Aids Prevention Through Consumer Communication: Ideas From Past and Current Research

Elizabeth Cooper-Martin, Georgetown University
Debra Lynn Stephens, University of Maryland
ABSTRACT - The purpose of this paper is to suggest workable communication approaches to increasing heterosexuals' condom usage to protect against AIDS transmission. First we review studies of communications aimed at reducing the likelihood of AIDS transmission among heterosexuals. Then we examine literature on efforts to alter health behaviors that are similar to condom usage. Both of these sets of studies indicate that behavioral changes are difficult to achieve, especially through communications presented in the mass media. Face-to-face interactions and other non-mass media appear to hold more hope for increasing heterosexual condom consumption. Furthermore, we argue, a thorough empirical analysis of any communication effort must focus on the separate effects of message source, medium and content on the receiver.
[ to cite ]:
Elizabeth Cooper-Martin and Debra Lynn Stephens (1990) ,"Aids Prevention Through Consumer Communication: Ideas From Past and Current Research", in NA - Advances in Consumer Research Volume 17, eds. Marvin E. Goldberg, Gerald Gorn, and Richard W. Pollay, Provo, UT : Association for Consumer Research, Pages: 288-293.

Advances in Consumer Research Volume 17, 1990      Pages 288-293

AIDS PREVENTION THROUGH CONSUMER COMMUNICATION: IDEAS FROM PAST AND CURRENT RESEARCH

Elizabeth Cooper-Martin, Georgetown University

Debra Lynn Stephens, University of Maryland

ABSTRACT -

The purpose of this paper is to suggest workable communication approaches to increasing heterosexuals' condom usage to protect against AIDS transmission. First we review studies of communications aimed at reducing the likelihood of AIDS transmission among heterosexuals. Then we examine literature on efforts to alter health behaviors that are similar to condom usage. Both of these sets of studies indicate that behavioral changes are difficult to achieve, especially through communications presented in the mass media. Face-to-face interactions and other non-mass media appear to hold more hope for increasing heterosexual condom consumption. Furthermore, we argue, a thorough empirical analysis of any communication effort must focus on the separate effects of message source, medium and content on the receiver.

In the early 1980s, a new and significant health care problem emerged: AIDS. It is a virulent, unforgiving disease, both incurable and fatal. Further, there is no vaccine against AIDS and there are very few effective therapies. Sexual contact and intravenous drug use are two important modes of AIDS transmission. Hence, certain changes with respect to these behaviors can reduce the risk of contracting this disease. Clearly, then, communication efforts that encourage people to make such behavioral changes are crucial to controlling this disease (Bayer 1989). This paper uses an understanding of consumer behavior to address this challenge.

This paper examines the relatively more simple problem of changing sexual behavior, rather than drug abuse. Ways to lower the risk of transmission through sexual contact include abstinence, monogamy and condom usage. Clearly, these alternatives vary in their suitability for different individuals, e.g., Catholic bishops have argued against promoting condoms as a response to AIDS (Bums 1988). However, given our interest in consumption behavior, we focus exclusively on condom usage. We will limit our discussion to heterosexuals, because they have not been studied as extensively as homosexuals.

For people who are sexually active (i.e., not abstaining) but not in a monogamous relationship, condom usage is an appropriate response to the threat of AIDS. In a national survey of 400 such adults, 67% of the women and 54% of the men said they were very likely to insist that a new partner use a condom. However, only 38% of the women and 48% of the men reported using a condom in the past year (Carter-Wallace 1988). Likewise, a national survey indicates that only 14% of sexually active unwed teenagers used a condom the last time they had intercourse (U.S. News & World Report 1988). Thus, it appears that many sexually active, heterosexual Americans are not using condoms. Therefore, the purpose of this paper is to suggest workable approaches for communication efforts that increase condom consumption in this population to protect against AIDS transmission.

Specifically, we search two sources of suggestions for communications that affect condom consumption. The first source is research specifically on AIDS. Given the dearth of research in this area, we also review a second source: literature on efforts to change other health behaviors, with a focus on behaviors judged to be most similar to condom usage. We base our definition of-similarity on key characteristics of condom usage and other health behaviors (e.&, seat belt usage, smoking cessation). Based or both sources, we present our conclusions on how to increase condom consumption. Last, we propose a future research study to test some of our conclusions.

RESEARCH ON AIDS

To answer the question of what type of communications would increase condom usage by heterosexuals to protect against AIDS, we first review research on this topic. Any communication effort involves a source, content, a medium (i.e., means of transmission), a receiver, and destination (i.e., opinion-change impact) (McGuire 1969). Because of our focus on behavior change by heterosexuals, we consider neither other groups of receivers nor destination. Rather, we examine each study for information on the effects of source, content and medium.

Of the few papers published on AIDS and heterosexual condom usage, the first we discuss examines the attitudinal and behavioral impact of a television-quality, soap opera-style videotape in which the female protagonist, with advice from her brother and girlfriend, convinces her boyfriend to use condoms (Solomon and DeJong 1989). Compared to those who did not see the videotape, clinic patients who watched it had greater knowledge and more positive attitudes toward condoms. A second group of patients who saw the videotape redeemed significantly more coupons for free condoms from the clinic. Thus, viewing the videotape affected knowledge, attitudes and behavior. The authors stress the videotape's source, i.e., members of the target audience, and several aspects of the message. The latter include portraying condoms as socially acceptable and normative, as well as sexually appealing, and focusing on interpersonal and communication skills. However, the effects of source, content and medium are confounded. In a related paper, Solomon and DeJong (1986) give a more complete list of their principles for STD and AIDS risk reduction message design. Most concern the content (e.g., develop strategies to acknowledge and reduce the stress that AIDS causes) with fewer focusing on the medium or source (e.g., use intermediaries with access to the audience).

The Solomon and DeJong study (1989) is the only one that demonstrates that communications can affect condom usage, assuming, of course, that redemption of coupons for condoms is a good proxy for such usage. Another study finds no effect on behavior (Sherr 1987). The communication was a full page advertisement that appeared once in every national newspaper in the U.K. and presented information and advice about risk factors for AIDS and safe sex guidelines. A content analysis (performed after its appearance) found that only 24% of the population could understand the advertisement, which also used unclear terms, such as "intimate kissing" and "rectal sex". In brief, the message was weak on readability and clarity. Perhaps not surprisingly, it had no impact on self-reports of intended sexual behavior or on attitudes, desire for more information, or AIDS anxiety among its readers. Although information gaps among readers decreased, this effect was not quite significant. These findings were based on comparisons before and after the message appeared; at each time, different samples of the same populations were questioned. Unfortunately, the sexual orientation of respondents was not adequately assessed. Moreover, the study confounds the effects of source, content, and medium. However, all three differ from the Solomon and DeJong (1989) study: the source was a group of medical.officials and the medium was a newspaper. The content was informational and did not address social norms, interpersonal skills, or the erotic nature of condoms.

The remaining two papers on AIDS and condom usage by heterosexuals do not examine the effects of specific communication efforts. However, they, along with Solomon and DeJong's (1986) earlier paper give good directions for message content. Siegel and Gibson (1988) discuss six barriers to heterosexuals' use of condoms to lower the risk of contracting AIDS: perceptions of low vulnerability, misperception of the efficacy of adaptive behaviors, barriers to the adoption of condoms, confusion regarding the magnitude of the threat to heterosexuals, interpersonal nature of sexual activity, and the stigma of AIDS. Based on these barriers, the authors make several recommendations, including one for wider availability of condoms. Their remaining suggestions focus on the content of communications efforts: operationalize terms such as "multiple partners" and "sexually active", destigmatize AIDS, convince people that they cannot identify AIDS carriers by their own judgments, change perceptions of condoms, and show people how to negotiate limits with sex partners. The latter two suggestions concur with Solomon and DeJong (1986, 1989).

In another study, heterosexual college students reported their reactions to two hypothetical scenarios involving condom usage (Hill and Stephens forthcoming). In the first, the student suggests condom usage to a new partner. The students reported they would be concerned about their partner's sexual history and consequently envision a short-term relationship. They are, as one respondent stated, "pointing an accusatory finger". The students also reported their responses to a scenario in which a first-time sex partner suggests using a condom. They anticipate responding with a feeling of shared responsibility and/or favorable reactions towards the suggesting partner. Since suggesting condom usage can be other-serving as well as self-serving, a partner may interpret it as an act of "mutual consideration", as one respondent suggested.

The students' positive reactions to the partner request scenario contrast with the more negative ones from the scenario in which the student him/herself suggests using a condom. But these positive feelings are consistent with the sexual intimacy literature which suggests that self-disclosure, revealing ones' fondest dreams as well as deepest fears, is often interpreted as a sign of the other person's continuing interest (Masters, Johnson and Kolodny 1986; Millett 1970). The implications for message content are clear: portray the positive responses of a part to the suggestion of condom usage.

Although our focus is on heterosexuals, we did examine communications about AIDS aimed at homosexuals. Bayer (1989) reports that gay groups provided information about safe sex to many members of the gay community and that subsequently, knowledge about safe sex has become widespread (e.g., 90% awareness in two samples of gay men). Further, there have been dramatic changes in sexual behavior (e.g., celibacy rose from 2% to 12% in a two-year period among a sample of 5000 men). However, many gay men continue to engage in risky behaviors (e.g., one third of the sample of 5000 do not use condoms). Bayer credits education with the changes that have been achieved, but also argues that personal knowledge and experience with those ill and dead from AIDS has had a powerful effect on behavior.

On the whole, the studies discussed above afford us little- opportunity to examine the effects of communication source, content, and medium on the beliefs and behaviors of heterosexuals regarding condom usage to decrease the likelihood of AIDS transmission. However, the studies do suggest useful guideline for designing messages for more detailed empirical testing.

CHARACTERISTICS OF HEALTH CHANGE BEHAVIORS

Our goal is to identify communication efforts that are successful in encouraging heterosexuals to use condoms as protection against AIDS transmission. However, there is little past research on this problem. Therefore, we examined literature on changing other health behaviors. We focused on behaviors that are similar, i.e., have dimensions in common with using condoms to protect against AIDS transmission. In this section, we discuss several characteristics or dimensions that describe health change behaviors. We will then review past efforts to change such health behaviors.

Frequency of Behavior

Health change behaviors can range in frequency from once in a lifetime to every day or every time a given set of conditions occurs. For example, inoculations, e.g., for hepatitis, or the installation of a smoke detector in one's home need to be done infrequently, while a seat belt must be used every time one is in a automobile. Likewise, condoms must be used every time sexual intercourse occurs. The more frequent the behavior, the more important are attention, memory, and motivation. Not only must the user pay attention to and recognize the conditions that require the behavior, but he/she must also be motivated to perform the required action.

Convenience

Convenience is a subjective belief, particular to an individual consumer. The convenience of a health change behavior depends on several dimensions: time, place, duration, pleasure, and usage situation. Note that convenience differs from repetition, i.e., a behavior can be repetitive but convenient. For example, taking a pill once a day is repetitive but convenient. However, taking AZT every four hours is repetitive and inconvenient, because of timing; the user must interrupt his sleep to take it. Most immunizations are infrequent, but a rabies or penicillin shot seems inconvenient due to unpleasant effects, unlike a hepatitis shot. Condoms are generally considered inconvenient, due to the delicacy of the usage situation, and because pleasure may be diminished (Felman and Santora 1981).

Individual versus Passive

This dimension contrasts health behaviors the individual must perform, with those that are performed for him/her, thus permitting the individual to remain passive (Robertson 1976). For instance, a seat belt is an individual responsibility while air bags are passive; likewise using fluoride gel is an individual responsibility while obtaining fluoridated water is passive, i.e., it requires no individual effort. The implication is that passive actions depend much less, if at all, on each person, while the motivation of each user is critical for individual actions. Clearly, condom usage is an individual responsibility, as are other changes related to preventing sexual transmission of AIDS.

Private versus Public

A public health behavior is done so that others can observe compliance, e.g., smoking cessation. However, a private behavior is observed only by the person doing it, e.g., flossing teeth. Condom usage is semi-private; two people are involved. The implication is that public behaviors have a greater opportunity for social influence than do private ones; a semi-private one should fall between these two extremes.

Consequences

The physical consequences of performing or not performing a health behavior may be to the self only or to the self and others. For example, drinking (without driving) may be harmful only to the drinker, but drinking and then driving is harmful to the occupants of other cars and to pedestrians. Similarly, the consequences of overeating affect the eater but overfeeding one's children clearly affects others. Condom usage has consequences for one other person besides the self. When a health behavior has consequences that extend beyond the self, appeals to change the behavior can focus on protecting other people, especially loved ones.

Summary

In summary, condom usage must occur every time there is intercourse, is perceived as inconvenient, and requires responsibility and action from the individual. It is a semi-private behavior, with consequences for the self as well as others.

RESEARCH ON OTHER HEALTH CHANGE BEHAVIORS

In reviewing research on health change behaviors, we begin with work related to other sexually transmitted diseases (STDs). Among the few studies on communication efforts with regard to other STDs, even fewer look at the effects on behavior. More typically, they examine gains in knowledge. For example, a programmed learning guide, an audiovisual tape and an interview all significantly increased patients' knowledge of STDs (Alkhateeb, Lukeroth and Riggs 1975). The interview was the most effective and evaluated the most favorably.

A few studies do examine effects on STD-related behaviors, such as levels of clinic use (e.g., Adler 1982) and gonorrhea patients' rate of return for test-of-cure examinations (Kroger 1980). Patients new to a clinic mentioned the media as a source of reference more often after the airing of a television program that concerned STDs and frequently mentioned the name of the clinic's hospital (Adler 1982). In this study, the effects of content, medium and source are all confounded. When nurses used "prescription" pads and simplified information sheets to communicate expected behavior, instead of verbal-only instructions and more complicated information sheets, more patients returned for test-of-cure (Kroger 1980). However, much of the improvement disappeared when the nurses were no longer monitored. Moreover, the impact of medium (pads versus verbal instructions) was confounded with content; without the pads, many times nurses did not give any instructions at all.

These findings are of limited usefulness for the problem of encouraging condom usage among sexually active heterosexuals. Both first time visits to a clinic and returns for test-of-cure are infrequent, somewhat inconvenient, and public, require individual responsibility, and have consequences for others. Hence these behaviors differ from condom usage on the dimensions of frequency, convenience, and their public versus private nature (see Table for behaviors that are dissimilar and similar to condom usage). Further, there are confounded communication-related effects in both studies.

TABLE

HEALTH CHANGE BEHAVIORS THAT ARE SIMILAR AND LESS SIMILAR TO CONDOM USAGE

Other behaviors, even though they are not related to STDs, more closely resemble condom usage, for example cessation of smoking (see Table). Like condom usage, it must occur every time given circumstances occur (i.e., there is desire for a cigarette), is inconvenient (i.e., the smoker gives up a pleasurable activity with addictive properties), is an individual responsibility and has consequences for others. But unlike condom usage, smoking cessation occurs in public as well as in private.

There is some evidence that communications efforts encourage smoking cessation. More Australian smokers in towns with media campaigns against smoking quit, compared to a control town (Egger, Fitzgerald, Frape, Monaem, Rubinstein, Tyler and McKay 1983). The media campaigns were intensive and included television, radio, print, stickers, posters, T shirts, balloons and self help "Quit" kits. In addition to media anti-smoking efforts, one town had community programs, such as quit smoking groups, fact sheets, and aids to help smokers quit. In this town, declines in smoking continued past the first year of the media campaign, to the second and third years. These results suggest that face-to-face media (e.g., quit smoking groups) or "little" media (i.e., fact sheets) are more effective for long-run behavior changes than mass media (e.g., television). Unfortunately, there may be confounds between the effects of medium and source or content.

Similar results occurred in a Finnish study of smoking (Puska, Niemensivu, Puhakka, Alhainen, Koskela, Moisio and Viri 1988). The proportion of smokers declined more in areas with both an anti-smoking media campaign (i.e., a 15-part television series) and worksite programs (i.e., opinion leaders, risk factor profiles and health education brochures) than in areas exposed only to the television series. Like those in the Australian study (Egger et al 1983), these results suggest that a mass medium (i.e., television) is less effective than other media, including face-to-face interaction (i.e., opinion leaders) and other non-mass media (i.e., brochures). However, once again, the study does not clearly control for differences in source (e.g., a known opinion leader versus unknown, albeit similar, workers in the television series) or in content (e.g., information from the risk factor profile) between different mass media, or between the various nonmass media channels.

Two other health change behaviors that resemble condom usage are exercise and diet or nutrition (see Table). Adequate nutrition and exercise both must occur frequency, require individual responsibility, and are often private. For many people trying to change their diet or increase their exercise level, these behaviors may well seem at least somewhat inconvenient. These four characteristics resemble those of condom usage; however, diet and exercise have consequences only for the self.

A study on osteoporosis prevention examined both exercise and nutrition (Rook 1986). All subjects received one page of information about the prevalence of osteoporosis, risk factors associated with it, and actions (exercise and diet) that would help prevent it. Some subjects read the information in an abstract version, i.e., in reference to women in general, while others read a vivid version, i.e., in reference to a particular woman. Their attitudes and behavioral intentions were combined into a measure of persuasiveness. Premenopausal women (for whom osteoporosis is a distant threat) found the vivid information more persuasive. But postmenopausal women (for whom osteoporosis is a proximal threat) found both presentations equally persuasive. However, after six weeks, none of the women reported changes in exercise or diet (i.e., eating calcium rich foods). Despite the disappointing results for behavior, this study does demonstrate the impact of one message characteristic, vividness, on attitudes and intentions. This demonstration reinforces Bayer's (1989) argument that personal knowledge of individuals who have suffered (i.e., vivid information) has affected sexual behavior of homosexuals.

In sum, these studies on health change behaviors that are similar to condom usage suggest that the medium has an effect on behavior and that one aspect of the content (i.e., vividness) may have an effect. Reviews of mass media campaigns on a variety of health behaviors, including smoking, drug use, alcohol use, general health, and obesity, conclude that mass media campaigns have no lasting effects on behavior (Atkin 1979, Flay 1981, Robertson and Wortzel 1978). Typically the mass media campaigns reviewed simply involve televised public service announcements (PSAs). Clearly, a series of short (30 or 60 seconds) PSAs, often aired at off-times when the audience is small, is similar to Rook's (1986) information sheet and to the newspaper advertisement reviewed by Sherr (1987) but very different from the two anti-smoking campaigns reviewed. The Australian study used brief PSA-like announcements on TV and radio; however, they bought the time to control the amount of exposure and also used a wide variety of other channels. Although in the Finnish study only one channel (television) was used, the messages were 35-minute programs.

Thus, as Bettinghaus (1986) concludes, few mass media campaigns have lasting effects on health behavior, although weak positive effects are likely and some campaigns with special features do generate significant behavior changes. Rather, mass media communications efforts are more effective for creating awareness, affecting attitudes and beliefs, initiating information search (Schlinger 1986), and reinforcing existing behaviors (Robertson and Wortzel 1978; Schlinger 1986). Also, as demonstrated in the studies discussed here, reviews of mass media campaigns on a variety of health behaviors conclude that face-to-face interactions are more effective than mass media campaigns for inducing behavior changes (Atkin 1979, Flay 1981).

CONCLUSIONS

In sum, there is very little information on communications efforts to change condom usage by heterosexuals, to protect against AIDS. Only one study reports encouraging results for changing behavior (Solomon and DeJong 1989). Despite many recommendations about message source, content and medium, there are no definitive results on the impact of each of these communication elements, due to confounding. Hence, we argue that a thorough empirical analysis of any communication effort must focus on the separate effects of message source, medium and content on the receiver. However, for message content, Solomon and DeJong (1986) and Siegel and Gibson (1988) provide worthwhile suggestions, although they have not been rigorously tested. As for the medium, studies concerning other, but similar, health change behaviors suggest that mass media are not effective for changing behavior, but that face-to-face and other non-mass media are.

Thus the soundest suggestion is not to rely on mass media campaigners to change condom usage. Instead, channels that allow for direct interaction (e.g., in groups or between a pair of individuals) or for more detailed information which receivers can process at their own pace (e.g., brochures) seem more effective

FUTURE RESEARCH

As the previous review illustrates, the most effective medium, source and content of communications for convincing heterosexuals to change their sexual behavior in response to AIDS is not clear. In particular, which type of non-mass media (i.e., face-to-face interactions versus printed matter such as brochures) is most effective is not clear. Further, there are no findings and few suggestions about source. Thus, work on message source and on the relative effectiveness of non-mass media seems quite crucial. We are currently developing a field study that will compare the effects of these two variables. It will take advantage of a college campus which has an important medium - small, peer groups -- to communicate information about AIDS

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