Source: International Journal of Sociology and Social Policy
V olu m e 18 N u m ber 7/ 8 1998 , pp. 1-25.
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ETH N I C I T Y , H I V / A ID S P R E V E N T I O N A N D P U B LIC
H EALTH ED U C A TIO N
b y Stella R . Q uah, D epartm ent of Sociology, N at ional U n iversit y o f
Sin gap o r e.
A fter nearly two decades of battling the H IV/ A I D S ep idem ic, m o r e
h as been lear n ed in m edical science than in public health policy
particularly concerning public health education program m es. O n e of
t h e main obstacles to advances in public health education is, of course,
t h e association of the disease with intangible and controversial
value-loaded issues such as p r ivacy and the co llect ive n o t ions of w h at
is perm issib le an d w h at is unacceptable or even forbidden behaviour.
Imaginative public health education policies often do not m eet
expectations due to im p lem en t at ion obstacles such as failure to reach
t h e target p o p u lation and lack of inform at i o n o n t h e populat ion’s
attitudes an d o n t h e public im age o f t h e disease. Sociological an d
o t h er social scien ce research o ffer p ertinent findings.
T h e gr o w ing body of research on the behavioral aspects of
H IV/ A I D S p r even t ion over the past t en years has encom p assed t h e
application and critical analysis of various conceptual fram e w o r k s,
including the H ealt h Belief M o d el. In spired by field theory and
sym b o lic in t eraction, the H ealt h Belief M o d el focuses o n subjective
perception and m o t ivatio n and proposes t h at t h e main triggers of
p r even t ive act ion are: perceived personal susceptibility to the health
p r o b lem ; perceived seriousness of the problem ; an d t h e su b jective
perception of barriers to and benefits of a given preventive action
(Rosenstock, 1974; Kirscht, 1988). T h is paper presents and discusses
empirical findings on the application of the H ealt h Belief M o d el to
H IV/ A I D S p r even t ion in the context of public health education.
Main assumptions explored
T h e ap p lication of t h e H ealt h Belief M o d el t o t h e study of preventive
behaviour concerning H IV/ A IDS has enriched the already large
b o d y o f lit e r a t u r e o n t h e M o d e l a n d , m o r e im p o r t antly, has
h igh ligh t ed several of its strengths and weaknesses. Am o n g t h e most
relevan t fin d ings are the positive influence of knowledge of the health
p r o b lem ; t h e im p act o f self-efficacy in carrying out preventive
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Intern ation al Journ al of Sociology and Social Policy
actions; t h e uncertain role of perceived personal susceptibility to the
d i sease in p r o m o t i n g p r e v e n t i o n ; a n d t h e i m p o r t a n c e o f
ack n o w ledgin g cu lt u r al variat ions in the dynamics of preventive
behaviour. T h ere is also increasin g aw areness am o n g research ers of
t h e difficu lt ies en countered in identifying specific preventive
behaviour that would constit u t e t h e target (i.e., depen d ent variable)
in studies on H IV/ A I D S p r even t ion.
Selected exam p les o f t h ese fin d ings will suffice. Em p irical test s of
t h e H ealt h Belief M o d el co n fir m t h at k n o w ledge o n t h e et iology of
H IV in fection (LeBlanc, 1993; W u lfer t and Biglan , 1995; A b r aham
and Sheeran, 1994) and self-efficacy (Vanlandingham et .al., 1995) ar e
part of t h e spectrum o f fact o r s facilitating preventive behaviour.
A n o t h er concep t u al co n sideration is “t h e predictive value of th e
com p o n ents of the m o d el” o r “belief specificity”: Kirsch (1988:37)
argues that “if an action is regarded as effective” preven t ive m easu r e
again st a health problem , “t h en taking the action should reduce the
perceived ... susceptibility” to that health problem . Yet, fin d ings
fr o m H IV/ A I D S research reveal that the dynam ics o f t h e disease
fr o m t h e tim e of H IV in fect ion to the onset of fu ll-b l o w n A I D S is
c h a r a c t e r i z e d b y g r e a t u n c e r t a i n t y o n t h e o u t c o m e o f o n e ’s
r isk -taking and preventive actions. U n cer t ain t y increases the
perso n ’s su b jective perception of personal susceptibility or risk of
contracting H IV/ A IDS even after ceasing risk-tak ing behaviour
(Prohaska et.al., 1990).
T h e im p act of cu lt u r al variat ions is now acknowledged. W h ile
t h e biom edical aspect of H IV an d A I D S is characteristically uniform
acr o ss geographical regions, the cultural dim ension of H IV/ A I D S
p r even t ion is undeniably im p o r t ant as m o r e th an 115 countries
around the world have been affected by the epidem ic (Jayasuriya,
1995). T h ere is in creasin g agreem ent am o n g researchers on the
sign ifican ce o f cu lt u r al variat ions on health behaviour involving
H IV/ A I D S. Cross-cu ltural differences in collective and in d ividual
perception the seriousness of, and susceptibility to the disease,
i n f o r m a t i o n o n p r e v e n t i v e m easu r es, an d r esp o n ses t o t h e
H IV/ A IDS threat, need to be identified and incorporated in
p r even t ive p r o gram m es. So m e American studies have confirm ed
V olu m e 18 N u m ber 7/ 8 1998
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cultural differen ces acr o ss et h n ic co m m u n ities w it h in the U n ited
States (P r o h aska et.al., 1990). M o r e specific co n fir m ation of cultural
variation s is sh o w n in recent studies that have focused directly on
com m u n ities o u t side N o r t h A m er ica an d E u r o p e, fo r exam p le,
dom est ic clien t s of fem ales sex w o r k er s in Bali, In d o n esia (Fajans,
F o r d an d W iraw an , 1995); N o r t h ern Thai males (Vanlandingham
et.al., 1995); Japanese and T h ais in Japan (Munakata, 1994); and som e
com m u n it ies in L atin A m er ican and African countries (H erdt and
Lin d enbaum, 1992).
H o w e v e r , t h e an aly sis o f sp e c i f i c p r e v e n t ive act i o n s is
p r o b lem atic (A b r aham and Sh eeran, 1994). T h e targeted preventive
act i o n i n m o st social scien ce st u d ies o n H IV/ A IDS is sexual
behaviour and, in particular, condom u se. H o w ever, th e co llective
perception of sexual activity as a fundam entally private activity in
som e co m m u n it ies co m p el people to deflect questions on the subject,
to provide socially acceptable responses, or to avoid discussing the
m atter altogether. C o n sequen t ly, specific questions on prevention
such as condom use, and/ o r ask ing the questions in a public setting,
m ay not elicit reliable inform ation (Van lan d ingham et.al., 1995).
In ad di tion to the hy p o t h eses o f t h e H ealt h Be lief M o d el, t w o
o t h er as sum p t ions are ex p lored in this study. O n e in v o lves t h e co n cep t o f stigm a which has been ex p lored in the study of H IV/ A I D S
fr o m vari o u s per spec tives. T h e so cial re jection per ceived b y A I D S
suf fer ers is co n sid er able in the U n ited States but the stigma is be lieved
to vary de pend ing o n t h e phase of the dis ease (Alonzo and Rey n o lds,
1995) al t h o u gh ac cord ing to som e stud ies, “o n ly a m i nor ity o f t h e
p u b lic p r o fessed t o h o ld h o st ile an d r e pres sive view s” (G r een ,
1995:563). Still, t h e pub lic i m age o f H IV/ A I D S is a rele van t p o l icy as pect to ex p lore in the plan n ing of pre ven t ive h ealt h edu ca tion p r o gram m es in spe cific com m u n i ties. T h e other assu m p t ion con cer n s
t h e per cep t ion of per sonal re spon si bil ity o r b lam e fo r ac quir ing the
disease. It is ex pected t h at th e st r o n ger a per son’s be lief in per sonal re spon si bil ity o r b lam e fo r ac qu ir ing H IV/ A IDS, the more in clin ed h e
o r sh e would be to take pre ven t ive m easu r es. It is fu r t h er ex pected
t h at stigm a an d b lam e are re lated an d t h u s may jointly in flu ence peo -
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Intern ation al Journ al of Sociology and Social Policy
p le’s b eliefs in ef fect ive p r e ven t ive m easu r es. T h e ex p lo ra tion o f t h ese
at ti tu di nal aspects will help in iden tify ing ef fect ive m o t i va t o r s of pre ven t ive be hav iour t h at m ay then be in cluded in p u b lic health edu ca tion pro gram m es.
The Study Pro ce dure
T h is pa per dis cusses t h e ap p li ca t ion of the H ealt h Be lief M o d el an d
t h e co n cep t s of stigm a an d b lam e t o t h e an aly sis o f pre ven t ive h ealth
be hav iour to w ards AID S am o n g t h r ee A sian com m u n i t ies, C h i nese,
M a lay , an d In dian Sin ga po re ans. A r ep re sen t a tive strat i fied ran dom
sam p le (N = 660) o f t h e t o t al p o p u la tion of Sin gap o r e cit i zen s co m p r isin g t h o se t h r ee et h n ic gr o u p s was in ter view ed in 1992-93. T h e
per so n al in t er view s fo l lo w ed a st r u c t u r ed question naire and took
p lace at t h e h o m e of the re spon dents an d in the lan guage o f t h eir
choice. T h e multi-et h n ic Sin gap o r e popu la t ion offers a ver y con du cive set ting to study cul t u r al var ia tions. T h e et h n ic co m p o sition has
re m ained sta b le fo r t h e past thirty years, with a C h i nese m ajo r ity
(77.5 per cent of the to tal 2.87 m il lio n p o p u la tion in 1993) an d t w o
sign ifi can t eth n ic m i nori t ies, M a lay s (14.2 per cent) an d In di ans (7.1
per cen t ). T h e re m ain ing 1.2 per cen t are from o t h er eth n ic gr o u p s
(D e part m en t o f Sta tis tics, 1994b ).
C o m pared t o t h e situa t ion in other coun t r ies, t h e H IV/ A IDS epi dem ic has not yet af fected Sin gap o r e seri ously . The first two cases of
H IV/ A I D S were dis cov ered in 1985. By July, 1996, the to tal n u m b er
o f H IV/ A IDS cases was 477, of whom 155 have died, 76 h ave cu r rently full-b low n A IDS, and 246 have not shown yet any symp tom s.
T h ere is n o in di ca tion t h at the dis ease h as affected one eth n ic co m m u n ity m o r e t h an the oth ers (Straits T i m es, 1994, 1996). N ev er t h eless,
ex perts an d t h e health authori t ies in Sin ga pore agree on the im p o r tan ce o f pur su ing p u b lic p r e ven t ive edu ca tion ef forts.
O rdinarily, the H ealt h Belief M o d el is u sed to predict b ehaviour.
But in this paper, the focus of discussion is the respondents’
perception of effective preventive m easu r es again st H I V / A IDS. The
perception of effective preventive m easu r es is ascer t ain ed by the
V olu m e 18 N u m ber 7/ 8 1998
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quest ions “Is there any effective way of protecting yourself from
A I D S?” an d “What way is that?” T h e main components of the H ealth
Belief M o d el b r o u gh t in to elucidate the perception of effective
p r even t ion are: the belief in one’s p e r so n al su scep t ibility to
H IV/ A I D S (ascer t ain ed th r o u gh a five-p o int Likert scale o n t h e
r e s p o n d e n t s ’ level o f agreem ent of disagreem e n t w i t h t h r e e
statem ents on their personal vulnerability to H IV/ A IDS); the
perceived serio u sness of H IV/ A I D S (a scale o f alternatives ranging
fr o m “not ser ious at all” t o “cau sing death and having no cure”); the
perception of benefits and barriers to preventive action (the
availab ilit y o f blood testing services an d t h e co st o f t h e test); an d t h e
level o f knowledge on H IV/ A IDS (definition and etiology). A set of
t w elve o t h er variables w as in cluded to ascer t ain t h e in fluence of
st r u ctural variables such as incom e, occupational prestige, level of
form al education, age, gender, m arital status, religion and ethnicity;
as w ell as personality characteristics such as future-o r ien t at ion, sense
o f co n t r o l over life even t s, an d p r even t ive o r ien t ation; and the im p act
o f mass media and exposure to public health cam p aign s. A s in d icated
earlier, tw o additional variables not part of the standard H ealt h Belief
M o d el are in t r o d u ced: t h e perceived im age o f people affected by
H IV/ A I D S, t o d etect social stigm a; an d t h e perception of possib le
social san ctions towards people with H IV/ A I D S (t h e at t r ibution of
b lam e to H IV/ A I D S victims).
D ata an aly sis co m p r ised t w o p h ases: t h e iden t ificat i o n o f
sign ifican t c o r r e l a t i o n (in d icat e d b y c h i -sq u ar e , Sp e a r m a n
correlation, C o r r elation Coefficient, and Pearson’s r) and factor
analysis. Both phases were applied to the data from t h e t o t al sam p le
and then separately to the three ethnic subsam p les, u sin g SP SS-P C fo r
M S Windows 6.0. Three rounds of factor analysis were conducted to
iden t ify t h e fact o r s exp lain ing the largest proportion of variance in
t h e perception of effective H IV/ A IDS prevention.
Find ings
T h e perception of effective preventive m easu r es again st H I V / A IDS
among the three main ethnic communities in Singapore is
sum m ar ized in T able 1 together with the aspect of social stigm a. T h e
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responses in this table are to the questions “W h at k ind of people do
y o u t h ink are most likely to get AID S?” an d “Is t h ere an effect ive w ay
o f preventing AID S?” T h e first quest ion refers to the social stigm a
t h at sh apes the public im age o f H IV/ A I D S su fferers. A b o u t o n e out
o f ever y four persons in the total sam p le (26 per cent) believed th at
t y p ical H IV/ A IDS sufferers were hom o sexuals, co m m ercial sex
w o r k er s, drug addict s, o r a co m b ination of these perceived ‘devian t ’
categories. A sm aller p r o p o r t ion of respondents (17 per cent) believed
t h at an y o n e may be affected because, in their view, H IV/ A I D S
sufferers are victim s of acciden t al in fect ion. H o w ever, t h e majority of
t h e respondents (57 per cent) perceived AID S su fferers as ‘r isk -takers’
t h at is, people who engaged in activities that put them at risk o f
H IV/ A I D S in fect ion such as having m u ltiple sexual partners and
p r o curing the services of com m ercial sex w o r k ers. T h ere is n o
sign ifican t v ariation in the perception of these three im ages o f
H I V / A I D S su ffer e r s am o n g C h i n e s e , M alay s an d I n d i a n s .
Interestingly, the inclination of the m ajo r it y t o see H IV/ A IDS
sufferers as risk -tak ers, an d o f only a m inority perceiving them as
devian t s, is sim ilar t o t h e fin d ings from a recen t study of a quota
sam p le o f 300 adu lt s in G lasgo w and Edinburgh (G r een , 1995).
O n t h e second quest ion, the majority of the total sam p le (82.5 per
cen t ) believe t h at t h ere is an effective w ay of preven t ing H IV/ A I D S.
A b o u t six out of ever y t en respondents believe that the m o st effective
perso n al p r o t ect ion against H IV/ A I D S is fo r p eople at risk to change
t h eir sexual h abits and behaviour. T h e seco n d m o st com m o n
p r even t ive m easu r e is “safe sex” t h at is, t h e use of condom s,
m entioned by 15.2 per cent of all respondents. T h ere are sign ifican t
eth n ic var iations in t h e perception of effective preventive m easu r es.
M alay s alm o st u n anim o u sly (96 per cent), indicate that there is an
effective preven t ive m easu r e; an d in contrast to Indian and C h inese,
M alay s em p h asize th at ‘ch anging risky sexual behavior’ is t h e most
effective preven t ive m easu r e. In d ian s an d C h inese are m o r e in clin ed
t h an Malays to rely on condoms as an effective preventive m easu r e.
T h e p r o p o r t ion of people believing that there is no effective
p r o t ection against H IV/ A IDS increases from 4 per cent among
V olu m e 18 N u m ber 7/ 8 1998
7
M alay s t o 18.5 per cent am o n g In d ian s an d 22.5 per cent am o n g
C h inese (T able 1).
T a ble 1.
Per cep tion o f H IV/ A IDS Suf fer ers and Ef fec tive Pre ven t ion Against H IV/ A I D S
(In p er cen t ages)
Per cep tions
“What kind of peo p le do you think are m o st
1
likely to get A IDS?”
‘D ev ian t s’
‘R isk -takers’
‘A cc ide n t al vic tim s’
W h at is an ef fec t ive way of pre ven t ing
2
A IDS?
3
(a) C h ang ing sex ual be hav iour
(b ) U sing con dom s: “safe sex”
4
(c) O t h er m easu r es
5
(d) T h ere is n o ef fec t ive w ay
T o tal
M a lay s
(174)
In di an s C h in ese
(65)
(418)
T o t al
(657)
27.6
62.1
10.3
100.0
23.1
52.3
24.6
100.0
25.8
55.5
18.7
100.0
26.0
56.9
17.0
100.0
71.8
13.8
9.8
4.6
52.3
16.9
10.8
20.0
56.0
15.6
6.0
22.5
59.8
15.2
7.5
17.5
100.0
100.0
100.0
100.0
1.T h e co r r e la tion bet w een eth n ic it y an d p er ceived i m age o f H IV/ A IDS suf fer ers is
n o t sta tis ti cally sign ifi can t ( p = .06). C ate go ries ex p lain ed in t h e pre ced ing page.
2.T h e co r r e la tion bet w een eth n ic it y an d t h e per cep t ion of spe cific p r e ven t ive m easu r es is sta tis ti cally sign ifi can t (C o n t in gency C o ef fi cien t C C = .216; p = .00001).
3.Ex cludes t h e use of con dom s an d r e fer s t o an swers su ch as “avo id ing prom iscu it y ”; “hav ing o n ly m o n o gam o u s re la tions”; “avoid ing vis it s t o p r o st it u t es.”
4.O t h er pre ven t ive m easu r es m en t ioned were:"Edu cat in g peo p le o n t h e prob lem ";
“avoid ing con tact w ith peo ple w ith H IV/ A IDS”; “seek in g a doct o r ’s ad vice”; “tak in g a b lood test”; “avo id in g drug ad dic tion ” an d / o r “the shar ing o f n ee dles”; “not
d o n at in g blood”; and “be ing care ful if y o u h ave to get a blood trans fu sio n .”
5.T h is cate gory in cludes t h o se w h o r esp o n d ed “N o ” t o t h e fir st question and a few
re spon dents w h o in t h eir r e ply t o t h e fir st quest ion said that H IV/ A IDS could be
p r e ven t ed but, af ter re flect in g on the sec o n d question, de cided t h at they could not
see an y ef fec t ive w ay of pre ven t ing this dis ease.
People’s perception of H IV/ A I D S su fferers ap p ears t o h ave a
st r o n g in fluence upon their beliefs on effective preventive m easu r es
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T a ble 2.
Link be t w een P er cep tion o f H IV/ A IDS Suf fer ers an d Beliefs about Effective
P r e ven t ion of H IV/ A I D S
1
(In p er cen t ages)
Beliefs o n E f fec t ive w ays to pre ven t
2
H IV/ A I D S
P er cep tion o f H IV/ A IDS suf 3
fer ers
A ll
‘D ev ian t s’
‘R isk -takers’
‘Vi ctim s’
“T h ere is n o ef fec t ive way”
8.8
7.2
65.5
17.6
“C h ang ing sex ual be h av iour”
54.4
73.4
23.0
59.8
“U sin g co n d o m s: ”safe sex"
22.8
14.9
4.4
15.2
O t h er m easu r es
14.0
4.5
7.1
7.4
T o t al
(All re sp o n d ents)
100.0
(171)
100.0
(376)
100.0
(113)
100.0
(660)
1.T h ere is a sig n ifi can t and st r o n g co r r e la tion be t w een t h ese tw o vari ables:
C C = .520; C r a mer’s V= .431.T h is co r r e la tion per sist s in t h e sam e di rec tion
among the three eth n ic co m m u n ities: Ma lays (C C = .510; V= .420); In d i an s
(C C = .538; V= .452); an d C h in ese (C C = .522; V= .433).
2.Re fers t o t h e question an d d ata re p o r t ed in t h e lo w er part of T a ble 1. See fo o t n o t es 3-5 o f T a ble 1.
3.Re fers t o t h e question re ported in the top part of T a ble 1 (see also foot note 1
o f T a ble 1).
again st H I V / A I D S. As suggested by the findings in T able 2, people
w h o consider H IV/ A I D S su fferers as ‘devian t s’ are m o r e in clin ed to
believe th at the use o f co n d o m s an d o t h er m easu r es such as not
sh arin g n eedles, are the most effective ways for com m ercial sex
w o r k er s an d d r u g addicts—t w o categories of people the respondents
consider t y p ical H IV/ A IDS sufferers— t o p r even t t h e disease. A b o u t
o n e out of ever y t w o r esp o n d ents believe th at th e only likely people
to get infected are ‘risk-tak ers’; t h ese respondents are the most
inclined to conclude that those people could have prevented the
disease b y changing sexual behaviour such as m u ltiple sexual partn er s
and visits to com m ercial sex w o r k er s. A s m a l l p r o p o r t i o n o f
respondents perceive H IV/ A IDS sufferers as hapless victim s of fate
o r b ad luck w h o b ecam e in fected acciden t ally . The data indicate that
t h ese respondents are typically poorly inform ed or not informed at
V olu m e 18 N u m ber 7/ 8 1998
9
all ab o u t t h e et iology of the disease and, consequently, they tend to
believe th at H IV/ A IDS cannot be prevented.
T h e lin k b et w een t h e perception of H IV/ A IDS sufferers and the
beliefs o n effect ive p r even t ion among the total sample (Table 2)
persists am o n g each o f t h e t h r ee et h n ic co m m u n it ies. T h is fin d ing
suggests th at the influence of the public im age o f H IV/ A IDS upon
t h e beliefs o n effective preven t ion goes beyond the particular cultural
o r r eligio u s values of each com m u n ity . In d eed, the association
rem ained am o n g Muslim s, C h rist ian s an d p eople of other religions or
w ith n o r eligio u s affiliation. T h is in t erestin g sim ilar it y acr o ss et h n ic
gr o u p s, h o w ever , is acco m p anied by significant differences revealed
b y separate factor analyses of the data from t h e Malay, Indian and
C h inese sam p les. T ables 3, 4 an d 5 sh o w t h e respective rotated factor
m atrices. T h r ee r o u n d s of fact o r analyses w ere used to iden t ify t h e
m o st important influences associated with the perception of effective
p r even t ive m easu r es again st H I V / A IDS.
T h e factor analysis fin d ings confirm t h e differences am o n g t h e
t h r ee et h n ic co m m u n ities in t h eir p erception of effective preventive
m easu r es again st H I V / A IDS. More importantly, it is evident that the
fact o r s sh apin g t h e perception of effective prevention also vary from
o n e et h n ic co m m u n it y t o t h e next. Factor analysis perm its t h e
estim ation of the proportion of variance in the dependent variable
exp lain ed by each fact o r .
T h r ee fact o r s were identified am o n g Malays (T able 3). T h e fact o r
Inform ed Y outh contributes only 3.2 per cent of the variance in the
p e r c e p t i o n o f e f f e c t i v e H I V / A I D S p r e v e n t i o n . 1 T h is fact o r
represen t s t h e trend towards better inform ation on the disease am o n g
y o u n g educated Malays and their inclination to see H IV/ A I D S
sufferers as ‘r isk -takers’ w h o sh o u ld ch an ge t h eir sexual behaviour.
T h e fact o r Self-directed Future-orien tation encompasses the sense of
c o n t r o l o v e r o n e ’s life, t h e in clin at i o n t o b e p r e p a r e d fo r
even t u alities, an d t h e exp o sure to health cam p aign s. T h is factor does
n o t contribute sign ifican t ly to the perception of effective H IV/ A I D S
p r even t ion am o n g Malays. T h e most influential of the three factors
iden t ified am o n g Malays is Concerned R espon sibility w h ich r epresen t s
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Intern ation al Journ al of Sociology and Social Policy
T a ble 3.
Fac tors In flu enc ing t h e Per cep t ion of Ef fec tive P r e ven t ion Against H IV/ A IDS:
1
R o t ated Fac t o r M a trix, M a lay Sam p le
(Fac tor load ings)
Vari ables
2
Fac tor 1
In form ed
Y outh
Fac tor 2
C on cerned
respon si bil ity
F ac t o r 3
Self-directed
futureorien tation
E ffective H IV/ A IDS pre ven t ion
-.17951
.73476
-.04180
AGE
-.77100
E D U C A T IO N
.66504
H IV/ A IDS IM A G E .
51836
KNOWLEDGE
.44309
BLA M E
.76130
SE RI O U SN E SS
.68122
SELF-D I R E C T I O N
.76939
F U T U R E -O R IEN T A T IO N
.65369
CAMPAIGN
.59666
1.T o in crease clar ity, only the high est fac t o r load ings for each fac t o r are in cluded in this ta b le.
2.T h e 9 var i ab les are des ignated by a code name as fol lows: A G E : re sp o n d en t s’
age; E D U C A T IO N : t o t al years of for m al edu ca tio n com p leted; H IV/ A IDS IM A G E : per ceived i m age o f AID S su ffer ers; K N O W L E D G E : k n o w l edge o n d efi n i t ion and eti o l ogy o f AID S; BL A M E : per cep t ion of per so n al re sp o n sib il it y for
get ting t h e dis ease; SE R I O U SN E SS: p er ceived sever ity o f t h e dis ease; SELFD I R E C T I O N : sen se o f co n t r o l over per so n al life even t s; F U T U R E O R IEN T A T IO N : ten dency t o wards p lan n ing for the fu t u r e; C A M P A IGN: ex p o su r e to pub lic health cam p aign s.
t h e co m b ination of a strong belief in the personal responsibility of
H IV/ A I D S su fferers fo r contracting the disease together with the
clear p erception of the disease seriousness. T h is is t h e st r o n gest o f t h e
t h r ee fact o r s, co n t r ibuting 54.0 per cent of the variance in the
perception of effective prevention. 2
M a l a y s b e l i e v e s t r o n g l y i n t h e i n d i v i d u a l ’s p e r s o n a l
responsibility for contracting H IV/ A I D S an d in the seriousness of
t h e disease. W h ile t h ese beliefs are also found in the Indian and
C h inese com m u n it ies, t h ey are particularly strong am o n g Malays.
V olu m e 18 N u m ber 7/ 8 1998
11
T a ble 4.
Fac tors In flu enc ing t h e Per cep t ion of Ef fec tive P r e ven t ion Against
1
H IV/ A IDS:Ro tated Fac t o r M a trix, In dian Sam p le
(Fac tor load ings)
Vari ables
2
Fac tor 1
Fac tor 2
C on cerned
Im age of
respon si bil ity H IV / A IDS
suf ferers
E ffective H IV/ A IDS pre ven t ion
.70172
SE RI O U SN E SS
-.74853
CAMPAIGN
.68587
BLA M E
.65133
-.03469
H IV/ A IDS IM A G E
.76108
AGE
-.69855
KNOWLEDGE
.57249
E D U C A T IO N
.51329
Fac tor 3
Self-directed
futureorien tation
-.13653
SELF-D I R E C T I O N
.88457
F U T U R E -O R IEN T A T IO N
.73276
1.T o in crease clar ity, only the high est fac t o r load ings for each fac t o r are in cluded in this ta b le.
2.T h e list o f var i ab les b y code nam e is pro vided in T a ble 3.
T h e p r o p o r t i o n o f respondents believing that a person with
H IV/ A I D S is responsible for contracting the disease is 93.1 per cent
among Malays, 83 per cent of Indians, and 64 per cent of C h inese.
T h is belief is co n sisten t w it h t h e perception of effective preven t ive
m easu r es again st HIV/AIDS reported in Table 1. In other words,
people who believe that H IV/ A IDS can be prevented by m ak ing a
perso n al decisio n such as changing personal sexual practices, are also
inclined to conclude that the disease is the consequence of wrong
choices or deviant behaviour. T h e logic of this reasoning is apparent
in all three com m u n ities b u t , again , it is m o st p r o m inent among
M alay s: t h e co r r elat ion between the perception of blam e an d t h e
belief in effective preven t ive m easu r es again st H IV/ A I D S is st r o n gest
among Malays (Pearson’s r= .632) co m p ared to Indians (r = .419) an d
C h inese (r= .390).
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Intern ation al Journ al of Sociology and Social Policy
T h e seriousn ess o f t h e disease is eviden t t o all et h n ic co m m u n it ies
as t h ere is n o sign ifican t d ifference in the proportion of respondents
indicating that H IV/ A IDS is a deadly disease that has no cure. T h e
perceived severity of the disease is closely associated w it h t h e belief in
perso n al responsibility and with the belief in effective preventive
m easu r es in t h e t o t al p o p u lat ion, as indicated in T ables 3, 4 an d 5
w h ere th ese t w o b eliefs are found in the same dimension or factor in
t h e Malay, Indian and C h inese sam p les. St ill, t h e salience of these two
aspects (b lam e an d seriousn ess) is particularly evident am o n g Malays
as it is o n ly in t h e Malay sam p le w h ere th ese t w o v ariables form a
sin gle fact o r , an d t h is is t h e fact o r t h at explain s t h e high est
p r o p o r t ion of variation in the perception of effective H IV/ A I D S
p r even t ion.
T a ble 5.
Fac tors In flu enc ing t h e Per cep t ion of Ef fec tive Pre ven t ion Against H IV/ A IDS:
1
R o t ated Fac t o r Ma t r ix, C h in ese Sam p le
(Fac tor load in gs)
Vari ables
2
F ac t o r 3
Fac tor 2
Fac tor 1
Im age o f
Self-directed C on cerned
respon si bil ity H IV/ A IDS
futuresuf fer ers
orien t ation
E f fec tive H IV/ A IDS pre ven t ion
-.19087
F U T U R E -O R IEN T A T IO N
.79221
SELF-D IREC T IO N
.69736
C A M P A IGN
.65091
E D U C A T IO N
.64583
.63342
BLA M E
.78175
SE RI O U SN E SS
.74163
H IV/ A IDS IM A G E
.56030
AGE
-.42665
.83387
-.54732
1.T o in crease clar it y , o n ly the high est fac t o r load in gs fo r each fac t o r ar e in cluded in t h is ta ble.
2.T h e list o f var i ab les b y code nam e is pro vided in Ta b le 3.
A s in t h e case o f Malays, three dim en sio n s or factors were
iden t ified in t h e In d ian sam p le b u t o n ly one of t h ese fact o r s,
V olu m e 18 N u m ber 7/ 8 1998
13
Concerned R espon sibility, co n t r ibutes substantially (49.2 per cent) to
t h e varian ce in t h e perception of effective H IV/ A I D S p r even t ion. 3
O n e in t eresting difference between the Indian and the Malay
com m u n it ies in t h e nature of this dim ension is the role of health
cam p aign s. P u b lic h ealt h cam p aign s ap p ear t o p lay an im p o r t ant part
in shaping the sense of concerned responsibility am o n g In d ian s.
A m o n g t h e Malays, however, exposure to health cam p aign s is m o r e
lik ely t h e outcom e of an inclination towards self-direction and
future-o r ien t ation.
T h e other two fact o r s iden t i fied in the In dian com m u n it y , Fac t o r s 2 an d 3, have a neg li gi b le in flu ence o n t h eir p er cep tion o f effective H IV/ A IDS pre ven t ion. Fac t o r 2 Im age of H IV / A IDS Suf ferers
cov ers t h e per ceived i m age o f H IV/ A I D S, age, level o f k n o w l edge on
A I D S , a n d l e v e l o f e d u c a t i o n . Fac t o r 3, Self-direct ed Futureorientation , rep re sen t s t h e sen se o f co n t r o l over one’s life an d t h e in cli n a tion t o b e pre pared for even t u ali ties. T aken to get h er, these fac t o r s co n t r ib ute less t h an 2 per cent of the vari ance in the per cep tion of
ef fec tive H IV/ A I D S p r e ven t ion.
T h e fac t o r analy sis o f data from t h e C h i nese re spon dents (T a ble
5) re veals in ter est ing sim i lari ties and differ ences com p ared to the
o t h er t w o eth n ic co m m u n i t ies. T h e fac t o r w it h t h e st r o n gest im p act
u p o n t h e per cep t ion of ef fec t ive p r e ven t ive m eas u r es again st
H IV/ A I D S is Fac tor 2 C on cerned R espon si bil ity. T h is fact o r con t r ib utes 40.1 per cen t o f t h e var i an ce in t h e per cep tion of effect ive p r e ven 4
tion. T h e t w o st r o n gest com p o n ents of this fac t o r , t h at is, t h e
com b ined in flu ence o f t h e per ceived ser i ousn ess o f H IV/ A I D S an d
t h e be lief in per sonal re spon si bil ity for con t r act ing the dis ease, are
also found in the In dian and Ma lay sam p les. H o w ever , am o n g t h e
C h i nese, t h ese t w o b eliefs are m o r e likely to be re in forced b y in for m a tion o n t h e eti ol ogy and progn o sis o f H IV/ A I D S o b t ain ed fr o m
sources other than health cam p aign s. A s in d i cated ear lier , it is t h e ex p o sure to health cam p aign s am o n g In d i an s t h at con t r ib utes m o r e to
t h eir level o f in for m a t i o n o n t h e dis ease’s seri ousness an d o n t h eir b e lief in p er sonal re spon si bil ity. N ev er t h eless, t h e st r o n g r o le o f in for -
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Intern ation al Journ al of Sociology and Social Policy
m a tion (whether ob tained from h ealt h cam p aign s or other sources) in
de ter m in ing t h e per cep t ion of effect ive p r e ven t ion am o n g C h i nese
and In di an s is co m p ara tively w eak er am o n g Ma lay s. A s in d i cated ear lier , th e per ceived seri ousn ess o f t h e dis ease and the be lief in the per so n al re spon si bil ity o f H IV/ A IDS suf fer ers fo r con tract ing t h e
disease con sti t u t e, in t h em selves, t h e most sub stan t ial in flu ence u p o n
t h e Ma lay s’ per cep tion o f effect ive p r e ven t ive m easu r es.
T h e seco n d in ter est ing aspect o f t h e Chi n ese fin d ings is th at w h ile
o n ly one promi n ent fact o r emerges am o n g Ma lay s an d In di ans, t w o
fact o r s co n t r ib ut ing sub stan t ially t o t h e var i an ce in p er cep tion o f effect ive H IV/ A I D S p r e ven t ion are iden ti fied in the C h i nese com m u n ity. In ad di tion to Con cerned R espon si bil ity, th e other fac t o r is Im age
of H IV / A IDS Suf ferers w h ich con trib utes 18.2 p er cent of the vari ance
5
in the per cep tion of effec tive p r e ven t ion among the Chi n ese. T h is
fact o r stresses t h e lin k b et w een age an d t h e per cep tion or im age o f
H IV/ A I D S su ffer ers fo u n d also am o n g Ma lay s an d In di an s (T a bles 3
and 4) but it is only am o n g t h e C h i nese t h at t h ese t w o in flu ences are
sign ifi can t in shap ing peo p le’s per cep tion o f effect ive H IV/ A I D S p r e ven t ion. T h is u n ique n ess n o t w it h stand ing, t h e co m b ined in flu ence
o f age an d p u b lic i m age o f H IV/ A IDS suf fer ers h as re vealed a n u n ex pected com m o n feat u r e in all t h e th r ee et h n ic co m m u n i t ies: t h e
y o u n ger t h e re spon dent is, t h e more in clined he or sh e is t o p er ceived
H IV/ A I D S su ffer ers as de vi an t s. In clear con t r ast t o fin d ings from
o t h er coun t r ies (G r een , 1995), o lder r esp o n d ents ten d t o lack ac cu r ate
in for ma tion o n t h e defi n i tion and eti o l ogy o f H IV/ A IDS (the cor re la t ion be t w een age an d k n o w l edge of H IV/ A I D S is r= -.397 am o n g
C h i nese; r = -.384 fo r In di ans; and r= -.283 fo r M a lay s) an d h ave n o
p r eju dice again st H I V / A IDS suf fer ers. In stead, older re spon dents are
m o r e in clin ed to think of H IV/ A I D S su ffer ers with sym p at h y as vic tim s of ac ci den t al in fect ion and thus are less in clin ed to at t r ib ute
b lam e. T a ble 6 il lus trates h o w t h is t r end per sists am o n g peo p le o f dif fer ent re lig io u s affilia tions by pro vid in g figu r es o n t h e co m b ined in flu e n c e o f re lig io n a n d a g e o n t h e p e r cep t i o n o f p e r s o n a l
re spon si bil ity for be com ing in fected w it h t h e H IV vi r u s. I w ill re turn
t o t h is u n ex pected in flu ence o f age later on.
V olu m e 18 N u m ber 7/ 8 1998
15
T a ble 6.
Per cep tion o f Per so n al Re spon si bil ity b y A ge an d R e lig io u s Af filia tion
(In p er cen t ages)
Per so n al re spon si bil ity
M u slim s
> 50
1
50+
C h r istians
> 50
2
50+
O t h er
> 50
3
50+
Is a per son t o b e blam ed
for get ting A IDS?
D o n ’t k n o w
No
Yes
T o t al
(N u m b er)
5.5
94.5
4.5
13.6
81.8
12.9
87.1
11.8
29.4
58.8
2.8
28.0
69.2
13.2
40.6
46.2
100.0
(145)
100.0
(44)
100
(62)
100
(17)
100.0
(286)
100.0
(106)
1.T h e co r r e la tion be t w een age an d p er ceived per so n al re spon si bil ity is sign ifi can t (Spear m an Sp = -.196; p = .007).
2.Sp = -.311; p = .005.
3.Sp = -.231; p < .00001. T h is cate gory in cludes re lig ions o t h er t h an Is lam and
C h r isti an ity.
D iscussion
O n ly the variables with significant correlations in the total sam p le
w ere included in the factor analyses of the three ethnic com m u n ities.
A s t h e basic idea of facto r analysis is to identify underlying
dim ensions in the data, variables with no statistically significant
correlations (p .05) w ere excluded. T h e separate factor analyses for
each com m u n ity reveal in t erestin g aspects of the influence of cultural
values and beliefs. T h e im p o r t ance of the latter for the planning and
implementation of preventive program m es is u n d eniable given that
t h e most well-k n o w n aspect of t h e H IV/ A IDS epidemic is the
enhancement of the link between private choices and public health. It
is n o w w idely ack n o w ledged t h at personal decisions on intrinsically
p r ivate activities h ave serious consequences for the health of entire
com m u n it ies an d n at ions (H erdt and Lindenbaum , 1995; Q uah,
1992; Bayer, 1991).
H o w m ay these differences am o n g t h e t h r ee et h n ic co m m u n it ies
be explained? T h e fin d ings contradict expectations. T h e sm all size of
t h e islan d r epublic, the corresponding high population density, and
16
Intern ation al Journ al of Sociology and Social Policy
t h e clo se proximity of the average Singaporean to information
sources an d services, w o u ld suggest a h igh d egree of cultural
h o m o gen eit y . M o r e o v e r , w h a t e v e r t h e i r e t h n i c i d e n t i t y , a l l
Sin gap o r ean s are exposed t o p o t entially ‘equalizing’ fact o r s t h at h ave
been in operation for the past three decades: A national educational
system covering all sch o o ls an d including aspects on health
education; television and radio program m es accessib le t o all; national
h ealt h cam p aign s b r o a d c a s t e d t h r o u g h a l l m ass m edia; an d
com p u lso r y n ational service for m en. In addition, Singapore’s h ealt h
a u t h o r it ies sin g l y a n d i n c o l l a b o r a t i o n w i t h n o n -go v e r n m e n t
o r gan izations, conduct periodic national educational cam p aign s
specifically t argeting the prevention of H IV/ A I D S (Q uah, 1992).
Based o n t h ese co m m o n st r u ctural conditions and equalizers, one
m ay expect to fin d n o sign ifican t d ifferences in the perceptions and
beliefs o f C h inese, In d ian and Malay Singaporeans concerning
H IV/ A IDS prevention. Yet, as the data indicate, the ethnic
differences are clear an d consisten t . Two tentative explanations of the
eth n ic var iations in t h e beliefs o n H IV/ A I D S p r even t ion identified in
t h is study m ay be found in two st r u ct u r al feat u r es o f Sin gap o r e’s
society, not usually associated with health and illness m atters. O n e
feat u r e is t h e ch aracteristically Sin gap o r ean effort at strengthening,
sim u ltan eously , t h e cit izen s’ belief in a co m m o n d est iny or national
iden t ity and in their different ethnic roots. T h e other feature is the
r o le o f religio n .
T h e first tentative explan at ion refers to the process of nurturing
Sin gap o r ean s’s n ational identity at the sam e t ime that they are
encouraged to cultivate the values of their own ethnic com m u n it ies
(Straits T i m es, 1989; Q uah, 1990). T h is p r o cess h as been exam ined by
social scien t ist s an d found to be workable and even positive (Vasil,
1995; Lai, 1995). A n exam p le o f t h is dual iden t ity drive is t h e effo r t s of
t h e Malay com m u n it y t o b eco m e fu ll-fledged participants in the
eco n o m ic develo p m ent of t h e co u n t r y w it h o u t losin g t h eir o w n
cultural and religious values (Vasil, 1995; M E N D A K I, 1993). A n
important aspect of the dual identity drive is the im p et u s given t o
channels of expression particular to each com m u n it y , most notable
V olu m e 18 N u m ber 7/ 8 1998
17
among these are Malay-, Tamil- an d C h inese-language newspapers,
televisio n and radio channels, and literary publications.
In sum , each et h n ic co m m u n ity in Sin gap o r e is encouraged to
inculcate am o n g its m embers its own values and beliefs, to shape the
com m u n it y ’s p er spective o n p r inciples guidin g a person’s behaviour.
C en t r al t o t h ese cu lt u r al gu idelin es are the m ean ing of privacy, the
m o r al aspects of private choices, an d t h e socially an d m o r ally
acceptable an d u n accep t able w ays of satisfyin g in d ividual n eeds
including those pertaining to sexuality. Mem b er s of one ethnic
com m u n it y m ay can d idly give m o r e or less sign ifican ce t o o n e aspect
o f co n d u ct com p ared to other eth n ic co m m u n ities as part of t h e
socially acceptable process of signalling (rather than concealing)
cultural differen ces.
T h e seco n d t entative explanation of ethnic differences is related
t o t h e fir st an d it is t h e im p o r t ant role o f religio n . O f t h e th r ee et h n ic
gr o u p s, M alay s disp lay a unique feature: the close overlap between
t h eir r eligio u s affiliation and their ethnic identity. As a com m u n it y ,
M alay s are the m o st h o m o gen o u s in r eligio u s identity: 99.6 per cent
p r o fess Islam (D epartm ent of Statistics, 1994a). In contrast, one of
ever y t w o p er sons in the Indian community is a H indu. T h e Chinese
display an even greater variety in religious affiliations. T h e religio u s
aspect is very im p o r t an t in understanding the differences between the
t h r ee et h n ic co m m u n ities, particularly betw een M alay s on the one
h and, and C h inese and non-Muslim Indians on the other hand. Islam
perm eates the informal everyday life of Malays (Lai, 1995) as well as
t h eir form al co llect ive even t s and develo p m ent plans (MEN D A K I,
1993). T h eir k een awareness of religious precepts guiding private
actions in cluding sexual behaviour, is m anifest in t h e em p h asis t h ey
give t o p ersonal responsibility and, consequently, in the attribution
o f personal blam e fo r contracting H IV/ A IDS. N inety-o n e per cent of
M u slim s believe in p er sonal blam e, co m p ared to 81 per cent of
C h r istian s; 56 p e r c e n t o f t h o s e i d e n t i f y i n g t h e m selves w ith
Buddhism , Taoism and Chinese syncretic religion; and 79 per cent of
people with other religious affiliations, including H induism .
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Intern ation al Journ al of Sociology and Social Policy
C o m p ared to secu lar values and the values of other religions, the
influence of Islam and C h ristian it y appear to be st r o n ger in shaping
p e o p l e ’s p e r c e p t i o n o f e f f e c t i v e p r e v e n t i v e m easu r es again st
H IV/ A I D S. While 93.7 per cent of Muslim s an d 90 per cent of
C h r ist ian s asser t t h at t h ere are effective w ays to prevent H IV/ A I D S,
t h is p r o p o r t ion drops sign ifican t ly to 76 per cent am o n g people w ith
o t h er r eligio n s (in cluding H indus) o r n o r eligio u s affiliat ion.
A n additional dim ension of the impact of religion is suggested by
t h e scr u t iny of t h e lin k b etw een age an d t h e perception of personal
responsibility for contracting H IV/ A IDS. It is assum ed in t h e
literature (cf., M u n akata, 1994; H erdt and Lindenbaum , 1992; Bayer,
1991; Lin d enbaum , 1992) t h at fir st , y o u n ger p eople are better
informed about the disease and second, that as they are less
conservative th an o lder p eople, young adults are also less lik ely to
“blam e th e victim .” A s sh o w n earlier, t h e first assu m p t i o n o n t h e
association between age and knowledge on H IV/ A IDS is confirmed
b y t h is study’s data (r= -.370); b u t t h e seco n d assu m p t ion is not
supported by the findings. O n t h e co n t r ar y , people 50 years old or
o lder are significan t ly less in clin ed th an younger p eople to attribute
perso n al responsibility to H IV/ A I D S victims.
T h ere are at least tw o p o ssib le reasons for this trend. The
m ajo r it y (93 per cen t ) o f Sin gap o r ean s in fected w it h t h e H IV vir u s up
to O ctober 1994 w ere below t h e age o f 50 (Straits T i m es, 1995a); and
people below 50 tend to be better inform ed on the etiology of the
disease. A s discu ssed ear lier , age an d r eligio n exer t a co m b ined
influence on the perception of personal responsibility. Seen fr o m t h e
angle of religious affiliation , th e st r o n ger inclination of people below
fift y y ears of age to believe in p er sonal responsibility persists am o n g
all religio u s gr o u p s. T h e in fluence of age, h o w ever, is w eak est am o n g
M u slim s an d m o r e prom inent among Christians. A large majority of
M u slim s whether below the age of 50 (94.5 per cent) or above 50 (82
per cent), believe in p er s o n a l r e s p o n s i b i l i t y f o r c o n t r a c t i n g
H IV/ A I D S.
T h e salien ce o f cu lt u r al an d r eligio u s values for people’s beliefs o n
t h is disease co n fir m ed by the findings of this study, needs to be
V olu m e 18 N u m ber 7/ 8 1998
19
considered in the context of the H IV/ A IDS scene in Singapore.
Sin g a p o r e i s l o c a t e d i n t h e r e g i o n w h e r e t h e W o r ld H ealt h
O rgan izat ion predicts t h e H IV/ A IDS epidemic “is just moving into
t h e ear ly explosive phase” (W H O , 1994). Y e t , c o m p ared to
n eigh b o r ing countries, the im p act of t h e disease h as been r elat ively
benign (Straits T im es, 1996; W H O , 1994).
T h e so u r ce o f H IV in fection has been changing rapidly: from
1985 to 1990, th e main source was homosexual contact and only 26
per cent of all cases contracted the virus through heterosexual
contact. T h e proportion of in fections through heterosexual contact
increased to 54.8 per cent of new cases in 1991, and it was over 70 per
cen t in 1995. T h is t r end has led the Ministry of H ealt h t o emphasize
in its public health cam p aign s “t h at th e only way to avoid AID S is to
avo id casual sex an d sex w it h p r o stitutes” (Straits T im es, 1995c) an d
“ C o n d o m s, u sed proper ly, can r educe the risk of infection. But they
d o n o t guarantee com p let e p r o t ect i o n ” (Sun d ay T i m es, 1993).
A n o t h er r elevan t aspect of t h e local H IV/ A IDS scene is that the
disease is n o t p ar t icu lar t o a given c o m m u n i t y . T h e et h n ic
d ist r i b u t ion of H IV cases at t h e en d o f 1994 sh o w ed a clo se
resem b lance to the ethnic distribution in the total population: 77.4
per cent of cases were C h inese; 11.5 per cent Malay; 7.3 per cent
Indian; and 3.8 per cent from o t h er e t h n ic gr o u p s (Straits T i m es,
1994).
F o llo w ing the pattern in many other countries, health authorities
in Singapore have confronted the threat of H IV/ A IDS by setting up
o r gan izatio n al responses, giving support to the private sector in this
endeavor, and stressing the im p o r t ance of public education (Q uah,
1992). P r even t ive education program m es are addressed t o t h e general
p u b lic as w ell as t o t argeted groups. Exam p les o f t h e latter include
H IV/ A I D S educational booklets in different languages such as the
pam p h let K enali dan H indari AID S (K n o w and Avoid AID S)
p r epared by the Malay section of the non-governm ental organization
A ct ion for AID S, set u p in May, 1992 (The N ew Paper, 1993) A n o t h er
special p r o gram m e is “P r o ject P r o t ect” geared to educate com m ercial
sex w o r k er s ab o u t sexually transm itted diseases (ST D s) including
H IV/ A IDS. The project began in 1992 and uses workshops,
20
Intern ation al Journ al of Sociology and Social Policy
counsellin g an d gr o u p d iscu ssio n s with commercial sex workers to
g i v e t h e m i n f o r m a t i o n o n h o w ST D s an d H I V / A I D S ar e
t r a n s m it t ed. T h e M i n i s t r y o f H ealt h also sells co n d o m s t o
com m ercial sex w o r k er s as part of t h e sam e preventive efforts (Straits
T i m es, 1995b ).
A fin al il lus tra tion o f t h e rele vance of cul t u r al dif fer ences is t h e
con tent o f pre ven t ive m essages in the mass me dia. T o m ini m ize im p le m en ta tion o b sta cles, t h e plan n ing of pub lic H IV/ A IDS edu ca tional cam p aign s need to take into con sid era tion t h e at ti tudes an d
val ues of the peo p le t o b e served or tar get , an d t o con form to Sin gap o r e’s m u lt i-et h n ic an d m u lti-religio u s lan d scape. A im ing to at t r act
t h e at ten tion o f young adults t o its pre ven t ion cam p aign s on AIDS,
t h e Min ist r y o f H ealt h u sed tele vi sio n ad ver tisem ents t h at deal w ith
regu lar h et ero sex ual en coun ter s an d t h e im p o r t ance of m o n o gam o u s
re la tion s. O n e of these tele vi sio n ad ver tisem ents sh o w ed a m an tell ing a frien d t h at t h e woman he slept with last night was great and that
h e will sleep w it h h er again t o n igh t . Af ter a pause, th e man said that
w o m an is his wife. T h is ad ver t isem en t w as cr it i cized as “in ap pro pri ate,” “aw k w ard,” “rude” an d “ob scen e” b y so m e mem bers o f t h e Ma lay / M u slim com m u n it y in let ters to a Malay-language news pa per.
T h e Min ist r y o f H ealt h apolo gized ex p lain ing that “If the com m er cial has caused dis com fort am o n g cer t ain M a lay m em bers o f t h e pub lic, it w as en t irely un in tended” and that it h as “taken note of t h e
feed back fr o m t h e Ma lay com m u n ity and will take it into con sid era t i o n w h en we plan our next anti-A IDS cam paign” (Straits T i m es,
1995a).
C o n clu sio n
A ssessing the conclusions of a social science conference on
H IV/ A IDS, Lindenbaum (1992:330) stated that all the papers
p r esen t ed had “provided evidence of alternate m ean ings an d
u n d erstandings of the epidem ic in d ifferent locations” and stressed
t h e im p o r t a n c e o f c o n t i n u e d r e s e a r c h o n b o t h “ b i o m e d i c a l
k n o w ledge” as w ell as “local k n o w ledge” o n A IDS. Lindenbaum’s call
for continued investigation of socio-cu lt u r al differences is sh ared by
an increasing number of social scientists. T h is study addresses th at
V olu m e 18 N u m ber 7/ 8 1998
21
n eed t o u n d er st a n d t h e ways in which different com m u n it ies
approach the worldwide H IV/ A I D S ep idem ic b y exp loring a few
assu m p t ions based on the H ealt h Belief M o d el am o n g t h e t h r ee m ajo r
eth n ic co m m u n ities in Sin gap o r e. M o r eover, frequent inform ation
o n cultural variations in the context of health contribute
substantially to the design and im p lem entation of health policy.
T h e study fin d ings confirm t h e pervasive in fluence of cultural
and religious values on health related behaviour in general and on
H IV/ A I D S p r even t ion in particular. T h e fin d ings also corroborate
t h e usefulness of the H ealt h Belief M o d el w h en it is used as an ‘ideal
t y p e’: its ap p licat ion to the an aly sis o f different com m u n ities helps to
iden t ify sim ilar ities an d ‘deviat ions’ that would not be detectable
o t h er w ise. T h e only H ealt h Belief M o d el co m p o n ent influencing the
perception of effective prevention against H IV/ A IDS in all three
eth n ic co m m u n ities is th e perceived seriousness of the disease. T h is
variable, togeth er w it h t h e perception of personal responsibility, are
ver y i m p o r t a n t d e t e r m i n a n t s o f t h e p e r c e p t i o n o f e f f e c t i v e
p r even t ion against H IV/ A IDS. N o n e of the other m ain com p o n ents
o f t h e model (i.e., perceived personal susceptibility and perception of
barriers to and benefits of preventive action) play a significant role in
t h is regard. Still, I m u st n o t e t h at although the belief in personal
susceptibility does not influence a person’s perception of effective
H IV/ A I D S p r even t ion, it m ay be relevant to preventive action as
found in other studies (Kir sch t , 1988).
T h e t w o additional variables com p lem enting the H ealt h Belief
M o d el h ave elucidated th e spectrum o f attitudes an d b eliefs ab o u t
H IV/ A I D S. These two variables are the perception of personal
responsibility or blam e fo r get t ing the disease, and the stigm a
characterizing the perception of H IV/ A IDS sufferers, that is, the
p u b lic im age o f t h e disease. O b serving it in isolation, a person’s im age
o f H IV/ A I D S su fferers ap p ears to influence significan t ly his or her
belief o n t h e availab ilit y o f effect ive p r even t ive m easu r es again st
H IV/ A I D S. Yet, a person’s im age o f H IV/ A IDS sufferers is m o lded
b y t h e person’s age an d level o f in form at i o n o n t h e disease. T h e latter
22
Intern ation al Journ al of Sociology and Social Policy
is t h e outcom e of h is o r h er form al educational level as w ell as o f h is o r
h er knowledge on the etiology of H IV/ A I D S.
C o n sequently, on the quest ion of what determ ines a person’s
perception of effective H IV/ A I D S p r even t ion, the factor analysis
fin d ings show that the image of H IV/ A IDS, per se, is less im p o r t ant
t h an the joint impact of the belief in personal responsibility and the
perceived serio u sness of the disease. T h e level o f k n o w ledge on
H IV/ A I D S is n o t alw ays in fluential: it does not play an im p o r t ant
part am o n g Malays/ M u slim s an d Indian s, an d it appears to work only
indirectly am o n g t h e C h inese by increasing their perception of
seriousn ess an d p ersonal responsibility.
F inally, the findings from t h is study confirm t h e im p o r t ance of
investigatin g “t h e local” sp h ere of t h is w o r ldw ide ep idem ic—as w ell
as o f an y m ajo r p u b lic health threat—t o b e ab le to design and
fin e-t u n e prevention program m es t h at take into consideration and fit
effectively t h e n o r m s an d b eliefs o f each com m u n ity. In Sin gap o r e,
t h e public discourse on H IV/ A IDS as presented in public health
cam p aign s (u sin g televisio n , printed m edia, radio, posters, an d o t h er
aven u es) n eeds t o continue distributing objective inform ation on the
etiology, preventive m easu r es an d p r o gn o sis o f t h e disease w h ile
tak ing into consideration the religious and cultural sensitivities of
different com m u n it ies. Bu t t h e fin d ings suggest that the focus on
perso n al responsibility for one’s act ions and on the seriousness of the
disease are likely to get the best response from t h e target population.
A ckn o w ledgem ents
T h e data discussed in t h is paper are part of a larger study supported by
t h e N at ional U n iver sit y o f Sin gap o r e Research G r ant RP910074.
V olu m e 18 N u m ber 7/ 8 1998
23
Endnotes
1. T h is p r o p o r t ion of variance explained w as calcu lated as t h e square
value of .17951 w h ich is t h e Factor 1 loading on the dependent
variable Effective H IV/ A IDS Prevention in Table 3.
2. C alcu lated as t h e square value of .73476 w h ich is t h e Factor 2
loadin g on the dependent variable Effective H IV/ A IDS Prevention
in Table 3.
3. C alcu lated as t h e square value of .70172 w h ich is t h e Factor 1
loadin g on the dependent variable “Effective H IV/ A I D S p r even t ion”
in Table 4.
4. C alcu lated as t h e square value of Factor 2 loading .63342 on the
depen d ent variable Effective A IDS Prevention in Table 5.
5. C alcu lated as t h e square value of Factor 3 loading -.42665 o n t h e
depen d ent variable Effective A IDS Prevention in Table 5.
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