Elsevier

Social Science & Medicine

Volume 103, February 2014, Pages 118-125
Social Science & Medicine

HIV prevention interventions to reduce sexual risk for African Americans: The influence of community-level stigma and psychological processes

https://doi.org/10.1016/j.socscimed.2013.06.028Get rights and content

Highlights

  • Structural stigma may hinder the success of interventions for African Americans.

  • We examined Whites' attitudes toward African Americans and residential segregation.

  • In communities with more stigma, HIV interventions failed to improve condom use.

  • Stigma strongly affected samples with younger participants, more African Americans.

  • Tailoring interventions to participants' needs buffered against structural stigma.

Abstract

Interventions to improve public health may benefit from consideration of how environmental contexts can facilitate or hinder their success. We examined the extent to which efficacy of interventions to improve African Americans' condom use practices was moderated by two indicators of structural stigma—Whites' attitudes toward African Americans and residential segregation in the communities where interventions occurred. A previously published meta-analytic database was re-analyzed to examine the interplay of community-level stigma with the psychological processes implied by intervention content in influencing intervention efficacy. All studies were conducted in the United States and included samples that were at least 50% African American. Whites' attitudes were drawn from the American National Election Studies, which collects data from nationally representative samples. Residential segregation was drawn from published reports. Results showed independent effects of Whites' attitudes and residential segregation on condom use effect sizes. Interventions were most successful when Whites' attitudes were more positive or when residential segregation was low. These two structural factors interacted: Interventions improved condom use only when communities had both relatively positive attitudes toward African Americans and lower levels of segregation. The effect of Whites' attitudes was more pronounced at longer follow-up intervals and for younger samples and those samples with more African Americans. Tailoring content to participants' values and needs, which may reduce African Americans' mistrust of intervention providers, buffered against the negative influence of Whites' attitudes on condom use. The structural factors uniquely accounted for variance in condom use effect sizes over and above intervention-level features and community-level education and poverty. Results highlight the interplay of social identity and environment in perpetuating intergroup disparities. Potential mechanisms for these effects are discussed along with public health implications.

Introduction

People who perceive greater bias against them because of their group membership – including being an ethnic minority, sexual minority, or mentally ill – experience poorer mental and physical health, utilize healthcare less, and suffer higher rates of mortality than those who perceive less bias (Bird and Bogart, 2001, Pascoe and Smart Richman, 2009, Williams and Mohammed, 2009). While perceptions of discrimination are not synonymous with actual discrimination because people may either underestimate or overestimate discrimination (Dumont et al., 2006, Vorauer, 2006), converging evidence of the health effects of discrimination is provided by indications of stigma at the structural level. For example, greater residential segregation is associated with poorer physical health among African Americans, not only because it differentially exposes African Americans to environmental toxins and limits access to healthy foods and quality health care (Smedley et al., 2003, Williams and Collins, 2001) but also because of the impact of segregation on psychological factors, including stress and social exclusion (Kramer and Hogue, 2009, MacDonald and Leary, 2005).

The present research is novel in its focus on bridging work on structural influences on health with psychological influences in the context of HIV prevention interventions. Although previous research suggests the importance of considering how structural factors may operate through and interact with individual-level factors, little empirical research has examined these influences jointly (Kramer and Hogue, 2009, White and Borrell, 2011). Moreover, previous work in this area has focused primarily on African Americans' perceptions of discrimination rather than directly on Whites' biases toward African Americans. We investigated how the efficacy of interventions designed to limit transmission of HIV by increasing condom use may be influenced by structural stigma – specifically, Whites' attitudes toward African Americans and residential segregation in the communities where intervention trials occurred – and explored the moderating role of psychological factors.

Despite recent medical advances in its treatment, HIV remains a major health issue in the United States and worldwide. There are approximately 48,000 new HIV infections annually in the U.S., with 44% of new infections occurring among African Americans (Centers for Disease Control, 2011). As the White House Office of National AIDS Policy (2010) noted, “HIV disproportionately affects the most vulnerable in our society—those Americans who have less access to prevention and treatment services” (p. ix). Transmission of HIV can be prevented through safer sex practices, including consistent and correct condom use (Weller & Davis-Beaty, 2002). Numerous trials have investigated behavioral interventions that deliver content interpersonally and address deficits as a strategy for increasing protective behaviors among African Americans.

The current research reports a secondary analysis of a meta-analysis of HIV prevention interventions targeted toward African Americans (Johnson et al., 2009). Meta-analysis, which provides an estimate of the magnitude of behavior change following interventions, is ideal for considering how geographic differences in stigma might shape intervention efficacy. Because intervention trials have been conducted throughout the U.S., meta-analysis allows for examination of whether Whites' attitudes and level of residential segregation in these different locations relate to intervention efficacy. Previous meta-analyses support that interventions targeting African Americans have generally increased condom use (Darbes et al., 2008). Johnson et al. found that interventions were efficacious up to three years later and were most successful when they included particular features, such as multiple intensive sessions and interpersonal skills training. Although previous meta-analyses have examined overall efficacy of interventions and have identified intervention features that are linked to greater success, they have not considered whether structural features of intervention communities may play a role in intervention efficacy. Indeed, Johnson et al. observed that, even after accounting for significant intervention-level moderators, condom use effect sizes lacked homogeneity, suggesting that other moderators may explain some of the heterogeneity in effect sizes. Thus, the present analysis considered not only whether structural factors influenced intervention efficacy, but also whether inclusion of structural factors altered Johnson et al.'s conclusions regarding which intervention-level features were associated with greater efficacy.

Whites' community-level attitudes and residential segregation are structural environmental pressures that intervention participants face before they enter and when they leave interventions. These structural factors are likely to influence intervention efficacy because they affect both the targeted behavior—condom use—and the extent to which participants are engaged in the interventions. Consistent with a growing body of research, Whites' attitudes and residential segregation are likely to be associated with both increased engagement in sexual risk behavior and increased risk for acquiring a sexually transmitted disease, implying lack of condom use (Biello et al., 2012, Roberts et al., 2012, Rosenthal et al., 2013, Stock et al., 2013). To the extent that coping with discrimination is stressful and depleting (Inzlicht, McKay, & Aronson, 2006), structural stigma is also likely to affect condom use via its influence on decreased levels of self-control and self-regulatory resources (Gibbons et al., 2012). Discrimination and stigma are also associated with mistrust of majority group members (Bergsieker et al., 2010, Dovidio et al., 2008); this mistrust is likely to translate into decreased engagement in and acceptance of intervention messages (Wyatt, 2009). When interventions fail to address these influences of structural stigma on condom use and on the intervention itself, efficacy for improving condom use would be expected to suffer (Johnson et al., 2010, Wyatt, 2009).

Whites' community-level attitudes toward African Americans and residential segregation may both affect intervention efficacy. Because African Americans are vigilant for cues of bias (Dovidio et al., 2008, Vorauer, 2006), either negative community attitudes or high levels of residential segregation may be sufficient to undermine intervention effectiveness. Research on intergroup contact demonstrates that intergroup orientations (e.g., intergroup anxiety and empathy) are the consequence of both the frequency of contact and the quality of contact, that is, whether contact is experienced positively or negatively (see Tausch & Hewstone, 2010, for a review). In general, the valence of contact is more influential for intergroup orientations than frequency of contact. However, intergroup orientations are most favorable when contact is both positive and frequent (Towles-Schwen & Fazio, 2001), suggesting that community attitudes and segregation may interact such that positive community attitudes and low levels of residential segregation may combine to produce an environment highly conducive to intervention efficacy. Given the importance of the valence of intergroup contact and the paucity of research on Whites' community-level attitudes, our examination of additional moderators of structural stigma focused on Whites' attitudes.

In addition to our central focus on the influences of residential segregation and Whites' attitudes toward African Americans on intervention efficacy, we examined factors that may exacerbate or buffer against the impact of structural stigma. Our inclusion criteria, described in detail in the Method section, permitted analysis of studies in which at least 50% of the sample identified as African American (M = 81%). As Whites' attitudes toward African Americans would be expected to influence African Americans specifically, we expected a stronger effect of Whites' attitudes for samples with higher proportions of African Americans. Late childhood to early adolescence has been suggested as a critical period during which experiences with discrimination may be especially detrimental, because identity is still developing and external evaluations of the self are being integrated into the self-concept (Gibbons et al., 2007). To this point, the impact of stigma tends to lead to riskier behavior, and increased sexual risk in particular, among younger African Americans (Roberts et al., 2012, Stevens-Watkins et al., 2011). Accordingly, more negative attitudes among Whites were expected to adversely influence intervention efficacy when samples were, on average, younger.

Conversely, due to the effects of stigma on self-regulation and mistrust (Bergsieker et al., 2010, Dovidio et al., 2008, Gibbons et al., 2012, Inzlicht et al., 2006), an effect of Whites' attitudes may be weakened by intervention features that potentially improved participants' self-regulation or communicated racial sensitivity and respect. Interventions that seek to improve self-control, potentially by teaching interpersonal skills for negotiating condom use with sexual partners, may buffer against an effect of Whites' attitudes. Similarly, tailoring content to participants' values and needs, which may communicate respect for participants' cultural values, may limit the effect of Whites' attitudes.

To summarize, we sought to investigate the interplay of structural and psychological factors related to stigma in influencing the efficacy of HIV prevention interventions for increasing condom use (or reducing unprotected intercourse) among African Americans. Based on previous research, we predicted that the efficacy of HIV prevention interventions for increasing condom use would be lower in communities where Whites' attitudes toward African Americans were less favorable or residential segregation was greater. We further predicted that interventions would be particularly successful in communities where Whites' attitudes were relatively positive and segregation was simultaneously low. Whites' attitudes were expected to be more strongly related to intervention efficacy when interventions had higher proportions of African Americans or younger participants but more weakly related to efficacy when interventions included techniques to improve interpersonal skills or tailored content for the targeted population. We also explored whether the effects of structural stigma remained over and above important intervention features and community-level poverty, education, and population density for Whites and African Americans.

Section snippets

Method

Because methodological details for this meta-analytic database appear elsewhere (Johnson et al., 2009), only a brief summary appears here. Published studies and dissertations were retrieved from (1) electronic databases (e.g., PubMed, PsycINFO), (2) the Syntheses of HIV/AIDS Risk Reduction Project's HIV intervention database, and (3) recent issues of relevant journals and reference sections of included articles. Studies available as of June 1, 2006 that met selection criteria were included,

Results

Trials were conducted in locations throughout the U.S, but primarily in medium to large cities in the Northeast and Southeast. The number of trials conducted in a particular site ranged from 1 to 11. Eleven trials were conducted in both Los Angeles County and Fulton County, Georgia, which encompasses Atlanta. In total, trials included over 40,000 participants who were predominantly African American (81%) and female (65%). Follow-up assessments of condom use occurred between 1 and 156 weeks

Discussion

The present research sought to conceptually integrate previous research on structural factors in stigma, commonly emphasized by public health researchers (e.g., Hatzenbuehler et al., 2009, Williams and Collins, 2001) and psychological factors, emphasized by health and social psychologists (e.g., Pascoe & Smart Richman, 2009) in the context of the efficacy of HIV prevention intervention trials predominantly involving African American participants. The use of meta-analysis allowed us to examine

Conclusions

The present research provides support for an influence of structural stigma on the efficacy of interventions for bringing about behavior change, highlighting the role of stigma in the environment in perpetuating health disparities. We acknowledge, however, that our findings provide a clearer demonstration that residential segregation and Whites' attitudes influence the efficacy of HIV prevention interventions than of the potential mechanisms that underlie these effects. Our meta-analysis was

Acknowledgments

Preparation of this article was supported by US Public Health Service grants T32 MH20031 and 5R01AA01251812 to Allecia E. Reid, R01HL 0856331-0182 and 1R01DA029888-01 to John F. Dovidio, and 5R01MH058563-14 and 1K18AI094581-01 to Blair T. Johnson. The authors gratefully acknowledge supplemental study information provided by Ralph DiClemente, Stevan Hobfoll, Susan Levy, Kathleen Sikkema, and Janet St. Lawrence, and input from participants at the Conference on Structural Stigma and Population

References (52)

  • M.W.L. Cheung

    Modeling dependent effect sizes with three-level meta-analyses: a structural equation modeling approach

    Psychological Methods

    (2013)
  • J.E. Cook et al.

    Intervening within and across levels: A multilevel approach to stigma and public health

    (2013)
  • L. Darbes et al.

    The efficacy of behavioral interventions in reducing HIV risk behaviors and incident sexually transmitted diseases in heterosexual African Americans

    AIDS

    (2008)
  • M. Dumont et al.

    Social comparison and the personal-group discrimination discrepancy

  • W.H. Frey

    New racial segregation measures for large metropolitan areas: Analysis of the 1990–2010 Decennial Censuses

    (2012)
  • W.H. Frey

    New racial segregation measures for states and large metropolitan areas: Analysis of the 2005–2009 American Community Survey

    (2012)
  • F.X. Gibbons et al.

    The erosive effects of racism: reduced self-control mediates the relation between perceived racial discrimination and substance use in African American adolescents

    Journal of Personality and Social Psychology

    (2012)
  • E.L. Glaeser et al.

    Racial segregation in the 2000 Census: Promising news

    (2001)
  • S.K. Goldman

    Effects of the 2008 Obama presidential campaign on White racial prejudice

    Public Opinion Quarterly

    (2012)
  • R.M. Harbord et al.

    Meta-regression in STATA

    The STATA Journal

    (2008)
  • M.L. Hatzenbuehler

    How does sexual minority stigma “get under the skin”? A psychological mediation framework

    Psychological Bulletin

    (2009)
  • M.L. Hatzenbuehler et al.

    State-level policies and psychiatric morbidity in lesbian, gay, and bisexual populations

    American Journal of Public Health

    (2009)
  • J. Iceland et al.

    Racial and ethnic residential segregation in the United States: 1980–2000

    (2002)
  • M. Inzlicht et al.

    Stigma as ego depletion: how being the target of prejudice affects self-control

    Psychological Science

    (2006)
  • J.B. Jemmott et al.

    Abstinence and safer sex HIV risk-reduction interventions for African American adolescents: a randomized controlled trial

    JAMA

    (1998)
  • B.T. Johnson et al.

    Depicting estimates using the intercept in meta-regression models: the moving constant technique

    Research Synthesis Methods

    (2011)
  • Cited by (71)

    • Community-level age bias and older adult mortality

      2023, Social Science and Medicine
      Citation Excerpt :

      A growing literature has examined effects of structural stigma on health, reflecting the “societal-level conditions, cultural norms, and institutional policies that constrain the opportunities, resources, and wellbeing of the stigmatized” (Hatzenbuehler and Link, 2014, 2). Living in communities marked by higher structural stigma is associated with worse mental and physical health among racial/ethnic and sexual minorities (Hatzenbuehler, 2014, 2016; Leitner et al., 2016a, b; Lukachko et al., 2014; Pachankis et al., 2014; Reid et al., 2014). Despite recent attention (Allen, 2016), limited research has examined whether structural indicators of age bias broadly, and community attitudes toward older adults specifically, predict older adults’ health.

    • Smaller Hippocampal Volume Among Black and Latinx Youth Living in High-Stigma Contexts

      2022, Journal of the American Academy of Child and Adolescent Psychiatry
    • Meta-analysis: Are Psychotherapies Less Effective for Black Youth in Communities With Higher Levels of Anti-Black Racism?

      2022, Journal of the American Academy of Child and Adolescent Psychiatry
      Citation Excerpt :

      Specifically, the erosion of treatment effects over time in the high racism group and the improvements over time in the low racism group support our interpretation that identity-threatening environments themselves may undermine treatment gains. These results are consistent with a spatial meta-analysis of HIV prevention interventions,16 which demonstrated that the ESs for condom use decreased over time in high-racism communities, relative to those in the control condition. Taken together, these results suggest that anti-Black cultural racism may manifest in an array of adverse experiences for Black youth that compete with the benefit of insights and skills developed in therapy.

    View all citing articles on Scopus
    View full text