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. Author manuscript; available in PMC: 2015 Apr 1.
Published in final edited form as: J Health Commun. 2013 Dec 30;19(4):478–492. doi: 10.1080/10810730.2013.821555

Tal Como Somos/Just As We Are: An Educational Film to Reduce Stigma towards Gay and Bisexual Men, Transgender Individuals & Persons Living with HIV/AIDS

Jesus Ramirez-Valles 1, Lisa M Kuhns 2, Dianna Manjarrez 3
PMCID: PMC3980004  NIHMSID: NIHMS474062  PMID: 24377496

Abstract

In this paper we describe the development and dissemination of a film-based educational intervention to reduce negative attitudes towards gay and bisexual men and transgender women (GBT) and people living with HIV/AIDS (PLWHA) in Latino communities, with a focus on youth. The intervention, Tal Como Somos/Just as We Are, is based on stigma and attribution theories, extensive formative research, and community input. Evaluation findings among educators and school youth suggest the film has the potential to effectively impact attitudes towards GBT and PLWHA. The film and intervention are being disseminated using diffusion of innovations theory through community-based organizations, schools, television broadcasting and film festivals.

Keywords: Film, HIV/AIDS, Homosexuality, Stigma, Latinos

Stigma towards gay and bisexual men, transgender women (GBT), and persons living with HIV/AIDS (PLWHA) contribute to the enduring high incidence of HIV and increase the risk of poor health among PLWHA (NIH, 2002; Link & Phelan, 2001; Ramirez-Valles et al., 2005; Ramirez-Valles, 2011). It hampers prevention efforts and places undue stress on families, friends, and caregivers (NIH, 2002; Link & Phelan, 2001). This is especially pertinent in Latino communities, which are disproportionally affected by HIV/AIDS (Blair et al., 2002; CDC, 2007, 2008; Harawa et al., 2004; Agronick et al 2004; Diaz, Heckert, & Sanchez, 2005; Fernandez et al., 2005; Wolitski et al., 2001) and which struggle with negative attitudes towards GBT and PLWHA (Herek and Gonzalez-Rivera, 2006). Regrettably, most efforts to tackle such stigmata target the stigmatized individual, rather than the source of stigmatization, and overlook Latino and Spanish-speaking communities (Sengupta et al., 2011).

In this paper we describe the development and dissemination of a film-based educational intervention to reduce negative attitudes towards GBT and PLWHA in Latinos, with a focus on youth. The intervention and the film, Tal Como Somos/Just as We Are, were created based on the idea that efficient measures to address stigma towards GBT and PLWHA must be directed to the potential sources of stigma, be based on sound research, and must take into account the cultural context of the target audience.

Stigma towards Gay and Bisexual Men, Transgender Women, and Persons Living with HIV/AIDS

Stigma refers to a process by which individuals are devalued and treated as less than others (Goffman, 1963). It involves labeling and separation, attribution of unfavorable qualities, and overt discrimination (Link & Phelan, 2001; Link et al., 1997; Fife and Wright, 2000). The stigma towards GBT and PLWHA may put individuals at risk for HIV through a negative impact on the self, or self-esteem, social support, and access to prevention and treatment (Diaz & Ayala, 2001; Diaz et al., 2001; Link & Phelan, 2001; Ramirez-Valles et al., 2005; Cochran & Mays, 2000; Huebner et al., 2002; Mays & Cochran, 2001; Paul et al., 2002; Williamson, 2000).

Although negative attitudes have declined in the last three decades in the U.S. (Herek, Capitanio, & Widaman, 2002; Loftus, 2001; Treas, 2002), GBT people still report discrimination (Herek, 1999; Kaiser Family Foundation, 2006; Loftus, 2001; Harper & Schneider, 2003; Herek, 1999; Kaiser Family Foundation, 2001; Rankin, 2003). Negative attitudes towards gay and lesbians are typically stronger among males, including young males (Horn, 2006), ethnic minorities, and those individuals with low education, high religiosity, and among those who endorse traditional gender roles (Hicks & Lee, 2006). While over half of Latinos support legalization of same sex marriage, 42% believe that homosexuality is a sin and 57% think LGBT commit deviant sexual acts (Social Research Sciences Solutions, 2012).

The HIV epidemic continues to deepen this stigma (Alonzo and Reynolds, 1995; Herek, 1999; Herek, et al., 2002). Many individuals still believe that people with HIV/AIDS are responsible for their illness (Herek, 1999, 2007). For example, in a national study of Latino gay men (Diaz, 2006), almost half of the HIV-negative participants stated that HIV-positive individuals are to blame for the spread of the disease. Paradoxically, the dominant HIV prevention message about personal responsibility and control may be perpetuating blame towards PLWHA. In many communities throughout Latin American and the Caribbean, PLWHA are thought of as deserving of their illness because they have engaged in “erroneous and immoral” actions (Parker and Aggleton, 2003; Varas-Diaz, Serrano-Garcia, and Toro-Alfonso, 2005). There have been significant improvements throughout the Americas in HIV/AIDS and LGBT rights, yet PLWHA and LGBT groups remain marginalized.

Theoretical Framework

We draw on the stigmatization model developed by Corrigan et al. (2003; see also Devine, Plant, & Harrison, 1999), and on a review of AIDS stigma interventions (Brown, Macintyre, & Trujillo, 2003). The stigmatization model is based on attribution theory, which posits that discriminatory behavior is determined by a cognitive-emotional process. Individuals make attributions about the cause and controllability of a particular characteristic (e.g., being gay, HIV-positive) that lead to inferences about responsibility. These attributions then trigger emotional reactions (e.g., aversion) that influence behavior. The emotional reactions are shaped by four factors: a. Personal responsibility (e.g., believing gay men are responsible for their sexual orientation). b. Controllability (e.g., thinking that risk behaviors that may lead to a disease, such as unprotected sex, are under the person’s control). c. Perceived dangerousness of the condition (e.g., fearing that homosexual men may influence youth to engage in homosexual acts). d. Familiarity (e.g., knowing someone with the condition).

Video-based interventions addressing stigmatization of mental illnesses and racial minority groups have shown some success, especially in increasing familiarity and decreasing blame (Corrigan et al., 2007; Penn, 2003; Reinke, 2004; Soble 2010; Wood and Wahl, 2006). Research on HIV/AIDS stigma interventions (Brown et al., 2003) suggests that an approach using video may reduce stigma when it emphasizes that PLWHA are not to blame for getting HIV/AIDS, increases familiarity, and includes a guided group discussion. Furthermore, a storytelling narrative style may be more effective in changing attitudes than other more didactic approaches, such as providing information (Slater, 1999).

Unfortunately, a review of available audiovisual education materials revealed that while there are some educational videos addressing stigma against GBT (e.g., De Colores, Barbosa and Lenoir, 2001) and HIV/AIDS, none has been developed from empirical research. The focus of the film presented here is on youth because they are in a developmental stage in which attitudes are still forming and amenable to change (Horn, 2006).

Development of the Film

The film-based intervention stems from prior research findings linking stigmatization to sexual risk and substance use among Latino GBT (Diaz et al, 2001; Ramirez-Valles et al., 2005; Latino GBT (Ramirez-Valles, 2011; Ramirez-Valles et al., 2010). The data revealed three primary areas of stigmatization: religion (Catholicism in particular), family, and school (e.g., elementary to high school). The findings pointed to an opportunity to intervene on the sources of stigma and focus on youth as a principal audience of the film and heterosexual adults as a secondary audience. The development and dissemination of the film were led by a team of two researchers, a film director, and a producer. The researchers are fully bilingual (English and Spanish) with extensive experience working with GBT, HIV/AIDS, and Latino communities. The production company’s expertise is in documentary film with a social justice focus, which was helpful given that stigmatization of GBT and PLWHA are embedded in a framework of social exclusion and inequality (Parker and Aggleton, 2003).

Film Concept

The film director, in conjunction with researchers, developed an initial concept paper, which outlined the presentation of the three areas of stigma (i.e., religion, family, and school) as manifested in the everyday lives of five Latino GBT activists - four gay men and a transgender woman - one of whom is also a PLWHA. They came from different backgrounds and four different cities - New York City, Washington DC, San Francisco, and Chicago - reflecting the diversity of Latinos and their social contexts. Using a documentary format, each person recounts childhood memories of stigmatizing, their struggle to cope with stigma, and their current experiences in the community as activists or volunteers in LGBT and AIDS-related causes. Activism and volunteerism were included to highlight GBT’s positive contributions to the fight against AIDS and the role of involvement in community affairs in coping with, and confronting, stigma (Ramirez-Valles, 2011). The story of one of these activists is overlaid on the others, working as the narrator for the film. He provides a common thread and guides the viewer through an interpretation of stigma, its consequences, and ways to address it through individual and social change.

Stake Holders Input

The conceptualization of the film was then presented to six focus groups in the above noted four cities with 45 Latino GBT individuals, 18 years old and older, and to two focus groups with 17 community educators from organizations and educational institutions (e.g., LGBT, Latino-related) in Chicago and San Francisco. We did not collect data on stakeholders’ HIV status.

Based on focus groups feedback, the concept paper was revised and developed into an initial film script and treatment (description of scenes). We made several changes. For example, focus groups participants cautioned against direct attacks on the Catholic Church for its stands against homosexuality. We eliminated a scene which showed a priest and an altar boy walking to the altar. Likewise, the importance of family was emphasized in the focus groups and thus, we included family members in several scenes. Some participants were conflicted about the inclusion of a transgender woman character in the film. They felt that the topic was too complicated to include in the film, because of the conflation of sexuality and gender identity. Others, however, noted that transgender women’s experiences of discrimination overlap with those of gay men. Thus, we decided to keep the transgender woman story. A major change we made was to produce two versions of the film: a feature-length version for broadcast television and film venues and a 30-minute version for use in time-limited community and educational environments for youth.

Focus groups participants endorsed the use of a guide to facilitate discussion of the film. Educators suggested that the discussion guide be brief and include a glossary of terms and resources for those who want to learn more or to become involved in the community.

Production

In pre-production, potential subjects were interviewed and locations were surveyed. In the focus groups described above, Latino GBT were invited to volunteer as potential subjects for the film. Selection of final subjects was based on how the life experiences and socio-demographic characteristics of potential subjects reflected the stories depicted in the film treatment and the diversity of the larger community of GBT and PLWHA of Latino descent. We first conducted phone interviews and then face-to-face interviews on location. During the latter, the team visited their homes and workplaces and met their families. These interviews served to build rapport between the film subjects and the production team. After these visits, we made additional changes to the working film treatment. For example, we added an extra subject, whose story did not fit the character and story prototypes developed in the film treatment. However, he and his partner showed very good presence and told a story about living between two cultures – Latin-American and mainstream U.S. Also, we identified a younger individual to narrate the short version of the film, which targets youth primarily.

The core content of the film, life histories, was elicited via an interview guide. Each guide was tailored to the participant (including family and friends). Subjects were told about the general themes to be addressed, but not provided with the actual guide. One of the investigators, an experienced and bilingual interviewer, conducted the questioning off camera. Questions were carefully crafted to draw out areas of interest (e.g., becoming HIV-positive, family rejection), generate audiences’ empathy, and avoid further stigmatization. For example, we did not ask whether the transgender woman had any surgical procedures done, so not to link gender identity with physiology. Similarly, we did not ask about mode of HIV infection, so that the audience would focus on compassion towards PLWHA rather than on assigning personal responsibility. Subjects used the language they felt comfortable speaking.

The film was shot following a documentary format. In addition to interviews with main subjects and their families, friends, and co-workers, we followed subjects through their daily activities and filmed background footage from their cities. Subjects provided personal photos used to portray memories. The film was shot in high definition digital video with JVC 24-frame cameras.

In post-production, English subtitles were added when Spanish is spoken and Spanish subtitles when English is spoken. Original music was composed and added throughout the film. A rough cut edit of the long version was shown to all main subjects (in a group gathering) to obtain their feedback and ensure they were comfortable with the material shown.

The Film Tal Como Somos/Just as We Are

Two versions of the film were produced, a feature-length version (70-minute) and an educational version (30-minute). The feature-length film is fully bilingual (English/Spanish) and portrays five Latino gay men, one bisexual man (living with HIV), and a transgender woman in four cities. Themes highlighted in the film address aspects of the stigmatization process (e.g., personal responsibility, controllability), to diminish negative emotional reactions. The individuals featured in this documentary, for instance, tell stories conveying the message that most GBT did not have an option not to be gay; that GBTs are not dangerous, and that stigmatization creates an undue stress that contributes to psychological distress. The accounts also emphasize that Latino GBT have made positive contributions to improve their own and others’ lives. The stories are focused on four areas: school, family, religion, and HIV/AIDS. Figure 1 shows a selection of the film subjects.

Figure 1. Selection of Tal Como Somos/Just As We Are Subjects: Gabriela, David, Ernesto, Oscar, and Marcelo.

Figure 1

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These are the main characters: Gus & Marcelo, an ambitious young Mexican couple in Chicago, whose love unites them despite a conflict over faith and the Catholic Church that rejects them. Their story addresses the difficulties of being raised in a predominant Catholic culture and not conforming to traditional gender roles. David, Columbian and single in New York City, buries his past with a new life in lower Manhattan, finding comfort in friends, purpose in work, and residual pain in confronting the humiliation of being branded “gay-boy” since grade school. He is a health educator in an AIDS service organization. Gabriela, once a boy who was repeatedly ridiculed, has spent a lifetime proving to her Mexican family and herself that she’s worthy of acceptance as a woman. As a teenager, she was forced to leave her family’s home. This rejection led her to abuse substances. Her mother and sister recount the family’s long path towards reconciliation and acceptance. Now in recovery and happily married, she works with Ernesto, in a Washington DC health clinic providing services to GBT Latinos. Ernesto fled Venezuela in search of HIV treatment. He is still struggling to share his status with his family. Oscar lives in San Francisco and is the only son of Cuban immigrant parents. He is learning to navigate family and societal contradictions of being born and raised in two cultures. In the same city, Dusty, a long-married Panamanian parent to two adopted children, narrates (the feature length version) and interweaves their stories from a place of wise experience.

The short version is narrated by, Moises, a young activist living in Chicago. He links five abbreviated stories (from the above subjects) and simultaneously shares his own experiences as a young, gay Latino man, with his parents on camera.

Discussion Guide

The guide is designed to be used by a trained facilitator, in a small group, after screening the short film. The discussion may last between 30-45 minutes. The guide includes 6 major parts following the film’s content (See Table 1).

Table 1. Discussion Guide Questions.

Introduction: Getting the Conversation Started
 What were your initial thoughts after watching the film?
 What did you like the most and why? What did you like the least and why?
School: David’s Story
David is called names by the other kids: “faggot,” “gay boy.” Is it OK to call guys, “fag”?
 What was David’s reaction to being called names?
 Why do you think the other kids call him, “gay boy”?
What does it mean to be gay?
What difficulties does David have as a young person (in school, at home, with himself)?
Can you relate to David’s experiences (being called names or harassed, feeling unsupported by family members)? If so, how?
Have you witnessed bullying of gay kids (or others like lesbian and transgender youth) at your school? Give examples of how bullying is tolerated or, alternatively, discouraged at your school.
David said that he tried several ways to make himself straight, including playing sports and dating lots of girls. Why do you think David wanted to change?
What happened to David as a result of how he was treated by others?
How is David dealing with these experiences now, as an adult?
Religion: Marcelo and Gus
Why is religion such a big issue for Gus and Marcelo?
What is the conflict that Gus and Marcelo each experience with religion?
 What does Marcelo say about his faith?
 What does Gus think about religion?
How do they each resolve this conflict?
How does your church treat a person who is gay or transgender?
Family: Gaby
What does it mean to be transgender?
What is the difference between sexual orientation and gender identity?
Do you think Gaby had more difficult experiences than the others? Why?
How did Gaby’s mom react to her changing appearance? Why? Do you think she could have reacted differently?
How has Gaby dealt with these challenges?
HIV/AIDS: Ernesto
What difficulties does Ernesto face?
What does it mean to be HIV-positive?
What does it mean to be bisexual?
What obstacles do people living with HIV/AIDS face?
How has Ernesto dealt with these challenges?
Questions for Action
Has this film changed the way you view gay, bisexual and transgender individuals? If so, how?
What would you do if you found out or thought that someone you know was gay, bisexual or transgender?
What if you found out someone you know was HIV-positive?
What can people do to help others who are dealing with issues of sexuality or gender?
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Pilot Testing

We conducted two pilot studies to assess the effectiveness and feasibility of the intervention. One involved school youth and the other, health educators.

Evaluation with Youth

We pilot tested the intervention (e.g., short film followed by discussion) in a large public high school with a majority of students of Latin American descent. Students’ participation was voluntary, that is, they were self-selected. Research staff collected pre-posttest data on attitudes towards GBT and PLWHA, before and after viewing of the education film, Tal Comos Somos/Just As We Are, using paper-and-pencil data collection instruments. The sample size was 44 students in grades nine through twelve, 41 of whom self-identified as Latino (See Table 2).

Table 2. Demographic Characteristics of Pre-Posttest Film Evaluation Participants in Chicago High School, 2008 (N=44).

Socio Demographic Characteristics* n (%)
Age
 15 13 (30)
 16 11(26)
 17 4 (9)
 18 11 (25)
 19 1 (2)
 20 3 (7)
Gender
 Female 26 (59)
 Male 18 (41)
Birthplace
 USA 31 (71)
 Mexico 4 (9)
 Puerto Rico 6 (14)
 Central America 1 (2)
 South America 1 (2)
 Other 1 (2)
Race/Ethnicity*
 Latino 41 (95)
 Non-Latino 2 (5)
Language spoken with friends*
 Spanish / Mostly Spanish 0 (0)
 English and Spanish equally 23 (54)
 English / Mostly English 20 (47)
Language spoken with family
 Spanish / Mostly Spanish 22 (50)
 English and Spanish equally 15 (34)
 English / Mostly English 7 (16)
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*

Not all percentages will add to 100 due to missing cases.

All pre and posttest questionnaires were completed in 10-20 minutes (in English, no participants requested Spanish version). Approximately one to three weeks after administration of the pretest, research staff returned to show the educational film to each class. Each film session lasted approximately 40 minutes and consisted of a brief introduction, showing of the film, and then a brief question and answer session. The posttest was administered within two days of film viewing.

Data collected included demographic variables, e.g., birth country, gender, grade in school. A measure of attitudes toward GBT was comprised of 15 items developed from previous measures (Price, 1982; Van de Ven, 1995). We combined and adapted these measures by creating and adding items which reflect theoretical aspects of stigmatization (e.g., blame, social distance; Corrigan et al., 2003). The new measure included more domains and less redundant items than the original ones. The new measure was linguistically equivalent to Spanish. Respondents were asked to respond to statements on a 4-point response scale (1=strongly disagree, 4=strongly agree). A sample item is “Gay men are not normal.” Cronbach’s alpha for the scale was .89 (X‒ at pretest was 2.15). The HIV/AIDS stigmatization scale was comprised of 9 items, drawn from previous measures (e.g., Herek, 1999). Respondents were asked to react to statements about PLWHA on a 4-point scale (1=strongly disagree, 4=strongly agree). A sample item is, “People with HIV/AIDS are disgusting.” Cronbach’s alpha for the scale was .83 (X‒ at pretest was 1.90).

The posttest included a set of 6 evaluation questions to rate the entertainment and educational value of the film on a 4-point scale (i.e., 1=strongly disagree, 4=strongly agree), including: 1) enjoyment of the film, 2) willingness to recommend it to friends, 3) willingness to recommend it to family, 4) learned new information from viewing the film, 5) liked the people featured in the film, and 6) found the film boring.

Findings

Pretest and posttest scores for the measure of negative attitudes towards GBT were contrasted. Mean scores were found to be significantly reduced at posttest in comparison to pretest (X‒ pretest = 2.15, X‒ posttest = 2.02; p<.05; n=44). A sensitivity analysis was conducted for Latinos only (n=41) with similar results (X‒ pretest = 2.14, X‒ posttest = 2.03; p<.05). Comparisons by gender showed that reduction between pre and posttest occurred in males (p<.05; n=18), but not in females (p>.05; n=26). Although the reductions are small, they are meaningful in the field of attitudes.

Pre and post attitudes toward PLWHA were similarly compared. While scores were reduced from pretest to posttest, the difference was not statistically significant (X‒ pretest = 1.93, X‒ posttest = 1.83; p>.05; n=44). A sensitivity analysis was conducted for Latinos only (n=41) with similar results (X‒ pretest = 1.93, X‒ posttest = 1.83; p=.12; n=41). Likewise, there were no differences by gender.

With regard to evaluation of the film, 65% of participants indicated that they learned something new from viewing the film, 72% enjoyed the film, and 77% said they would recommend it to their friends.

Evaluation with Educators

We also assessed the potential use of the feature film by collecting data from HIV/AIDS educators and service providers. Fifty individuals attending a National HIV Prevention Conference viewed the film and completed an evaluation. These educators overwhelmingly (≥85% agreed/strongly agreed) indicated that the film was enjoyable, informative, high quality, accurate in its portrayal of Latino GBT, and potentially highly effective in reducing stigmatization. Anecdotally, both youth and educators commented on the absence of lesbian women. We restated that the purpose of the films was to address stigma in the context of HIV risk.

Dissemination

The dissemination of the film (in both versions) consisted of a train-the-trainer program, broadcasting, screening, and commercialization.

Train-the-trainer

Following Diffusion of Innovations theory (Rogers, 1995), we trained educators from organizations working on health, HIV/AIDS, Latino, youth, and LGBT issues as early adopters in Chicago. These trainees were then expected to adopt the film (i.e., short version with discussion guide) in their educational activities and help disseminate the film. The assumption was that they would find the film effective and fitting a gap in their resources. Organizations participated voluntarily and the training was considered part of their staff’s roles and responsibilities. The training was conducted in partnership with two local organizations working with Latino gay men and sexuality education.

We conducted three 2 hour training workshops with 40 educators (about 12-15 per workshop) from 22 organizations. Trainees worked, primarily, in areas of HIV prevention and sex and health education. These organizations serve diverse populations, such as Latinos, African Americans, and LGBT. They were trained to conduct small group presentations of the film, use the discussion guide, and collect evaluation data from their participants after each presentation. They received copies of the film and evaluation forms.

At the end of the workshops, attendees completed an evaluation about the film and the effectiveness of the training. All trainees (100%) said they enjoyed watching the film, they liked the people in the film, their organization would use the film, and they found the film to be of high quality. Also, 97% said they found the film informative, 93% felt the film accurately portrayed the lives of Latino GBT who also live with HIV/AIDS, 97% felt the film will help reduce stigmatization of Latino GBT individuals, and 90% felt the film will help reduce stigmatization of Latino GBT individuals with HIV/AIDS. Trainees found the workshop to be effective (42%) or very effective (58%); and agreed (45%) or strongly agreed (55%) that the workshop helped them learn how to use the educational film in group settings.

Following the training workshops we provided technical assistance. Staff contacted trainees regularly (e.g., every 3 weeks) to identify and address barriers in the implementation of the educational film in their on-going activities. The main obstacles noted by trainees were work overload and administrative and budget problems within their organizations, which gave them little flexibility with their usage of time.

Six months after being trained, 4 (of the 22) organizations contacted used the film. They reached an audience of 229 individuals (complete data). Their age ranged from 16 to 75 years old; 47% were between 14 and 18 years old; 51% was female, 48% male, and 1% transgender women; 43% was Latino, 21% African American, 19% White, and 7% percent reported being Asian American. Males rated the film less positively (X‒ = 2.67; SD=.74, on 1=strongly disagree, 4=strongly agree scale) than females (X‒ = 3.14; SD=.53; p<.05). Latinos rated the film more positively than any other ethnic group (data not shown).

Broadcasting and Commercialization

The feature film has been broadcasted several times by four local PBS stations (i.e., Chicago; San Francisco; New York, Philadelphia) and officially selected by six national and international film festivals. Tal Como Somos/Just As We Are is being commercially distributed by Films for the Humanities & Sciences. The short version of the film has been adopted by Chicago Public Schools as a classroom resource for a variety of subjects.

DISCUSSION

The goal of this project was to develop a culturally appropriate film-based intervention to reduce negative attitudes towards GBT and PLWHA in Latinos. It is assumed that if negative attitudes decrease, HIV prevention and care as well as the mental health and quality of life of GBT and PLWHA will improve. The film is based on empirical research on stigma, stigma and storytelling theories, and community input. It uses a documentary genre to portray the lives of Latino GBT and PLWHA and their families. To our knowledge, this is the first educational intervention aimed at changing stigma towards GBT and PLWHA among Latinos. The evidence suggests that the development and dissemination of the intervention were partially successful.

Several elements contributed to the partial effectiveness of this intervention. Social science research among Latino GBT helped uncover the need for this form of educational intervention and guided the content of the film. Qualitative data helped identify foci and prototype stories. Likewise, the film is rooted in a theoretical framework, which further directed the selection (and exclusion) of specific messages. Throughout the development of the intervention, from conceptualization to dissemination, community members and stake holders provided feedback. Furthermore, the research and production team developed a solid collaboration with multiple community organizations to make possible both community input and the production of the film. They also built strong rapport with all the individuals portrayed in the documentary.

We also believe that the documentary and storytelling style added to the effectiveness of the film by fostering involvement. Involvement (also referred to as “transportation”) means being engaged in the events, characters, and story (Hinyard and Kreuter, 2007; Moyer-Guse, 2008). The film provided a sense of realism and identification between subjects and audience. The intent was not to tell a subject’s story in chronological order, but to build a capsule of drama and discovery that imprints the storyteller’s experience on the audience. The value of film as an educational tool is that it allows the audience to “discover” the speaker’s story and insights at the same time that s/he does, by creating a condensed and dramatic “real time” story. From a narrative and storytelling theoretical perspective, the storytelling approach might have helped the delivery and reception of the message. Generally, storytelling and entertainment-education strategies are more effective than explicitly persuasive pedagogical ones because they diminish audience’s resistance, especially on issues embedded in morality and religion (Hinyard and Kreuter, 2007; Moyer-Guse, 2008).

The team brought together expertise in social and behavioral research on Latino and LGBT communities and documentary film production. The mixture of talents was complementary, and at times conflicting, requiring robust collaboration throughout the process. For example, on the one hand, the researchers not only are fully bilingual, but have lived extensively in Latin American and conducted research in GBT and HIV/AIDS. Their skills were critical in building relationships with subjects and their families and avoiding (to the extent possible) stereotypes by looking for the nuances and diversity within Latin-American cultures. On the other hand, the producers and film directors were able to create and tell an engaging and sympathetic story. Their role as outsiders (e.g., having very limited knowledge on GBT and Latino issues) led them to ask questions about content which at times was self-evident to researchers. However, on a few of occasions, the documentary perspective of the director and producer differed from that of social scientists. The director sought the “true” story from subjects and material that would entertain or create controversy to engage the viewer, while the researchers wanted the film to be educational and based on social science theory. What the filmmakers sometimes regarded as an appealing fact, the researchers considered a distraction from the core educational components of the film.

Although there is some evidence about the effectiveness of this intervention in changing attitudes, noteworthy caveats must be taken into account. The evaluation with school youth did not involve a control condition and random assignment, precluding us from concluding that exposure changed attitudes. Also, the posttest was conducted relatively shortly after the intervention. Ideally, we would use a randomized controlled trial with follow up assessments at 3 and 6 months after showing the film to observe the sustainability of changes in attitudes. Furthermore, the participating youth were not randomly selected, they volunteered, so those who agreed to complete the pre-posttest could have a positive predisposition towards GBT and PLWHA. These biases may also apply to individuals who attended the presentation conducted by the organizations that took part of the dissemination process.

There are several shortcomings in the dissemination phase as well. The diffusion through the train the trainer model was conducted only in one city and the number of organizations that conducted presentations was modest. This is partly due to the limited financial resources we had for this aspect of the study. Also, educators, while being very receptive to the film, felt somewhat overwhelmed with projects of their own and unable to conduct more presentations before our follow up efforts were terminated. The number of participant organizations that used the film was quite low, which reflects not only the logistical barriers that community organizations face, but also the difficulty of engaging communities on what is considered to be a somewhat controversial issue in particular. Providing financial resources for organizations (e.g., a paid staff educator) to distribute the film would certainly increase their involvement. Last, the long-term objective – to promote positive attitudes towards GBT and PWHA as a means to improve the health of Latino GBT and PLWHA -- has not yet been assessed. This would require extensive resources and a large community-wide intervention, including advocacy. Institutional changes and advocacy may be needed to reach beyond audiences who are already somewhat sensitized to the issue (or at least open to watch these types of films). These might include local or state policies requiring schools to provide diversity education that includes content on sexual orientation and gender identity. Such strategies could be accomplished via strong advocacy work with school and public officials and through groups such as Parents, Families, and Friends of Lesbians and Gays (PFLAG) and the Gay, Lesbian and Straight Education Network (GLSEN).

A single educational intervention cannot be expected to make long lasting changes in attitudes and cultural norms. We do not presume this intervention, for example, will result in large-scale transformation in teenagers’ attitudes towards those peers who do not conform to traditional gender norms, or that it will alter a school’s environment. But what is possible to expect is that Tal Como Somos/Just as We Are will be effective in generating initial, albeit limited, changes. For example, the film may raise awareness and generate discussion on this topic (Prochaska, DiClemente, & Norcross, 1992; Slater, 1999), and may complement ongoing efforts to create sizeable changes.

Acknowledgments

This research was supported by grants from the National Institutes of Mental Health (R01MH62937-01; R42 MH071157-02) and the Chicago Community Trust to the first author.

Contributor Information

Jesus Ramirez-Valles, University of Illinois-Chicago.

Lisa M. Kuhns, Children’s Memorial Hospital.

Dianna Manjarrez, University of Illinois-Chicago.

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