Prevention in Focus

Fall 2011 

Fear-based campaigns: The way forward or backward?

Zak Knowles and Laurel Challacombe

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.

Activists divided

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:

  • contained arguments aimed at changing attitudinal beliefs (for example, discussions of the positive implications of using condoms for the health of one’s partners);
  • provided educational information (for example, factual information on the transmission and prevention of HIV); and
  • provided people with behavioural skills (for example, discussions of what to do when a partner won’t wear a condom and role-playing activities that promote condom use)

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.10,11,12

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.

Potential pitfalls of fear-based campaigns

Unlike other HIV prevention initiatives, a fear-based campaign does not educate people about their own personal risk—that is, the message does not contain the information people need to decide whether or not their behaviour puts them at risk for HIV. This makes it difficult for people to make informed decisions about their own behaviours.

Fear-based campaigns can also lead to stigma and discrimination against people living with HIV (PHAs) and to the target group of the campaign (in the case of the “It’s Never Just HIV" campaign, young Black and Hispanic MSM). These campaigns make HIV/AIDS something to be fearful of, which can affect people’s views and lead to stigmatizing and discriminating behaviours. This can create a climate that makes it more difficult for people with HIV to disclose their HIV status to potential sex partners. This can have both health and legal implications.

There may also be ethical issues surrounding fear-based campaigns. Research has shown that appealing to people’s fears may work better on people who are well equipped to change their behaviour.13 These people, who are said to have higher self-efficacy (a higher sense of competence), are better resourced, psychologically and socially, to process the messages and make the recommended behaviour change. However, for those with a lower sense of competence—those who are less equipped to handle these messages and adopt the recommended behaviour—the messages may make them feel worse and can lead to behaviours that increase their risk. Therefore, fear-based messaging can potentially cause harm to people who may already be more vulnerable to HIV. 

Finally, some HIV fear campaigns have depicted the “horrors” of anti-HIV drugs in an effort to get people to avoid becoming infected with HIV. This can have unintended repercussions. Such messages may dissuade HIV-positive people from starting or adhering to HIV treatment.14 For the individual, this could lead to faster disease progression and poorer quality of life. For the larger society, this could lead to increased HIV transmission.

What does this mean for prevention messaging in Canada?

The number of new HIV infections among all groups in Canada each year has remained fairly stable; however, the fact that incidence rates in certain at-risk populations remain static and are not decreasing may suggest that current messaging is not working well enough. For example, in 2008 an estimated 33,600 of the 65,000 Canadians living with HIV were MSM; and 47% of new infections (an estimated 1000 to 1900) were in this group.15

Five Canadian urban-based studies have reported that between 21% and 31% of MSM had had unprotected sex with a casual partner in the previous six months.16,17,18,19 This shows us that a significant number of MSM are putting themselves at risk for HIV despite current prevention efforts.

To reduce the number of new infections, we need to find ways to help reduce the number of men having unprotected sex. Are some gay men having unsafe sex because they do not fully understand the implications of becoming infected with HIV? Are they complacent about the realities of HIV infection? Are there other factors that make the choice to use a condom difficult or impossible? The challenge is to effectively target people at risk without reverting to a fear-based approach that may alienate them or further stigmatize those already living with HIV.

Whether or not the “It’s Never Just HIV” campaign is the right approach, this bold campaign has reignited the debate about prevention messaging and provides us with an opportunity to rethink prevention campaigns in Canada.

Related article

For a discussion on fear-based campaigns with community members, see Views from the front lines: Fear-based campaigns.

References

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About the author(s)

Zak Knowles is CATIE’s Manager of Web Content. Before coming to CATIE, he worked as an HIV counsellor at Hassle Free Clinic, a sexual health clinic in downtown Toronto. Zak has been living with HIV for 20 years.

Laurel Challacombe holds a Masters degree in Epidemiology and is currently Manager of Research and Evaluation at CATIE. Laurel has worked in the field of HIV for more than 10 years and has held various positions in both provincial and regional organizations, working in research and knowledge transfer and exchange.