that although these parents are having influence on school
boards, they do not speak for the majority of the parents. One educator said he
thinks the school board is fearful of parents. "They think this is what parents
want," he said. "I don't think they really ask the parents because [the results
from a community-wide survey being conducted by his organization shows] . . .
most parents are in favor of sex education in schools, as well as of
distributing condoms."Another interviewee said he is not allowed to talk about
sex in the schools despite the fact that 47% of ninth graders and 88% of 12th
graders are sexually active. He blames a small but vocal group of parents.
The schools aren't allowing this because of a small core of
parents. The state of Florida has a sexuality curriculum advisory
board made up of parents, and seemingly, the parents who have the
time and energy to dedicate to this particular endeavor seem to be
the parents who don't want their kids to learn anything, and so they
make the decisions for all of us because we are not there making our
voices heard.
Many of the interviewees said these parents who are in favor of the extensive
AIDS education need to let the school boards know how they feel. One AIDS
educator offered this advice to parents:
You have a job to do. You need to let your board know that you
indeed want this because your school board is a representative of
you, and they can only do what they think you want them to do, and if
you don't let them know, then the same kind of information that you
got today that you want your kids to know, they are not going to do
it . . . . You need to talk to your school board -- be a participant
and a partner with your school board.
Economic Constraints: Lack of Funding
Lack of funding at all levels -- locally, as well as nationally and
internationally was an obstacle mentioned by virtually all of the respondents.
"You'd be amazed at how little money the state overall gets (and) what certain
regions receive," said one prevention coordinator. She said that with budget
cuts at the federal level, programs at the state and local level, such as the
one she coordinates, are not getting the much-needed increases in funding that
they need to be effective. Instead, they are seeing decreases in funding.
One educator said funding for AIDS prevention is being cut at the federal level
because people like Jesse Helms and his family do not have AIDS. "It's not close
enough to anyone up there, high enough, and that's the bottom line, really," he
said.
This lack of funding prohibits the educators from doing the kinds of prevention
campaigns they know would be effective. One interviewee said outreach in the
streets in her area is the most effective method of prevention education.
However, because of a lack of funds, she does not have the staff to do this:
We know that it is effective for someone to go into the
community of a high-risk area and target them one-on-one, but
[because of lack of funding] we have one person to go into a large
area, and that's the problem, you're going to reach five people
instead of 50.
The Power of Religious Groups' Influence
Not only do religious groups have an influence over what is being taught in the
schools, these groups have become obstacles in other areas, as well. One
educator said some churches send out materials trying to discourage condom use:
Some churches do send out information saying condoms are
ineffective -- that condoms have holes in them. I've seen actual
things produced by religious groups that say don't use condoms
because they don't work. Their message then is that the only safe sex
is no sex, and yes, I totally agree with that, but there's a big
problem -- people won't listen.
Still others said religious communities don't approve of helping those with
AIDS because of the disease's association with homosexuality. On this point, one
interviewee said:
They (churches) are interested in segregating and putting down
people with AIDS . . . . The Baptist Church called for all of their
members not to go to Disney [World] because they had a day for gay
people, and homosexuality is associated with AIDS, so it's that whole
connection there. So that's probably created a huge block as well --
that AIDS is associated with homosexuality, and there's a lot of
discrimination against us as a result of that . . . a huge barrier to
doing the prevention programs, as well as people's attitudes towards
it. . . .There's a guy who wrote an article in the (local newspaper)
who said don't treat people with AIDS because they brought it on
themselves. So that attitude is still out there, and it is alive and
well.
Although churches and religious groups have been obstructionists, some churches
have been very supportive. Some even have opened their doors to AIDS victims and
their families. However, most of the educators said that overall, religious
institutions have been deleterious.
Lack of Political Action
Although many of the respondents blamed school board members for lack of
cooperation in the schools, most of the respondents said other politicians
usually just stay away from the AIDS issue altogether. Still others blame the
conservative politicians who are backed by the Religious Right. For example, one
educator said the Religious Right funds many of Florida politician's campaigns,
so these politicians essentially have their hands tied:
To find out why the money is decreasing from the federal
government and state government, you have to look at who is running
the government -- it's basically still very conservative people that
are being funded by the Religious Right. I would think a good part of
our government's political campaigns are funded and influenced in a
large part by the Religious Right, and how can they go against their
funders, their backers? They are worried enough about getting
re-elected without crossing the groups that are supporting them the
most.
Denial from the Audience
Denial among target audiences and the community is another obstacle many
educators discussed -- AIDS usually is perceived as something happening
somewhere else to someone else. Several of the educators said it is difficult to
reach teenagers: "Teens think they are invincible," said one educator. "Teens
think it's not them -- it's older people. They think, 'We're young, healthy, and
we won't get AIDS and HIV.'" However, teens are not the only group educators are
have difficulty reaching. College students are in denial, according to some of
the educators. For example, one interviewee said: "You are dealing with a group
of individuals who believe they are immune -- that HIV can't happen to them.'"
Several of the respondents said they also meet resistance from the
community. One educator said her county health department still senses denial in
the community. They don't believe AIDS is happening in their county or state,
she said. Another educator agreed. He said the problem he encounters when he
tries to implement effective AIDS prevention programs is that the community does
not want to get involved.
Resistance from the Audience
In addition to denial from target audiences and the general public, some
respondents said they often meet resistance from the audience. One interviewee
blamed "conservative attitudes" for her lack of success in meeting her program
goals -- people just are not comfortable discussing the issues:
People [are] not willing to talk about what really are risk
behaviors and what activities people participate [in]. We don't want
to talk about it, so we [think if we] don't talk about it (sex), it
will go away. . . . People want the information, but they don't like
it when they hear it. It's intimidating, or it causes anxiety to say
the word sex or needle use.
An AIDS educator at a university agreed:
I . . . think a lot of people just don't want to hear the
realities of how some people demonstrate their sexuality, so there
are those kinds of challenges. I think it's taken a while for the
government and others to come around to comfort level with this s
ubject.
Another educator for an AIDS service organization that targets the homosexual
community said this resistance from the community to AIDS education prevents his
organization from reaching its target audience:
The city is a conservative area, and if they're a gay population
that's here, they are not very likely to come out of the closet. Many
people won't come in for things like testing and prevention education
because this area is very conservative, and they don't want people to
know that they are gay.
Because of the stigma attached to homosexuality that then translates into a
stigma attached to AIDS, not only will people refuse testing, but other
individuals will not donate money. One AIDS educator said his organization has a
program called "road tolls," where various members of his task force and
miscellaneous volunteers stand at a busy location and have a bucket for people
to put money in. He said that although this program is successful, he has not
been successful with other fundraisers:
If we try to do a general fundraiser where people come to us, we
won't get anything . . . . [With a] road toll, you can put some money
in and keep going, and your identity is not exposed. . . . Whereas if
you have to come to something where people say "What are you doing at
that AIDS place?," then they are at-risk.
The New Drug Is Creating a False Sense of Hope
In addition to battling already existing obstacles, many educators said they
are facing a new constraint: advancements in treatment are creating a false
sense of hope. Many of the respondents believed that people now think protease
inhibitors will cure people with HIV. One educator said he has to explain that
the drug is not a cure. He said: "The message they are getting from the media is
now there's this great cure. So people are now saying, 'So what I get HIV, I can
just take the medicine.'"
Another interviewee said all the publicity is making his job more difficult:
It has put us back because if we get a cure, we'll forget all
about prevention. We're continuing to look towards other people for
an answer instead of making it a personal, individual empowerment,
and that's the whole lesson that I'm trying to get across. The
educators know that, those of us in the field know that, but when you
try and get that to the legislative arena so we can have
comprehensive education . . .the legislators don't care about the
scientific part, they go on popular opinion, and popular opinion is
not weighed by facts, it's weighed by feelings. I don't think we've
won any rounds as an entire society.
One prevention coordinator fears that this increased attention about a "cure"
will translate into decreased funding for prevention. "There is a misconception
that with all the drugs out there now for patients who are infected with HIV
that they don't need money for prevention, which I think is a false sense of
hope," she said.
Another educator agreed:
[With] some of the research [that's out there now], especially
with the protease inhibitors, it's being billed as a cure, so when
you look at the front of Newsweek, and it says a cure, people are
less likely to donate to an AIDS organization because they think
there's a cure. . . . it may be a step towards a cure, but it is not
a cure - it's not something that people can go off of.
DISCUSSION AND CONCLUSIONS
The data collected illustrate that there is no easy answer to what makes an
AIDS prevention program effective. The AIDS prevention coordinators interviewed
had very diverse, yet somewhat comparable perspectives and opinions. All of the
respondents faced some barriers to the implementation of their programs, and the
barriers included many of the same social, economic, political, and religious
constraints discussed in the review of literature. Most of the health
communication researchers and AIDS prevention program coordinators agree about
what constitutes an effective AIDS prevention program. However, both groups also
have discussed various obstacles to the implementation of such programs. Some of
these constraints even overlapped. Although the respondents did differ in their
responses, certain themes emerged, and the obstacles that were the most
prevalent seemed to stem from the conservative, right-wing movement that has
been sweeping the United States since the 1980s. The group of vocal individuals
who represent this movement have created numerous obstacles for the
implementation of effective AIDS prevention programs.
The Religious Right's backing of former presidents Ronald Reagan and George
Bush affected and influenced the presidents' decisions to remain quiet about the
disease and to severely limit funding for research and prevention during the
first decade of the disease. Even in the second decade of the disease, the
Religious Right movement has had an influence on the implementation of AIDS
prevention and education programs.
Since the Republicans took over Congress, these AIDS program planners have
worried that funding for AIDS will decrease in various areas. Their fears may be
well founded. By March 1995, the new majority had attempted to reduce AIDS
prevention funding by $23 million (Hodel, 1995).
Today, the federal government seemingly has washed its hands of the AIDS issue,
delegating it to the states, which in turn have given the issue to local
governments. One critical component of local government structure has been
individuals on schools boards. What the schools boards are allowing in terms of
AIDS education in the schools, which seems to be only an abstinence-based
curriculum in most of the Florida schools, represents the demands of that same
far-right Christian Coalition movement that Reagan and Bush embodied in the
1980s.Although surveys and anecdotal evidence seem to indicate that most of the
parents want more explicit AIDS prevention education in the schools, the schools
boards are listening to the parents who are vocally opposed to such a
curriculum.
Some of the respondents speculate that another reason the educators cannot
accomplish many of their AIDS education goals is because the stigma associated
with the disease still prevails. AIDS still is seen as a "gay disease," which
connotes sin in the eyes of some of the churches that have vocally opposed AIDS
education efforts. These religious groups see AIDS prevention education as
condoning homosexual lifestyles. Therefore, many homosexuals will not go into
prevention centers, and other individuals are scared to donate money for fear of
being labeled an advocate of homosexuality.
Of course individual donations would not be as necessary if more federal money
were made available for AIDS prevention efforts. The amount of funding for AIDS
continues to decrease, according to many of the respondents and other research.
And whatever money is available goes to treatment, not prevention. Of course, as
one respondent pointed out, if more money were available for prevention, then
less would be needed for treatment.
Furthermore, the prevention educators also say they are not able to do what is
most effective because they lack adequate funds. To reach the groups that are
not changing their behavior, more long-term behavior modification programs,
which also must be in depth, need to be established because the research shows
these programs have been effective in changing the risk behaviors that lead to
the transmission of HIV. Unfortunately, they are costly and time consuming to
conduct, so they are not being implemented as much. Instead, educators said they
are funded to go out into big groups for one presentation without much follow
up, which they know is not as effective.
In addition, individuals continue to believe they are more powerful than the
disease, and the community refuses to accept that people are engaging in
unmarried sex or intravenous drug use. Thus, people refuse to see AIDS as an
issue in their community. These mentalities have created tremendous barriers for
AIDS prevention coordinators: they cannot get individuals to change their
behaviors, and they cannot get the community to believe AIDS is enough of a
problem to warrant donations or education in the schools.
Finally, the sudden media hype about new treatment drugs, which the media have
dubbed the cure for AIDS, has resulted in a new pervasive attitude: if there's a
cure, what's the need for prevention? Not only do individuals now think they are
at less risk of dying from the disease, donors are not giving as much to
prevention efforts.
Recommendations
Health communication researchers' recommendations for the implementation of
effective AIDS prevention programs may not always be feasible. So although the
researchers have very valuable and astute recommendations for future AIDS
prevention programs, it may be unlikely that they will see many of their
recommendations ever become reality. Health communication researchers have made
many of these recommendations over the past two decades. However, many still are
being blocked.
For example, both the researchers to be effective in facilitating behavior
change they need to teach interpersonal communication skills to individuals,
especially teenagers. This means individuals need to be taught sexual
negotiation skills to enable them to negotiate condom use and safe sex with
their partner. Although two of the respondents have been allowed to develop
programs designed to teach sexual negotiation skills, most of the respondents
have not. Opponents to such programs say teaching sexual negotiation skills
actually promotes promiscuity among teens and unmarried persons.
Perhaps the only way AIDS prevention coordinators could work around this
obstacle is to try to encourage the schools to teach self-efficacy and
self-control to the students about other issues. For example, teach students
that they have control over how well they do in school or that they have the
control to say no to drugs. This new sense of self-efficacy and self-control
then may translate into the approach the students take when they encounter
"sexual" situations. If they feel in control, they may be more inclined to
demand condom use or to abstain from sex.
The individuals who oppose teaching students sexual negotiation skills also are
opposed to condom distribution and condom education in the schools. Most health
communication researchers agree that abstinence is the most effective way to
stop the transmission of HIV. However, they also agree that for many people,
abstinence is not an option, but condom use can be. So the researchers would
like to make condom use the norm. However, the prevention coordinators cannot
get into the schools to provide education about condom use because of a small,
vocal group of parents who opposes this approach.
Although condoms may never be accepted by conservative groups such as the
Religious Right, AIDS coordinators should try to implement panel discussions
between the abstinence-only advocates and the safe sex advocates who encourage
abstinence and condom use. These panel discussions could take place in the
schools and the community. These discussions would give the audience both
options and allows each audience member to listen to both sides and then make a
choice. This also would allow for more collaboration among the different
organizations so they could learn from each other's triumphs and failures.
Program coordinators then can use this knowledge to implement the programs that
have been the most successful.
One program that many of the AIDS coordinators already agree is the most
effective is long-term AIDS prevention programs. One shots are not that
effective. Program planners need to be able to talk to the same group several
times. However, this method is too costly to execute, so it is doubtful program
planners will be able to implement such programs. As funding for prevention
continues to see massive cuts, the probability of the implementation of
long-term, behavior modification programs continues to decrease. So the most
effective programs continue to be the least feasible.
The leading cause of death for 25- to 44-year olds is AIDS, and the disease can
stay in remission for up to 10 years -- so the youngest victims contracted the
AIDS virus when they were in high school. Eighty-eight percent of high school
seniors in Florida have had sex already. Despite the obvious need for AIDS
education in the schools, educators cannot get in to teach them. However,
surveys continue to show that most parents want comprehensive AIDS education. So
these parents need to speak out. They need to let school boards know that they
support education that includes discussing condom use. More parents need to get
involved in the fight against AIDS.
This is where AIDS educators need to direct their energies: developing
strategies to get more parents involved. If most parents are in favor of
explicit education efforts, school boards will listen. But program planners need
to make sure the voices of these parents are heard over the voices of the
opponents. Prevention coordinators should encourage a grassroots effort similar
to Mothers Against Drunk Drivers. An organization like this would be less
expensive and more effective because the parents would be the volunteers that
speak out to the schools boards and the community.
But these parents need help, and the federal government can help. The
government is set up to serve the common welfare of it all of its constituents,
especially children because children are not capable of protecting themselves.
AIDS is 100 percent preventable, so the government must demand that public
schools discuss the realities of AIDS -- how it is transmitted and how it can be
prevented. This includes an obligation to discuss condom use as a method of
protection. The federal government is not fulfilling its responsibility, and as
a result, adolescents and young adults are contracting the disease.
One way to make the policy makers at the federal and state level more
responsive to AIDS prevention efforts is to make the issue more personal to
them. In other words remind the legislators that they may know someone with
disease. This personalization of risk strategy was used successfully in
California. When the legislators were asked to address the stalking issue, a
female legislator who had been stalked testified about her experience. Then
legislators passed strict stalking laws. If prevention coordinators could get a
person the policy makers could relate to, such as a legislator's child or a
former politician, to testify about what it is like to live with AIDS, perhaps
Congress and even the President would be more likely to increase funding and
allow more education in the schools.
Although President Clinton and Congress should require comprehensive AIDS
education in schools, it is unlikely either will make such a bold move. So,
prevention coordinators could try to go around the schools. Perhaps AIDS
educators could conduct programs for adolescents at after-school programs and
organizations, such as Boys and Girls clubs and other such United Way programs.
Although a few of the prevention planners have started such programs, the
majority of the respondents have not. Finally, as Congress continues to propose
budget cuts for AIDS programs, communities need to join together to demand a
surge in funding for AIDS prevention programs. More attention to prevention will
no doubt mean less money is needed for treatment.
However, a movement like this actually may be unrealistic. The American public
has yet to mobilize in its fight against AIDS. Small pockets of conservative
politicians and religious leaders are leading the battle in AIDS education.
Unfortunately, what they propose is inadequate, ineffectual, and truly dangerous
to society. However, until the silent majority of individuals who are in favor
of the kinds of programs research says are effective become more vocal,
individuals will continue to suffer from HIV.
Areas for Future Research
This study only used AIDS prevention and education coordinators in Florida, so
another study could be conducted to compare the obstacles encountered in Florida
with other areas of the country. Perhaps interviewing prevention coordinators in
other regions would yield different experiences and results.
It also would beneficial to the body of research on AIDS prevention to compare
what these practitioners say with what prevention programs planners for other
ailments such as heart disease and cancer discuss as their obstacles.
Furthermore, the topic of how to measure effectiveness also needs to be examined
more. What is the most meaningful measurement of effectiveness of AIDS
prevention programs (besides drop in the number of infections)?
Conclusion
Health communication researchers have discussed strategies for the
implementation of effective AIDS prevention and education programs -- ones that
will change the risk behaviors that lead to the transmission of HIV -- since the
disease first surfaced. This study illustrated that when AIDS prevention
coordinators try to implement the types of programs health communicators call
for, they are being blocked by groups such as the Religious Right.
Even though surveys and other research have shown that most individuals want
the kinds of programs that these researchers and prevention coordinators
recommend, this silent majority has failed to be vocal. So, as a result, those
in power are listening to those who shout the loudest -- those individuals who
are opposed to comprehensive AIDS education prevention efforts. Unless the
silent majority speaks up, truly effective programs may never be implemented.
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[1] 1 In March 1986, Switzerland distributed a free 10-page pamphlet on AIDS,
printed in all four of the country's official languages. In November 1986, the
British government planned an explicit $7 million national leaflet and
advertising campaign to combat AIDS. Norway, a country with only a handful of
AIDS patients (as of 1994), implemented an even bolder program targeting AIDS as
a venereal disease of concern to all. Norway has used billboards that were not
small or subtle. Also, to reduce AIDS and addiction among intravenous drug
users, the Municipal Health Service in Amsterdam instituted a needle-exchange
and free condom program. (Krieger & Appleman, 1994).
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