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Social Sides of Health Risks: Stigma and Collective Efficacy

Rachel A. Smitha; Merissa Ferrarab; Kim Wittec
a
Department of Communication Studies, University of Texas, b Department of Communication,
College of Charleston, c Center for Communication Programs Johns Hopkins Bloomberg School of
Public Health,

To cite this Article Smith, Rachel A. , Ferrara, Merissa and Witte, Kim(2007) 'Social Sides of Health Risks: Stigma and
Collective Efficacy', Health Communication, 21: 1, 55 64
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 HEALTH COMMUNICATION, 21(1), 5564
Copyright 2007, Lawrence Erlbaum Associates, Inc.

Social Sides of Health Risks: Stigma and

Collective Efficacy
Rachel A. Smith
Department of Communication Studies
University of Texas

Merissa Ferrara
Department of Communication
Downloaded By: [Canadian Research Knowledge Network] At: 14:01 27 January 2011

College of Charleston

Kim Witte
Center for Communication Programs
Johns Hopkins Bloomberg School of Public Health

Health threats may not occur in a vacuum; one may need others support to address a
given health condition. For example, in Namibia, parents dying from AIDS-related illnesses
leave their orphaned children in need of adoption. If people do not feel threatened by HIV
personally, social threats might motivate them to action. We extend the extended parallel
process model (Witte, 1992) to include 2 social perceptions: (a) stigma and (b) collective
efficacy. We found that Namibian respondents (n = 400) who did not feel threatened by HIV
personally showed a relationship between these social perceptions and their willingness to
support those living with HIV and their willingness to adopt AIDS orphans. These effects
appeared for those who did not assess HIV as a health threat, suggesting that social threats,
combined with efficacy, may motivate intentions to adopt recommended actions. Practical
applications and intervention designs are discussed.

HIV prevalence (20%) remains high in Namibia, despite 10
years of health education and health campaigns (UNAIDS,
2004). These interventions focused primarily on reducing
the rates of HIV transmission, yet the impact of HIV
extends beyond those living with the virus. In 2003, 53,000
Namibian children were orphaned because of AIDS-related
deaths of one or both of their parents (UNAIDS, 2004). With
many people living with HIV and numerous children in need
of adoption, one might ask who is willing to care for those
living with HIV and these orphaned children. The purpose
of this article is twofold. First, we attempt to predict who is
willing to provide care to people living with HIV/AIDS and
to adopt AIDS orphans. To make these predictions, second,
we propose an extension of the extended parallel process
Correspondence should be addressed to Rachel A. Smith, PhD, Depart-
ment of Communication Studies, University of Texas, 1 University Station
A1105, Austin, TX 787120115, E-mail: rachel.smith@mail.utexas.edu
model (EPPM; Witte, 1992, 1994) to include two additional
variables: (a) stigma and (b) collective efficacy.
SOCIAL SIDES TO HIV
Health threats may not occur in a vacuum; one may need the
support of others to address a given health condition. When
the health threat is HIV or AIDS, people may not receive
help from members of their community and their families
(UNAIDS, 2002). Fear, denial, stigma, and discrimination
quickly followed scientists identification of HIV and AIDS
(Frediksson & Kanabus, 2004). Since its discovery, HIV
has inspired social responses of compassion and solidarity
as well as anxiety and prejudice against those living with
HIV, such as rejection by their loved ones and banishment
from their community (Frediksson & Kanabus, 2004). HIV
and AIDS are as much about social phenomena as they
are about biological and medical concerns (Frediksson &
Kanabus, 2004, p. 1).
 56 SMITH, FERRARA, WITTE
For example, a pregnant woman in Namibia explained
that she and others would rather have their babies die than
to be put out on the streets with no one to care for them
(personal communication, July 7, 2003). This woman stated
concerns over social stigma when she does not breastfeed and
a lack of community/family support for her children (personal
communication, July 7, 2003). Because of social repercus-
sions, women living with HIV may not take HIV medicines,
such as Nevirapine and Zidovudine, or they may not stop
breastfeeding. Both medicines and baby formula signifi-
cantly reduce the risk of transmitting HIV from HIV-positive
mothers to their babies (UNAIDS, 1998). A greater under-
standing of social factors in HIV behaviors would improve
the effectiveness of HIV/AIDS campaigns to increase the
frequency of these behaviors. Before social factors may be
integrated, we need an understanding of what factors predict
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community/family support for those affected by HIV.
HIV/AIDS researchers have paid some attention to social
context, given that it shapes and situates personal values,
beliefs, and behaviors. Several studies have investigated
contextual effects on increasing HIV prevention behav-
iors (e.g., Cohen, 2000; DeGraff, Bilsborrow, & Guilkey,
1997; Grady, Klepinger, Billy, & Tanfer, 1993; Maharaj
& Cleland, 2004; Newman & Zimmerman, 2000), such as
increasing condom use to reduce sexual transmission of
HIV. Behaviors such as caring for people living with HIV
or adopting orphaned children, however, have been virtually
unexplored.
To begin this exploration, we extend one theory that
explains reactions to health threat or fear appeals, the EPPM
(Witte, 1992, 1994), by incorporating collective efficacy
and stigma. For recommended behaviors such as providing
personal support for people living with HIV or commu-
nity efforts to adopt AIDS orphans, we argue that poten-
tial caretakers assess their communitys collective efficacy
in supporting those affected by HIV in addition to their
personal ability to resist social opposition. In addition, we
propose that potential caretakers assess the stigma associ-
ated with HIV/AIDS in addition to their personal suscep-
tibility and the seriousness of HIV/AIDS when faced with
these decisions. In the next section, we review EPPM,
followed by stigma and collective efficacy, to integrate these
social perceptions into EPPM.
EPPM
Past health theorists have found that when a health threat
looms, people address either the health threat or their fear
(Witte, 1992, 1994). More specifically, the EPPM predicts
that peoples perceptions of both threat and efficacy, in
tandem, predict whether they attempt to control the danger
(e.g., take positive action) or their fear (e.g., avoid the
issue or attack the messenger; Witte, 1992, 1994; Witte,
Meyer, & Martell, 2001). The EPPM essentially incorpo-
rates Leventhals (1970; Leventhal, Safer, & Panagis, 1983)
parallel process model with elements of Rogerss (1975,
1983) protection motivation theory. If people fear for those
living with HIV or their dependents, and they believe they
can do something to support those affected by HIV, then
they would adopt the recommended attitudes, beliefs, or
behavior to support those affected by HIV. To date, the
EPPM has been used to predict how people reacted to
HIV/AIDS messages displayed in pamphlets and educa-
tional materials (Witte, 1994) and entertainment education
(Smith, Witte, & Downs, 2003).
The EPPM predicts that peoples perceptions of both
threat and efficacy, in tandem, influence whether they
attempt to control the danger or their fear (Witte, 1992,
1994; Witte et al., 2001). The first cognitive appraisal is
of the threat. When presented with a health risk, people
initially consider whether it is relevant to them (e.g., Am
I at risk for experiencing this threat?) and whether the
threat is substantial (e.g., How serious could this health risk
be?). In other words, people evaluate the susceptibility and
severity of the health threat. Susceptibility refers to peoples
subjective perception of the likelihood that they will face
the situation (e.g., I am at risk for knowing people living
with HIV and/or their orphaned children). Severity refers to
subjective perceptions about the magnitude or significance
of the situation (e.g., I believe the consequences associated
with HIV are horrible; Witte et al., 2001).
Perceptions of severity and susceptibility create peoples
perceptions of threat. As people perceive contracting HIV
as a more serious danger (severity) and their contrac-
tion as a more likely occurrence (susceptibility), they feel
more threatened. As people feel more threatened, they
get more scared; hence, they have greater motivation to
do something about this health threat. Feeling threatened
motivates behavior (e.g., Casey, 1995; Murray-Johnson,
Witte, Liu, & Hubbel, 2001; Rosenstock, 1974; Witte,
Cameron, Lapinski, & Nzyuko, 1998). Without feeling
afraid, people pay little attention to health messages; without
sufficient threat, the motivation to do something, espe-
cially something new, is missing. For example, if people
in Namibia hear about an outbreak of poison ivy rashes
in Canada, they would perceive this threat as personally
irrelevant and a rash as minor problem. Consequently,
they would pay little attention to such a health promotion
message.
Threat motivates action. Perceived efficacy, the second
part of the EPPM, determines the nature of this action.
People evaluate how successfully they could perform
the recommended responsesself-efficacyand how effec-
tively these recommendations alleviate the health threat
response-efficacy (Witte, 1992, 1995; Witte et al., 2001). In
this study, we focus on self-efficacy (e.g., I could take care
of a family member living with HIV, or I could adopt an
AIDS orphan). Self-efficacy also includes peoples percep-
tions of their ability to cope with emotional burdens (e.g.,
stress and boredom), to mobilize resources, and to take

action influence their intentions to perform the response.
This intention includes how much effort they will expend
in these efforts and their persistence in the face of chal-
lenges, barriers, and setbacks (e.g., Lee et al., 2004).
Empirical research shows that individuals perceived effi-
cacy relates positively to HIV prevention behavior (e.g.,
Blake, Simkin, Ledsky, Perkins, & Calabrese, 2001; Casey,
1995; Kvalem & Traeen, 2000; Levinson, 1995; Longmore,
Manning, Giordano, & Rudolph, 2003; Murray-Johnson
et al., 2001).
In summary, the EPPM predicts that if people believe
that HIV is a prevalent and serious health concern, and
they believe they could take care of a family member
living with HIV, then they would intend to help this family
member. This study focuses on those people who do not
feel threatened by HIV as a physical health threat. In
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general, prior research has defined health risks as personal;
people consider their personal susceptibility and the seri-
ousness of contracting HIV when considering personal deci-
sions to avoid HIV transmission. Without feeling threat-
ened by the physical illness, the assumption is that no
other threat could motivate action. Social perceptions
surrounding threat and efficacy have not been addressed
in theories such as the EPPM. For example, peoples
risk assessments of social punishment, or stigma, associ-
ated with HIV may be more salient and more dramatic
to those considering helping people living with HIV or
AIDS orphans in contrast to concerns about the phys-
ical consequences of HIV. In the following paragraphs we
review two social perceptions: (a) stigma and (b) collective
efficacy.
STIGMA AND HIV
Many health concerns are considered severe and unavoid-
able; however, contracting such illnesses may or may not
come with social consequences as well. Contracting HIV
often carries a stigma, defined as a process of devalua-
tion based on an undesirable or discrediting attribute or
attributes that a person possesses (Brown, Macintyre, &
Trujillo, 2003). Stigma derives from stereotypes or beliefs
about the attributes used to characterize a group of people
(e.g., all people with HIV are immoral, people with HIV
got it because they are careless, etc.; Ashmore & Del
Boca, 1981). Like stereotyping, the qualities to which
stigma adheres (e.g., the color of the skin or the way
someone talks) can be quite arbitrary (Herek, 1999; Herek &
Capitanio, 1998). The stigma associated with HIV/AIDS
creates barriers to prevent further infections and to
provide adequate care, support, and treatment (UNAIDS,
2004). International health organizations, such as UNAIDS,
suggest that people worldwide stigmatize HIV/AIDS, which
leads them to prioritize the assessment and the reduction
of AIDS stigma on international health agendas (UNAIDS,
2004).
SOCIAL SIDES TO HEALTH RISKS 57
Several factors contribute to stigmatizing HIV/AIDS.
These include limited knowledge of HIV, knowledge of
HIV myths, prejudice, lack of treatment, and fears relating to
illness and death, the lack of a cure for HIV, and associations
with illicit drugs and injecting drug use (Brown et al., 2003;
Herek, 1998). Victim blame, or holding infected persons
responsible for what has happened to them, is common;
people living with HIV/AIDS often are held responsible
for becoming infected (Herek, 1999). Religious or moral
beliefs lead some people to believe that having HIV/AIDS
results from moral failings (e.g., promiscuity or deviant
sex) that deserve punishment. People describe those
living with HIV as behaving inappropriately or immorally
(Parker & Aggleton, 2003):
A number of scholars have pointed to the discourses
of pollution, plague, deviance, sin, and punishment/poetic
justice (e.g., the wrath of God) that are invoked so often in
reference to AIDS (e.g., Lupton, 1993, 1994; Patton, 1994;
Redman, 1991) and that have powerfully shaped peoples
perceptions and behaviors toward those living with AIDS.
(Greene, Frey, & Derlega, 2002, p. 10)
Governments, communities, employers, churches, health
care providers, coworkers, and significant others have enacted
stigma behaviors regarding HIV/AIDS (Bond, Valente, &
Kendall, 1999; Brown et al., 2003; Cameron, 1993). Some
behaviors include firing people living with HIV from jobs,
forcing them to leave their homes, refusing them medical
treatment, and abusing them physically (Brown et al., 2003;
Ogunyombo, 1999). Stigma does not just affect an individual;
families, tribes, and races have been subjected to stigma
because of their connection to HIV/AIDS (Bond et al., 1999;
Brown et al., 2003; Cameron, 1993; Greene et al., 2002).
People may fear stigmas, and they may attempt to
manage their fear of others stigmatizing them. Some people
prefer uncertainty of their HIV status versus testing because
of the discrimination they would face (Cameron, 2000).
Those considering HIV testing fear unwanted disclosure
by health workers to family, employers, and commu-
nity officials (UNAIDS, 2002). When people realize that
they could be included in a stigmatized group (e.g., they
think they have HIV), they engage in coping strategies
such as secrecy, denial, deception, and social withdrawal
in order to avoid rejection (Markowitz, 1998). Concerns
about stigma are associated with reductions in test- and
treatment-seeking behavior, disclosure of HIV status, the
level of social support solicited and received, personal iden-
tity/esteem, and the quality of health care received (Chandra,
Deepthivarma, & Manjula, 2003; Greene et al., 2002; Leary
& Schreindorfer, 1998). The fear of being found out by
the community, fear of disgracing self and family, and the
fear of mistreatment by health care workers are related indi-
rectly to health-seeking behaviors (Chandra, Deepthivarma,
& Manjula, 2003; Herek, 2002). These behaviors resonate
with fear control described in the EPPM. We add that
 58 SMITH, FERRARA, WITTE
when people fear social threats, this fear provides the same
motivation to act or, where stigma outweighs efficacy, the
motivation to control fear.
People living with HIV may not be the only ones to bear
stigmas. People socially connected to those living with HIV
may receive a courtesy stigma (Goffman, 1963). Commu-
nity members treat both those living with HIV and their
supporters as though they all carry the virus. Caretakers or
public supporters may be as ostracized from the commu-
nity as persons living with HIV. Community members may
criticize people who are sympathetic to persons living with
HIV and may interrogate these sympathizers about their
own HIV status.
Just as physical consequences of health threats may
motivate a response, so too may social consequences,
such as stigma. The literature suggests that high levels
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of stigma carry serious consequences, and fear of these
consequences may prevent people from caring for family
members infected with HIV/AIDS or keep people from
agreeing to take in AIDS orphans. As suggested by the
EPPM, only if people feel a simultaneous level of efficacy
(e.g., confidence that they could help even if the commu-
nity objected) will they help those affected by HIV. Stigma
extends perceptions of threat to include social threats. For
those who do not evaluate HIV as a physical health threat,
we made the following hypothesis:
H1 : As people report (1) more stigmas about HIV and
(2) more ability to help people living with HIV (in
spite of social opposition to such help), then they
will report more willingness to care for their family
members living with HIV.
If community members want to avoid stigma, why would
they risk a courtesy stigma and support those living with
HIV and their dependents? Just like with physical health
threats in the EPPM (Witte, 1992, 1994), as people feel
efficacy about the recommended responsesin this case,
supporting people living with HIVthen their sense of
threat will compel them into acting on the recommended
response, instead of controlling their fear through denial
or blaming the messenger. People may help others living
with HIV from a distance, such as supplying food to a
local church. This interpersonal distance allows people to
avoid a courtesy stigma and to take the recommended action
to support those affected by HIV. In a community where
helping others is normative, a person may maintain his
or her social grace and status within the community by
supporting persons with HIV and their dependents as long
as he or she feels that doing so would not put him or her at
a greater risk, either physical or social.
In the next section, we review a social extension to effi-
cacy, collective efficacy. With greater confidence in the
communitys ability to mobilize resources to help people
living with HIV, its members would report more willing-
ness to help those living with HIV and their associated
dependents, that is, their children.
COLLECTIVE EFFICACY
Collective efficacy refers to group members confidence (or
a groups confidence) in their groups abilities to attain their
goals and to accomplish desired tasks (Bandura, 1986). It
involves perceptions or beliefs that an effective collective
action to address a social or public health predicament is
achievable (Figueroa, Kincaid, Rani, & Lewis, 2002).
Health communication research recognizes the role
of communities in explaining social change (Arcury,
Austin, Quandt, & Saavedra, 1999; Baum, 1999; Berkman,
1995; Bracht & Tsouros, 1990; Campbell & Jovche-
lovitch, 2000; Dube & Wilson, 1996; Dutta-Bergman,
2003; Kennedy, 2001; Rappaport, 1987) and positive health
outcomes (Dutta-Bergman, 2003). Research shows strong
positive correlations between collective efficacy, group goal
setting, group achievement, and group performance (Bray,
2004). For example, city neighborhoods with reports of
greater collective efficacy had fewer incidences of violence
in their neighborhood (Sampson, Raudenbush, & Earls,
1997).
Members of communities with high collective effi-
cacy versus low collective efficacy participate more in
their sociocultural environments, secure and access more
community resources, develop stronger networks of social
support, and feel more personal empowerment (Baum,
1999; Dutta-Bergman, 2003; Rappaport, 1987; Repucci,
Woolard, & Fried, 1999). Preventive behaviors have a
greater likelihood of success in communities where indi-
vidual members are highly involved (Dutta-Bergman,
2003). As members participate more in empowered and
organized communities, they are more likely to recog-
nize and to mobilize resources to promote positive health
outcomes (Dutta-Bergman, 2003; Treno & Holder, 1997).
The theory of reasoned action (e.g., Ajzen & Fishbein,
1974), the theory of planned behavior (e.g., Dutta-Bergman,
2003), and social cognitive theory (e.g., Bandura, 1977) high-
light the impact of group members, social networks, and
important others as catalysts of health behavior. A person is
more likely to perform preventative behaviors when his or her
(trusted) peers, community leaders, and role models endorse
or enact these behaviors (Campbell & Jovchelovitch, 2000;
Dube & Wilson, 1996; Dutta-Bergman, 2003). For example,
members of communities reporting greater collective efficacy
felt greater expectations to intercede and to decrease violent
activity (Sampson et al., 1997).
Perceptions of group efficacy may carry more power than
self-efficacy. Even if individual group members feel effi-
cacy in their personal ability to help adopt an AIDS orphan,
low collective efficacy may hinder community dialogue

about AIDS orphans and collective actions to help or to
adopt them, as well as persistence in performing collec-
tive activities when barriers arise (Figueroa et al., 2002).
Dutta-Bergman (2003) argued that
health-enhancing behaviors are determined more by collec-
tively negotiated social identities rather than by individual
rational choice and high social capital communities are more
likely to provide a supportive context to their members
with opportunities for collectively renegotiating their social
identities with respect to health behaviors. (p. 6)
Community participation instills member confidence and
motivation. Communities with high levels of collective
efficacy are more likely to have members who report greater
perceptions of control over their lives (Campbell & Jovch-
elovitch, 2000, p. 262). A sense of self-efficacy and an
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internal locus of control, which define health awareness,
also can motivate health-conscious people to participate in
their community (Dutta-Bergman, 2003; Walker, Sechrist,
& Pender, 1987; Wilkinson, 1996). Motivated community
members, versus unmotivated ones, show more capability of
taking control of their lives and performing positive behav-
iors (Campbell & Jovchelovitch, 2000; Dutta-Bergman,
2003). We proposed the following hypothesis for those who
do not feel threatened by HIV as a physical health threat:
H2 : As people perceive that their group members have
(1) more stigmas about HIV and (2) greater capa-
bility to mobilize resources to help those affected by
HIV, then they will report that their group members
are more willing to adopt AIDS orphans.
METHOD
Respondents and Procedure
Namibian health care workers and households (n = 400)
immediately adjacent to a mission hospital located in
Andara were interviewed. A map was developed, listing
all formal and informal households within a 10-km
area surrounding Andara Catholic Hospital. Interviewers
branched out in a circle around the hospital until they
completed 400 interviews. Interviewers had to be fluent in
English and Afrikaans as well as local tribal languages (e.g.,
Thimbukushu) to help respondents through the survey in
respondents native languages.
Interviewers approached each household and asked to
talk to the head or older person in the household, explained
the study, obtained an inventory of all eligible members
(age 15 years and older who resided in the household), and
then chose at random the person to be interviewed. The
interviewer then asked to talk to the selected respondent;
took him or her to a private place, either inside or outside
of the household; and read the informed consent informa-
tion, explaining that participation was voluntary and that
SOCIAL SIDES TO HEALTH RISKS 59
all answers were confidential. It took approximately 90 min
for respondents to complete the survey. On completion, the
interviewer thanked respondents and gave them a household
food item (e.g., a small bag of rice or flour).
The entire instrument contains questions assessing
behaviors related to HIV prevention and care and support,
psychosocial factors believed to influence these behav-
iors, perceptions of the community-level characteristics, and
exposure to mass media and community-based messages
related to HIV/AIDS. The rest of the survey will appear in
future documents.
Respondents ranged in age from 15 to 87 (M = 35,
SD = 14.6). Just over half of the respondents were women
(53%). Most respondents spoke Thimbukushu (91%) and
practiced Roman Catholicism (75%). Many respondents
attended school (78%); half of them had completed at least
6 years of school (53%). Most respondents reported no
current employment (62%), followed by students (8%) and
farmers (6%). Most respondents reported being married
(43%) followed by being single (31%); 20% of the respon-
dents had a child who had died. Almost half of the respon-
dents considered themselves the head of the household
(46%). About 23% of respondents reported being away from
home for more than a month in the past year. Half of the
respondents knew someone who lived with HIV or who had
died of an AIDS-related illness (51%), whereas fewer knew
someone receiving medicines for an AIDS-related illness
(33%).
Instrumentation
In the midst of a long interview, two measures, individual
stigma and group danger control, were reduced to single
items. Single items leave us without the ability to calculate
measurement unreliability, which is a limitation addressed
in the DISCUSSION section. We used multiple items for
other variables and conducted confirmatory factor anal-
yses to verify the items unidimensionality. Unidimensional
factors meet two statistical criteria (Hunter & Gerbing,
1982): (a) items are internally consistent (i.e., share strong
positive correlations of similar magnitude) and (b) exter-
nally consistent (i.e., share correlations of the same direc-
tion and magnitude with items in an external factor). The
following measurements passed these criteria.
Health threat. Respondents were asked four items
concerning HIV as a health threat. First, they were asked
whether contracting HIV is the worst thing that could
happen to them and whether contracting HIV is a sure
death sentence. They marked their agreement on a scale
that ranged from strongly disagree (1) to strongly agree
(4),  = .80 (M = 3.31, SD = 0.86). Respondents also were
asked about their personal chances of contracting HIV, the
seriousness of AIDS in their social group, and the serious-
ness of AIDS in Namibia. They marked their evaluations
 60 SMITH, FERRARA, WITTE
on a scale that ranged from not a problem at all (1) to a
very serious problem (4). These items were averaged into
a single score (M = 2.93, SD = 0.64). The two components,
susceptibility and severity, were combined into one score for
threat,  = .65 (M = 3.12, SD = 0.55); higher scores indicate
more threat.
Self-efcacy. Respondents were asked three items
concerning how confident they are that they would help
someone living with HIV even if their spouse, members
of their social groups, or their community opposed them
helping. They marked their agreement on a scale that
ranged from strongly disagree (1) to strongly agree (4).
Their answers were averaged into one score,  = .81,
(M = 3.00, SD = 0.87); higher scores indicate more personal
efficacy.
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Collective efcacy. Respondents were asked three
items concerning how well members of their group are
willing to join in and do their share of the work to help
people affected by AIDS, could work together, and mobilize
resources to help those affected by HIV. They marked their
agreement on a scale that ranged from strongly disagree (1)
to strongly agree (4). Their answers were averaged into one
score,  = .74 (M = 3.26, SD = 0.71); higher scores indicate
more collective efficacy.
Group stigma. Respondents were asked four items
concerning whether people in their most important social
group would avoid those who have HIV, and these group
members would judge those who contracted HIV as care-
less and immoral. They answered these questions on a scale
that ranged from strongly disagree (1) to strongly agree
(4). Their answers were averaged into one score,  = .70
(M = 2.84, SD = 0.76); higher scores indicate more belief
that their peers stigmatize those with HIV.
Personal stigma. Respondents were asked whether
they would keep information about a member of their family
contracting HIV secret. They answered this question on a
scale that ranged from definitely no (1) to definitely yes
(5; M = 3.26, SD = 1.85); higher scores indicate that the
respondent associates more stigmas with HIV.
Willingness to care for those living with HIV.
Respondents were asked three questions about their
behavior with someone living with HIV: (a) If a member of
your family became sick with HIV would you care for him
in your household?; If you knew a shopkeeper or food
vendor had HIV, would you buy fresh produce from him?;
and (c) If a teacher has HIV but is not sick, should he
continue teaching in school? Respondents presented their
answers on a scale that ranged from definitely no (1) to defi-
nitely yes (5). Their answers were averaged into one score,
 = .64 (M = 4.41, SD = 0.92); higher scores indicate more
willingness to have contact with and to support those living
with HIV.
Peers willingness to adopt AIDS orphans. Respon-
dents were asked if they thought that members of their most
important social group would take in an AIDS orphan. They
answered this question on a scale that ranged from strongly
disagree (1) to strongly agree (4; M = 3.25, SD = 0.91);
higher scores indicate more willingness to adopt an AIDS
orphan.
RESULTS
Descriptive Statistics
Respondents assessed HIV as a serious and likely health
threat (M = 3.12, SD = 0.55). They also reported being able
to help someone living with HIV even if their spouse,
members of their social groups, or their community opposed
them helping (M = 3.00, SD = 0.87). They also felt that their
social groups could work together and mobilize resources to
help those affected by HIV (M = 3.26, SD = 0.71). Overall,
respondents felt threatened by HIV, and they felt personal
and collective efficacy to help those living with HIV and
their dependents.
HIV also carries a stigma. Respondents agreed that
people in their social groups would avoid people who
have HIV, and these group members would judge those
who contracted HIV as careless and immoral (M = 2.84,
SD = 0.76). They also agreed that if a member of their
family contracted HIV they would keep it secret (M = 3.26,
SD = 1.85). They felt stigma on a personal and collective
levels.
Last, respondents generally thought that they and their
groups would support people with HIV. They generally
thought that members of their social groups were willing to
take in an AIDS orphan (M = 3.25, SD = 0.91). They also
agreed that they were willing to care for a family member
with HIV in their own household, continue to buy produce
from a shopkeeper with HIV, and encourage a teacher
to continue teaching if the teacher had HIV (M = 4.41,
SD = 0.92). The apparent contradiction presents an inter-
esting finding: Respondents would keep their familys status
a secret, but they were willing to care for those affected
by HIV.
Predicting Support
To test the hypotheses, we split respondents on the basis
of their perceptions of HIV as a health threat.1 Those who
evaluated HIV as a physical threat, greater than the mean
of the scale (67% of the respondents), were evaluated sepa-
rately from those who did not evaluate HIV as a physical
1
Traditional statistics are relatively insensitive to interaction effects
(Wahlsten, 1990). The decision to split data into high and low threat allows
interaction effects to be observed (MacKinnon, Lockwood, Hoffman, West,
& Sheets, 2002).
 SOCIAL SIDES TO HEALTH RISKS 61

threat, lower than the scales mean (33% of them). Those
who felt threatened by HIV physically were more likely
to know someone living with HIV or who had died of an
AIDS-related illness (60%) than those who did not feel
threatened (40%), X2 (1, N = 398) = 14.50, r = .20. Other-
wise, the subsamples did not differ by gender or by status as
head of household. We tested the hypotheses with regression
analysis, thereby calculating the independent contribution
of stigma and efficacy perceptions on intentions to support
those impacted by HIV.
For respondents who did not assess HIV as a phys-
ical health threat, we hypothesized that greater self-efficacy
and less personal stigma would increase their willingness
to support those living with HIV. The model was statisti-
cally significant, F(4, 116) = 3.76, p < .05, R2 = .12, but
Hypothesis 1 received only partial support. Personal stigma
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however, the model predicted more variance for those who
did not assess HIV as a health threat, F(4, 115) = 26.33,
p < .05, R2 = .48, compared with those who did, F(4,
240) = 2.64, p < .05, R2 = .07 (see Table 1 for standardized
beta weights). For both subsets, more collective efficacy
predicted greater belief that members of their social groups
would adopt AIDS orphans. Hypothesis 2 received support.
For respondents who did not assess HIV as a physical health
risk, greater assessments of group stigma also corresponded
to greater belief that group members would adopt AIDS
orphans ( = .46, p < .01). In an independent-samples t test,
those who assessed HIV as a physical health threat reported
that their groups would be more willing to take in an AIDS
orphan (M = 3.39, SD = 0.80), in contrast to those who did
not (M = 2.98, SD = 1.05), t(397) = 4.24, p < .05, r = .21.

predicted willingness to care for those with HIV (= .34,

DISCUSSION
p < .01), but self-efficacy to resist social pressures did not
(see standardized beta weights in Table 1). As predicted,
This study tested the utility of adding social perceptions to
for respondents who already assessed HIV as a physical
the EPPM (Witte, 1992, 1994) to predict willingness to care
health threat, none of the social factors accounted for vari- for people affected by HIV. We proposed adding stigma
ance in their willingness to provide care, F(4, 241) = 1.15, to perceptions of health threats and collective efficacy to
ns, R2 = .02. In an independent-samples t test, those who perceptions of efficacy. Stigma, or social consequences of
assessed HIV as a physical threat reported as much willing- HIV, was proposed to scare Namibians as physical conse-
ness to care for those living with HIV (M = 4.41, SD = 0.87) quences of contracting HIV do. Those who feel threatened
as those who did not (M = 4.41, SD = 1.03), t(397) = 0.94, by HIV need no additional motivation to adopt recom-
ns, r = .00. mended actions, such as taking care of people living with
Hypothesis 2 predicted that, for those who did not assess HIV or adopting AIDS orphans. For those who do not feel
HIV as a physical health threat, greater collective efficacy threatened by HIV physicallythat is, it is neither serious
and group stigma would increase respondents perceptions nor likely to happen to themthe threat of stigma would
of group members willingness to adopt an AIDS orphan. motivate their intentions to provide care to those affected
For both subsets of respondents, the model accounted for by HIV, as long as their efficacy perceptions also remained
perceptions of peers willingness to adopt an AIDS orphan; strong. As predicted, the more those who did not feel threat-
ened by HIV sensed that their groups held a stigma about
TABLE 1 HIV as well as an ability to mobilize resources, the more
Summary of Standardized Beta Weights for Stigma ad Efcacy in they believed that their group members would adopt AIDS
Predicating Support orphans. Personal stigma (but not self-efficacy) to resist
social pressure predicted Namibian respondents willing-
Department variables
ness to support people living with HIV. The more they held
Willingness to care for Peers willingness to a personal stigma, the more they reported willingness to
Variable those living with HIV adopt AIDS orphans help people living with HIV. The addition of stigma and
Low threat collective efficacy to understand health intentions found
Self-efficacy  .12 .03 support in this study. Social consequences, such as physical
Collective efficacy  .04 .30 consequences, need consideration in health research.
Personal stigma  .34 .10 Alternative explanations for our results exist. The
Group Stigma  .02 .46
empathyaltruism hypothesis suggests that empathic
Model R2 .12 .48
High threat
emotion evokes altruistic motivation (Cialdini, Brown,
Self-efficacy  .03 .01 Lewis, Luce, & Neuberg, 1997). People who do not believe
Collective efficacy  .05 .25 that they are at risk for HIV/AIDS may feel bad for others
Personal stigma  .11 .00 who are affected by HIV and report a desire to help them.
Group Stigma  .09 .07 Most of our respondents identify with Catholicism and may
Model R2 .02 .07
be taught to help persons who are less fortunate. Perception
Note. N = 400. Model R2 refers to variance explained with all four of altruism is significantly associated with willingness to
variables simultaneously. participate in AIDS surveys and educational interventions

p < .05. (Sengupta et al., 2000).
 62 SMITH, FERRARA, WITTE
Another possible explanation is a perception of self
other behavior. Respondents said that they would continue
to have contact with family and community members who
contracted HIV but that they would want a family members
status to remain a secret. The respondents also reported
more confidence in themselves than in other people in the
community to help people affected by HIV/AIDS. These
findings presents a self-serving bias, that is, I am OK with
being around people who are HIV positive, and I am a caring
individual, but others in my community are not. Future
research should consider these alternative explanations.
Limitations
As described earlier, single-item measures limit our ability
to assess measurement reliability and, consequently, our
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ability to correct for measurement error, leaving our effect
sizes constrained. Specificity of measurement is also a
concern. We asked very specific questions to assess what
type of contact our respondents were willing to have with
people who are affected by HIV. Future investigations
should expand supportive options (e.g., donate clothing,
deliver food, etc.). Additionally, we did not test other
reasons why someone would not be willing to help. Limi-
tation in money and space could keep respondents from
strongly agreeing to help those affected by HIV/AIDS.
There are a few concerns with our sample. Andara is in
the northern section of Namibia, where residents have seen
other threats, such as malaria and civil wars. These other
threats may provide a context for HIV that does not gener-
alize to other communities. The central social group is the
Roman Catholic Church. Faith-based messages about HIV,
its transmission, and the need to provide support to people
in need may not generalize to other communities founded
in other religions or secular practice. Last, our sampling
procedure did not ensure a random sample of respondents in
the area as much as a consensus of the communitys center.
We anticipate future studies that attempt to replicate these
findings in other communities, with representative samples,
and to test actual behavior rather than perceptions.
Practical Implications
Understanding social norms and collective efficacy would
help in the design of interventions as well. Traditional fear-
appeal research suggests that the physical health threat is the
key motivating behavior change. However, our data imply
that even if people do not fear the physical health threat,
they may fear stigma associated with the health threat.
Practitioners, with limited resources, attempt to
encourage as many people as possible to receive testing,
to take treatment, and to provide support for persons with
viruses such as HIV. If the community associates a stigma
with HIV, then campaigns may need to encourage efficacy
in resisting this stigma as much as efficacy in prevention
behaviors. Some women may continue to breastfeed their
infants, even if they know that they are HIV positive, in
order to not raise suspicion. Some viruses, like HIV, incu-
bate for years, so the social consequences of being ostra-
cized within the community may be more salient and more
potent than the physical effects of an AIDS-related illness.
If social pressures present themselves more than physical
ones, then practitioners may want to focus on group activ-
ities to support people living with HIV and their depen-
dents. Often, respondents in this study reported discussing
HIV transmission in their group meetings. If these group
meetings already provide a mechanism to distribute infor-
mation, then they may also distribute norms of support and
acceptance, instead of ostracism and stigma. Realistically,
these group meetings already may provide the multilayered
message. Practitioners need to assess knowledge and norms
(positive and negative) provided within group meetings in
order to design effective messages for health promotion.
Health threats bring physical and social risks to people,
their loved ones, and their communities. The social condi-
tions surrounding health threats need as much consideration
as physical effects. The inclusion of social aspects of health
threatsstigma and collective efficacywould further our
theoretical explanations for processing fear appeals and
health risk messages. The finding that people may be moti-
vated to address health threats, even if they do not feel that
the health condition is serious or likely to happen to them,
needs further investigation. They feel efficacy in themselves
and their community to make a difference in the lives of
people being stigmatized for association with HIV/AIDS.
ACKNOWLEDGMENTS
This research was supported with primary support
from the United States Agency for International Develop-
ment under the Health Communication Partnership project
(GPH-A020000800). We thank personnel at JHUCCP-
Namibia and Research Facilitation Services for their contri-
butions to this study.
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