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OCR for page 259
4
Facilitating Change in Health Behaviors
This chapter summarizes some of the major findings of research
that has been undertaken to understand how to facilitate change
in human behavior to prevent disease and promote health.) Special
attention has been given to the way this research relates to altering
the behaviors associated with the transmission of HIV infection.
At the beginning of its study, the committee had hoped that
factors clearly associated with altering HIV-related behaviors could
be identified by examining evaluations of existing AIDS prevention
programs. Unfortunately, although considerable behavioral change
has been documented among the individuals who reported engaging
in high-risk behavior, much less attention has been paid to under-
standing how and why those changes occurred. There has been little
useful evaluation of the few major intervention programs that have
been undertaken, and there have been even fewer studies that com-
pared the efficacy of alternative interventions (Office of Technology
Assessment, 1988~. Consequently, the committee has had to rely on
a more basic analysis of intervention strategies, using principles of
human behavior established through empirical research in the social
and behavioral sciences, to suggest useful programs to prevent the
spread of HIV infection.
1 there are many literatures that report empirical findings of behavioral studies that have
attempted to modify individuals' health-related behaviors (e.g., promotion of seat belt
use, participation in screening and immunization programs, compliance with prescribed
regimens). However, because of the many unique features surrounding the behaviors
involved in the transmission of HIV, this chapter emphasizes only those principles of
behavior and research findings that appear to be most directly related to the behaviors
that can transmit HIV.
259
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260 ~ LIMITING THE SPREAD OF HIV
AIDS intervention programs have been established out of the
need and desire to act quickly. The tremendous effort that has al-
reacly been expended to halt the spread of infection is laudable;
nevertheless, the committee has concluded that much more could be
accomplished. Well-designed research programs and effective inter-
vention strategies are-needect to maximize the likelihood of progress.
Furthermore, the design of such activities must take into considera-
tion a wicle range of conceptual and empirical research approaches,
derived from the various fields that make up the social ant! behav-
ioral sciences. There are also methodological issues that must be
addressed. (These are discussed in detail in the next chapter.) Much
is understood about human behavioral change and about messages
and their effectiveness. Yet the application of these ideas to spe-
cific groups typically can be undertaken in more than one way, and
rarely is theory strong enough to tell us in advance which method
will be the more effective. This state of knowlecige leads to two
central methoclological principles: (1) the practice of using planned
variations in messages, programs, and campaigns should be standard!
in AIDS intervention programs, and (2) a plan for evaluating the
comparative success of the variations should be a critical component
of any intervention. Only in this manner can the most effective in-
terventions be rapidly and reliably determined. To "streamline" the
preparation of educational materials and intervention programs by
choosing a single, "best-we-think-we-can-do" product is to delay the
identification of effective intervention strategies.
Two fundamental themes can be seen in the principles of behav-
ior presented in the following pages:
1. For behavior to change, individuals must recognize the
problem, be motivated to act, and have the knowledge
and skills necessary to perform the action.
2. To increase the likelihood of action, impediments in the
social environment must be removed or weakened and
inducements for change provided whenever possible.
By focusing on facilitating change in risk-associated behavior,
the committee does not wish to impute a diminished importance
to maintaining those behaviors that are not associated with risk.
Clearly, the best way to prevent IV cirug-associated HTV transmis-
sion is to prevent the use of drugs. However, intravenous use of illicit
cirugs is a Tong-standing problem in U.S. society; it has resisted pre-
vention efforts to date and is unlikely to disappear in the foreseeable
future. Sexual behavior must also be considered in realistic terms.
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FACILITATING CHANGE | 261
Although social norms present sexual abstinence as a lauciable goal
for the aclolescent population and monogamy as an appropriate sta-
tus for adults, the data presented in Chapter 2 clearly show that
the realities of sexual behavior are not always consistent with the
norms. Changing the behavior of individuals is important in the
management of many health problems; it is critical in the prevention
of AIDS.
Motivating anti sustaining change in risk-associated intimate and
addictive behaviors are not easy; they will require a continued com-
mitment to diverse and, at times, innovative approaches. Yet there is
much reason to be hopeful about the potential for success of behav-
ioral interventions to prevent the spread! of HIV infection. A wealth
of research on health behavior indicates that indivicluals are certainly
capable of undertaking changes in important areas of conduct; in-
deecI, substantial changes in individual behavior have already been
reported among homosexual men and IV drug users in response to
the AIDS epidemic (Becker and Joseph, 1988; Office of Technology
Assessment, 1988~. Surveys of IV drug users from the New York City
area indicate high levels of awareness and knowledge about AIDS,
increased demand for treatment, and substantial changes in needIe-
sharing practices and the sterilization of injection equipment (Des
JarIais, 1987~. The variations in the amount and types of change
that have been reported across groups and by geographic location
should not detract from the substantial modifications made by those
at greatest risk of this fatal disease. As Becker and Joseph have
noted, "in some populations of homosexual/bisexual men, this may
be the most rapid and profound response to a health threat which
has ever been documented" (1988:407~.
In this chapter the committee identifies factors that are likely to
help an individual alter risk-associated behaviors and sustain healthy
ones. Providing accurate, appropriate, and effective information is
the logical starting point for any health program. Education plays
an important role in facilitating behavioral change, allaying unnec-
essary fears, and reducing discrimination. However, as the commit-
tee's discussion of education programs indicates, information alone
is generally insufficient to alter behavior. Therefore, the chapter also
provides an analysis of the strategies needed to motivate in(livi~luals
to change unhealthy behaviors and to sustain healthy ones. Because
the behaviors of interest are enacted in social situations, the final sec-
tions of the chapter include discussions of the social support needed
to facilitate health behavior and the existing social impediments that
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262 ~ LIMITING THE SPREAD OF HIV
hinder change in individual behavior and the implementation of HIV
prevention programs.
EDUCATION PROGRAMS
For behavior to change, individuals must unclerst end the risks they
incur by engaging in that behavior. In this section, the committee
reviews the role of education programs in preventing HIV infection,
including the behavioral mollifications that increased knowledge can
reasonably be expected to accomplish. The remainder of the section
focuses on three aspects of such programs that have- particular rele-
vance for AIDS prevention: (1) the content of health messages and,
especially, the level of fear evoked by the message; (2) the role of the
merlin in purveying health messages ant! the effect of risk percep-
tion on taking appropriate action; and (3) the problems associate<]
with the introduction and adoption of new ideas and technologies,
including antibody testing.
The Role of Education ant! Knowledge in Preventing the
Spread of HIV Infection
Information is necessary but often insufficient by itself to effect be-
havioral change. Consequently, the association between knowledge
and facilitating behavioral change is of particular interest to interven-
tion planners. Empirical studies have found knowledge about HIV
and its transmission to be of varying importance in effecting and sus-
taining behavioral change (Emmons et al., 1986; Kelly et al., 1987b).
Becker and Joseph (1988) postulate that there may be a "threshold"
effect: beyond a certain level, increases in knowledge or changes in
attitude may not increase changes in behavior. Alternatively, an
indirect relationship may exist between knowledge and attitudes, on
the one hand, and behavior, on the other; another possibility is that
intervening variables may link these factors. Yet the uncertainties
surrounding the role of information in behavioral change do not oh
viate the need for this basic element of health programs: it would be
unconscionable not to provide accurate, comprehensible information
about HIV and AIDS.
Thus, the logical starting point for any AIDS education program
is the provision of information. General information about AIDS,
including facts about the causative virus and routes of transmis-
sion, has been successfully disseminated through posters, pamphlets,
radio and television, word-of-mouth, community communications
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FACILITATING CHANGE ~ 263
networks, and, recently, a brochure from the Public Health Service,
which was mailed to every househoIcl in the United States. AIDS
is very much on the public's mind. In national surveys, approxi-
mately 90 percent of respondents reported seeing, hearing, or reacting
something about AIDS within the last week (Dawson et al., 1988~;
in public opinion polis,-almost all respondents knew that AIDS is
caused by a virus that is transmitted through sexual behaviors or
shared injection equipment (Turner et al., in press). The public also
holds numerous erroneous- beliefs, however, and questions persist
about the role of kissing and toilet seats in the transmission of HIV.
It is important, therefore, to understand how to provide additional
information.
As AIDS education efforts continue, more attention must be di-
rected toward how the material is presented. Print and broadcast
media offer the economy of reaching many people with a unified
message. However, face-to-face communication for hard-to-reach in-
clividuals (e.g., {V drug users) is also needed to clarify questions, deal
with fear or inertia, ant! facilitate access to needed goods and services.
It must be recognized by those designing education programs that
access to mainstream sources of information for minority groups and
others may be limited by Tower levels of eclucational achievement and
a limited capacity to comprehend messages in English. Information
must be delivered in a manner that is comprehensible and relevant to
the audience it is intended to reach. Clearly, this requirement will en-
tai] providing written and spoken messages in the different languages
and idioms of the various ethnic, racial, social, age, and sexual ori-
entation groups that make up the national population. Much of the
currently available information on AIDS and HIV transmission floes
not fulfill these criteria. An analysis of 16 educational brochures on
AIDS prevention found that, on the average, they were written at a
14th-grade (second year of college) reading level (Hochhauser, 1987~.
This is clearly unsatisfactory.
There is also a need in AIDS education for frank exchange that
allows no misunclerstanding. Clear, explicit language is required; yet
its use in AIDS education continues to be impeded by the pervasive
American reticence about discussing sexual behavior (see Chapter
7~. The results of such reticence and the lack of straightforward com-
munication are seen in the misconceptions that remain about HTV
transmission. For example, the use of the expression "exchange of
bodily fluids" in early information campaigns left many people with
unsubstantiated concerns about the risk associated with kissing; oth-
ers may not have understood this term to include the presem~nal and
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264 ~ LIMITING THE SPREAD OF HIV
vaginal fluids present during foreplay. Many adolescents continue to
believe that HIV infection can be acquired through casual contact,
such as shaking hands or simply being near someone with AIDS (Di-
Clemente et al., 1986, 1988; Reuben et al., 1988~. In some instances,
the lack of clear information encourages continued risk-associatec!
behavior. Some IV drug users, for example, still believe that water is
sufficient for sterilizing injection equipment; others believe infected
individuals can be identified by their appearance. Moreover, homo-
sexual men who believed they had successfully "fought off" the virus
(as one would fight off the flu- by mounting an antibody response)
were more likely to report continued participation in high-risk sex-
ual activities than men who had a clearer, more accurate sense of
whether or not they were infected (Coates et al., 1985~. In other
instances, misinformation impedes desirable behavior. Among the
general population, more than one quarter of a national sample (26
percent) believed that a person could get AIDS from donating blood
(Dawson et al., 1988~.
Mocles of information dissemination are another aspect to be
considered in providing AIDS education. An example of the use of a
spectrum of networks to disseminate AIDS messages is the program
created by the San Ffancisco AIDS Foundation in the early years of
the epidemic (Communication Technologies, 1987~. One component
involved advertising campaigns that were designed to reach large
numbers of people: ads urging safer sexual practices and providing
information about AIDS were placed in newspapers and magazines,
on billboards, ant! in buses and other forms of public transportation.
They were also carried on television and radio. To achieve greater
visibility and acceptability in the local gay population, a widely dis-
tributec3 and controversial poster featured two nude men embracing
with the caption, "You Can Have Fun and Be Safe, Too" (Com-
munication Technologies, 1987:11~. Later communications used the
theme, "The Best Defense Against AIDS Is Information" and tar-
geted a broader population. Pamphlets published in the languages
spoken in the community were (distributed through the mail, in the
streets, at public forums, and through health care facilities. (These
materials included "Can We Talk?," a brochure for homosexual men
that has been translated and copied around the world.) A project
to provide anonymous antibody testing with counseling was also
implemented, anti appeals to provide protection through anti~lis-
crimination legislation were promoted.
The program also attempted to teach safer sex skills and en-
hance the erotic attractiveness of safer sex. One project, called
. . . . . . . . .
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FACILITATING CHANGE ~ 265
"Bartenders Against AIDS," provided information on AIDS preven-
tion to local bartenders and included training on how to support
safer sex among customers (Communication Technologies, 1987:17~.
Small group meetings were helcT in individuals' homes and elsewhere
(the Stop AIDS Project-) to clarify the guidelines of safer sex practices
and produce commitment to their use through face-to-face interac-
tion and discussions. Over time, the design of the campaign was
altered, based on the findings of marketing research. In addition,
pamphlets anct flyers were updated regularly to reflect new material
and epiclemiological findings and to reach new audiences. Founda-
tion personnel collaborated with journalists to assist in the process
of creating informative, accurate articles.
The community-level programs noted above are supported and
complemented by educational efforts at the federal level. CDC is
the lead agency for AIDS prevention programs in the Public Health
Service. It supports a range of extramural information and education
activities and selected intramural efforts, including
. a multimillion-dolIar school education program;
. a national hot line;
. a multimedia advertising campaign whose slogan is
"America Responds to AIDS";
· a national clearinghouse for printed AIDS information
available to the public on request;
. multimillion-(lollar cooperative agreements with the 50
states, 5 territories, and 4 other locales to support com-
munity task forces, hot lines, and antibody testing and
counseling; and
. community demonstration projects to disseminate in-
formation, promote change in social norms and risk-
associated behavior, and provide antibody testing anct
counseling.
.
As cletailed later in this chapter, there is clearly more to influenc-
ing health behavior than the provision of information, as has certainly
been seen in smoking and drug prevention campaigns. To change be-
havior, at a minimum, indivi(luals need to perceive that they are
personally at risk of acquiring a serious condition, that efficacious
preventive actions can be undertaken, and that barriers to initiat-
ing or continuing these preventive practices can be minimized or
overcome (Janz and Becker, 1984~. Supportive environments ensure
a quicker adoption and more consistent maintenance of behavioral
change. Education, however, is the beginning. Various agencies in
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266 ~ LIMITING THE SPREAD OF HIV
the public and private sectors have been making considerable efforts
to provide information on the AIDS epidemic to the public. Federal
efforts have been hampered by constraints on the use of language
that can convey the AIDS prevention message frankly and explicitly.
The committee finds that the gravity of this epidemic allows no room
for misunderstanding. The committee recommends making in-
formation available in clear, explicit language in the idiom
of the target audiences
The Function of Fear in Health Messages
Information, prevention, and treatment programs for sexually trans-
mitted diseases (STDs) for both the military ant! civilian populations
have relied to varying extents on threatening messages that evoke
high levels of fear. Similar tactics have been used in programs to
prevent AIDS. (For example, such messages as "Bang Bang You're
Dead" have been used to call attention to the fatal consequences of
sexually transmitted HIV infection.) Whether these messages have
been effective in changing behavior is not known because there have
been no controller! studies or evaluations of their impact. Research
suggests, however, that the efficacy of such a frightening and unin-
forming message is doubtful.
Messages designed to evoke high levels of fear or those that rely
exclusively on threats may be intuitively appearing in the case of pre-
venting a deadly disease, but they have been shown to be effective
for most people only if coupled with advice about how behavioral
change can reduce the threat (Sutton, 1982; Becker, 1985~. Anxiety
alone does not necessarily lead to behavioral change. For example,
in the syphilis campaign undertaken early in this century, the edu-
cational messages crafted for the military sought to arouse fear in
the troops (Brandt, 1987~. Knowlecige about STDs was measured
in military inductees before and after STD prevention films (e.g.,
"Fit to Fight" and "Fit to Wind. Premovie and postmovie mea-
surements revealed that these strategies changed general impressions
about STDs (e.g., horror and fear were increased and persisted for
weeks after the viewing), but knowledge and behavior did not change
(LashIey and Watson, 1922~. During World War IT, however, when a
prophylaxis program based on condoms and treatment was initiated,
soldiers responded favorably. As many as 50 million concloms were
accepted by soldiers each month, and rates of syphilis declined in this
population over that time (Brandt, 1987~. Nevertheless, the lack of
a systematic evaluation of the message and prophylaxis programs (a
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FACILITATING CHANGE ~ 267
shortcoming of most STD programs) foils any attempt to draw con-
clusions as to what factors did or clid not work in reducing syphilis
in this population.
Like the military STD prevention programs, early drug preven-
tion programs for youths were largely aimed at providing information
ant! evoking fear (Polich et al., 1984~. The content of the message and
the time devotee! to the presentation of information varied greatly
across the programs, making it difficult to compare their relative
effectiveness. Yet general trends in the findings that have been pro-
duced indicate that knowledge alone floes not change drug-associatec!
behaviors, nor do messages with high threat content. School-basec!
programs that rely heavily on fear have not been successful, appar-
ently because the fear is associated with a Tow-probability event and
because there is a substantial time lag between risk-associated be-
havior and adverse outcome (Des JarIais and FYiedman, 1987~. The
assumption that teenagers would not use drugs if they were informed
about the inherent dangers of drug use clid not take into account the
social factors involved in initiating and sustaining drug-use behavior.
Ideally, health promotion messages should heighten an individ-
ual's perceptions of threat and his or her capacity to respond to that
threat, thus moclulating the level of fear. Job (1988) has proposed
five prescriptions for the role of fear in health education messages:
1. Messages containing elements of fear should be intro-
ducec! before discussing the desired behavior.
2. The behavior or event that is associated with the risk
should be perceived as real ant! likely to occur to the
audience targeted for that message.
3. A reasonable, desirable alternative behavior that pro-
tects against the undesired health problem should be
offered. Attention to short-term benefits is desirable
and can reinforce Tong-term behavioral change.
4. The level of fear invoked should be sufficient to cre-
ate awareness of a potential problem but not so high
as to evoke denial. Similarly, the fear level should be
low enough that it can be effectiveIv managed bv the
adoption of the desired behavior.
5. The resulting reduction in fear should be of such mag-
nitude that it will reinforce the desired behavior and
confirm its effectiveness.
~ ~7 ~
What is not yet known is how to introduce fear in the right way in
a particular message intended for a particular audience. Acquiring
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268 ~ LIMITING THE SPREAD OF HIV
that knowledge will require planned variations of AIDS education
programs that are carefully executed and then carefully evaluated.
The committee recommencIs that AIDS prevention mes-
sages strike a balance in the level of threat that is conveyed.
The level should be sufficiently high to motivate individuals to take
action. However, it should not be so high that it paralyzes individuals
with fear or causes them to deny their susceptibility. Fear-arousing
health promotion messages must also provide specific information on
steps that can be taken to protect the individual from the threat to
his or her well-being.
The Role of the Media
The media play an important role in informing individuals about and
alerting them to health risks. They can also help people develop rele-
vant protective social skills (e.g., how to resist peer pressure without
losing face, how to ask questions, how to receive information from
authority figures) and technical skills (e.g., how to use a condom,
how to sterilize a needled. In addition, the media influence and are
influenced by the norms of the community. This committee concurs
with the findings of the {OM/NAS AIDS committee (IOM/NAS,
1988) and the Presidential Commission on the Human Immunodefi-
ciency Virus Epidemic (1988~; both of these bodies found that the
gravity of HIV infection calls for an expanded use of the media in
educational activities.
Because of a lack of evaluation of AIDS media campaigns in
the United States, little can be said about their impact on risk-
associated behaviors. Yet there can be little doubt that the media
play important roles in transmitting factual information and in help-
ing to create a social climate conclusive to the successful change of
health-related conduct. An obvious example is the use of the mass
media in antismoking campaigns. Since 1973, adult per capita to-
bacco consumption has fallen every year; it is presently at its lowest
point in a century. There is general agreement that extensive, sus-
tained mass merlin health promotion programs played an important
role in this achievement (Flay, 1987~.2
2To date, evaluations have been conducted of 40 mass media campaigns that attempted
to influence smoking behavior through broadcast information on health risks posed by
cigarettes, printed information to promote smoking cessation (fact sheets, self-help man-
uals, and hot lines), and self-help clinics. At follow-up intervals ranging from 3 to 12
months, the following mean percentages of participants had continued success in quit-
ting smoking (the data are presented by type of cessation program): American Lung
Association cessation manual, 3-4 percent; American Lung Association manual and
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The media can arouse interest, transmit information, demon-
strate skills, and assist in the process of diffusing new ideas. In the
1987 National Health Interview Survey (Dawson et al., 1988), 82
percent of the sample reported getting information on AIDS from
television, 60 percent indicated that newspapers were an important
source of knowledge, 28 percent acquired information from maga-
zines, and ~ percent heard about AIDS on the radio. TV drug users
reported learning about AIDS from the media and from existing
communication networks within the drug-using community (O~ce
of Technology Assessment, 1988~. Media messages can influence the
ideas of individuals both directly and indirectly that is, through
their effects on opinion leaders and by legitimation of-the message.
To maximize media effects, the media should be linked to local public
health resources to ensure that appropriate messages are crafted for
the local targeted audiences and that well-designed evaluations of
media efforts are conclucted. Of course, the media are not meant to
replace one-on-one communication or face-to-face interactions that
permit the clarification of issues and answering of questions.
Limitations and conventions in print and broadcast journalism
constrain the extent to which media material can influence behavioral
change (Check, 1987~. For example, the media are not a scientific
institution; they have to popularize news topics to make them ap-
peal to a mainstream audience. Nevertheless, despite the somewhat
constrained role of the mass media, they have made significant con-
tributions to efforts to prevent the spread of HIV infection.
Theories of social learning (e.g., Banclura, 1977; N. M. Clark,
1987) and social modeling (e.g., Green and McATister, 1984) and
moclels of information processing suggest how people aclopt ideas
proffered by the media. Some learning occurs through observation
and imitation. There are certain attributes of the role models por-
trayed by the media that encourage imitation. These inclucle at-
tractiveness, perceived social competence, expertise, and trustwor-
thiness, qualities that are essential in changing attitudes, beliefs,
decision making, and behavior. After presenting a scenario that
includes these attributes, the learning process approaches comple-
tion when the individual perceives herself or himself to be similar to
(i.e., identifies with) these models. However, additional skills may
be needed in order to imitate the behaviors. The acquisition of these
skills may be a more graclual process, requiring specific (lemonstra-
tions and guidelines that are repeated (Green and McAlister, 1984~.
maintenance, 5-6 percent; media alone, 5 percent; media plus printed material, 8 per-
cent; media plus self-help clinics, 16 percent (Flay, 1987~.
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It is likely that sex education curricula will be expanded in
coming years, given the concerns about AIDS (Boyer et al., 1988~.
Large urban school districts in this country have already initiated
AIDS education programs, although current programs tend to be
short and nonspecific.- To successfully prevent risk-associated be-
havior, AIDS education programs must begin before the behavior
is initiated. Therefore, AIDS education should begin in elementary
school, and programs should take into account the cognitive differ-
ences of various age groups, differences that affect their ability to
understand HIV transmission. Similarly, community concerns about
the "appropriateness" of information need to be considered. AIDS
education programs can begin in elementary school; the focus of such
programs shouIcI be to allay excessive anxiety. In junior high school,
the topic of sexual transmission wouIcI be incluclecI in the curricu-
Jum. In high school, more information would be added, including
HIV transmission by homosexual and heterosexual behaviors, skills
training and decision making, and the effective use of contraceptive
methods (DiClemente et al., 1987~.
The committee supports school-based AIDS education efforts for
adolescents that encompass planned program variations and evalu-
ation to provide information on educating youths more effectively
about the risks posed by HIV infection. These programs need to in-
form both mate and female, and both homosexual and heterosexual,
adolescents.~4
Most intervention programs that try to prevent adolescent drug
use and pregnancy operate in the schools. An obvious and serious
limitation to school-based programs is their inability to reach those
adolescents who are not in school. For example, many drug users
drop out of school before they make the decision to inject drugs
(Des JarIais and Friedman, 1987~. It is important that prevention
efforts located in the schools begin at a sufficiently early age to
reach those at high risk for drug use, early sexual experimentation,
and cropping out of school. Other programs are needed to reach
beyond the schools to make contact with dropouts, runaways, and
unemployed aclolescents on the street and in the various institutions
that serve adolescent populations.
School-based clinics, a hotly debated major programmatic ef-
fort that has been implementec! in some communities, are another
approach to dealing with a range of health-relatecl problems in the
adolescent population, including unintended pregnancy, contracep-
tive use, ant] the prevention of HIV and other sexually transmit-
i4The IOM/NAS (1988) AIDS committee recommended the development of programs
to reach youth who were just becoming homosexually active.
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306 ~ LIMITING THE SPREAD OF HIV
te(1 infections (Brooks-Gunn and Furstenberg, in press). Typically,
other services are also provided, including physical examinations,
treatment for illness and injury, immunization, and drug and alcohol
programs. Most programs require parental consent, with blanket per-
mission for all health services offered. Test results and consultations
are confidential. Evaluations of school-based clinics are currently
being con(lucted, with promising results reported for some programs
(Edwards et al., 1980; Zabin et al., 1986~. Given the resistance ev-
idenced in some communities, however, it remains to be seen how
many school-based clinics will- be opened in the coming decade. The
committee believes that such clinics require the systematic evalua-
tion of planned variations to understand! in what settings and for
which individuals these programs can promote contraceptive use and
HIV prevention.
The committee recommends that sex education be avail-
able to both male and female students ant! that such educa-
tion include explicit information relevant to the prevention
of HIV infection. Comprehensive services for adolescents, both
those offered in the community and in the school context, should
include components that focus directly on the high-risk behaviors-
unprotected sex and {V drug use that are associated with the spread
of HIV infection.
In focusing its attention on the problems associated with pre-
venting HIV infection among aclolescents, the committee was not
able to acIdress AIDS prevention outside the context of sex educa-
tion and school-based clinics. Nevertheless, the committee recognizes
that the majority of school-based AIDS education takes place outside
these venues and that joint efforts involving the schools and commu-
nities may hold the greatest promise for preventing HIV infection,
other STDs, and unintended pregnancies (Vincent et al., 1987~. The
CDC Guidelines for Effective School Health Education to Prevent
the Spread of AIDS (CDC, l98Sb), as well as the Presiclential AIDS
Commission, the Institute of Medicine, and other national health
and education organizations, have recommended that AIDS educa-
tion be integrated within a planned and comprehensive school health
education program. Age-appropriate curricula that address HTV
prevention, sex education, and drug prevention education have been
proposer! for children in kindergarten through grade twelve. A com-
prehensive school program that is integrated into community efforts
is needed to prevent the unnecessary problems that result when cat-
egorical efforts are developed in isolation and without broader public
and administrative support. The committee finds health education
for children of all ages, especially as it relates to HIV prevention, to
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FACILITATING CHANGE ~ 307
be a very important issue and one that it hopes to address in detail
in future activities.
THE ROLE OF PLANNED VARIATIONS
AND EVALUATION
It was the committee's hope that those factors clearly associated with
altering sexual and drug-use behaviors could be identified by exam-
ining the evaluation data of well-designed programs. Unfortunately,
such data do not exist. There are self-reported data on relevant
behavioral change: some {V drug users report changes in neecIle-
sharing practices and increased sterilization of injection equipment,
while some homosexual men report less unprotected anal intercourse.
Yet little attention has been paid to understancling how and why
these changes have occurred or the extent to which they have been
instituted by different groups in different places.
Altering the course of the AIDS epidemic will depend on an iter-
ative process in which intervention programs are implemented, their
effects assessed, and a new and better set of intervention programs
designecl and implemented. Any intervention program is likely to
involve many aspects, each of which would require choosing from a
set of possible alternatives (there may be several choices available
among target groups and approaches to them, media, program ma-
terials, delivery modes, timing, and so forth). The "best" choice is
not always clear for at least some of these aspects. This fact poses
a strategic opportunity that should not be lost: progress in program
improvement can be much accelerated by deliberately using two or
more alternatives for some of the key choices. This strategy has
been referred to in this chapter as planned variation. The com-
mittee recommends that planned variations of key program
elements be systematically and actively incorporated into
the design of intervention programs at an early stage.
There are great advantages to conditions in which several acl-
missible variants can be tried out in parallel. First, some successful
combination is more likely to emerge if several promising variants are
used. Second, ideas that are actually inferior can be more promptly
identified and dropped. Third, ideas that are actually superior can
be more quickly recognized. Fourth, a broader understanding of
what works and why it works can build up a systematic base of
knowlecige. The principles of behavior discusser! in this chapter
form the basis for selecting the most promising program variations.
The committee recommencIs that the Public Health Service
OCR for page 308
308 ~ LIMITING THE SPREAD OF HIV
and others conducting or supporting intervention programs
ensure the implementation of planned variations in AIDS
messages, programs, and campaigns.
Careful evaluation is crucial to improving the nation's ability to
contain the spread of HIV infection. If the United States is to build
its capacity to intervene effectively to retard the spread of HIV, it
must learn from ongoing prevention programs. To learn from such
programs, they must be evaluated. The current situation does not
appear to reflect a misperception of the need for evaluation or a lack
of desire to conduct it. Rather, therefore insufficient resources to
conduct such work at the program implementation level. It may be
most helpful to begin marshaling and allocating evaluation resources
at the federal level. The next chapter discusses these and other issues
related to the evaluation of AIDS interventions.
In sum, learning new behaviors and breaking established pat-
terns of behavior that are known to be associated with risk will not
be simple, nor will complete change be achieved. What is important
to remember, though, is that people can change. It is also impor-
tant to note that many stereotypical notions about the behavior of
those at highest risk are not only incorrect but may slow the pros
cess of preventing further infection. Multiple strategies that repeat
a coherent message are necessary to initiate and support behavioral
change. Creating and sustaining behavioral changes in people have
many aspects: producing an awareness of threat and the motivation
to change while providing people with alternative ways of behaving;
involving the relevant community or communities in such efforts;
ant! creating economic, political, and social environments that sup-
port the new behaviors. Strategies that focus only on the in(livi~lual
must be supplemented with strategies that address those macro-level
conditions that cause or reinforce high-risk behavior.
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Representative terms from entire chapter:
hiv infection
