National Academies Press: OpenBook

AIDS, Sexual Behavior, and Intravenous Drug Use (1989)

Chapter: 4 Facilitating Change in Health Behaviors

« Previous: II Intervening to Limit the Spread of HIV Infection
Suggested Citation:"4 Facilitating Change in Health Behaviors." National Research Council. 1989. AIDS, Sexual Behavior, and Intravenous Drug Use. Washington, DC: The National Academies Press. doi: 10.17226/1195.
×
Page 259
Suggested Citation:"4 Facilitating Change in Health Behaviors." National Research Council. 1989. AIDS, Sexual Behavior, and Intravenous Drug Use. Washington, DC: The National Academies Press. doi: 10.17226/1195.
×
Page 260
Suggested Citation:"4 Facilitating Change in Health Behaviors." National Research Council. 1989. AIDS, Sexual Behavior, and Intravenous Drug Use. Washington, DC: The National Academies Press. doi: 10.17226/1195.
×
Page 261
Suggested Citation:"4 Facilitating Change in Health Behaviors." National Research Council. 1989. AIDS, Sexual Behavior, and Intravenous Drug Use. Washington, DC: The National Academies Press. doi: 10.17226/1195.
×
Page 262
Suggested Citation:"4 Facilitating Change in Health Behaviors." National Research Council. 1989. AIDS, Sexual Behavior, and Intravenous Drug Use. Washington, DC: The National Academies Press. doi: 10.17226/1195.
×
Page 263
Suggested Citation:"4 Facilitating Change in Health Behaviors." National Research Council. 1989. AIDS, Sexual Behavior, and Intravenous Drug Use. Washington, DC: The National Academies Press. doi: 10.17226/1195.
×
Page 264
Suggested Citation:"4 Facilitating Change in Health Behaviors." National Research Council. 1989. AIDS, Sexual Behavior, and Intravenous Drug Use. Washington, DC: The National Academies Press. doi: 10.17226/1195.
×
Page 265
Suggested Citation:"4 Facilitating Change in Health Behaviors." National Research Council. 1989. AIDS, Sexual Behavior, and Intravenous Drug Use. Washington, DC: The National Academies Press. doi: 10.17226/1195.
×
Page 266
Suggested Citation:"4 Facilitating Change in Health Behaviors." National Research Council. 1989. AIDS, Sexual Behavior, and Intravenous Drug Use. Washington, DC: The National Academies Press. doi: 10.17226/1195.
×
Page 267
Suggested Citation:"4 Facilitating Change in Health Behaviors." National Research Council. 1989. AIDS, Sexual Behavior, and Intravenous Drug Use. Washington, DC: The National Academies Press. doi: 10.17226/1195.
×
Page 268
Suggested Citation:"4 Facilitating Change in Health Behaviors." National Research Council. 1989. AIDS, Sexual Behavior, and Intravenous Drug Use. Washington, DC: The National Academies Press. doi: 10.17226/1195.
×
Page 269
Suggested Citation:"4 Facilitating Change in Health Behaviors." National Research Council. 1989. AIDS, Sexual Behavior, and Intravenous Drug Use. Washington, DC: The National Academies Press. doi: 10.17226/1195.
×
Page 270
Suggested Citation:"4 Facilitating Change in Health Behaviors." National Research Council. 1989. AIDS, Sexual Behavior, and Intravenous Drug Use. Washington, DC: The National Academies Press. doi: 10.17226/1195.
×
Page 271
Suggested Citation:"4 Facilitating Change in Health Behaviors." National Research Council. 1989. AIDS, Sexual Behavior, and Intravenous Drug Use. Washington, DC: The National Academies Press. doi: 10.17226/1195.
×
Page 272
Suggested Citation:"4 Facilitating Change in Health Behaviors." National Research Council. 1989. AIDS, Sexual Behavior, and Intravenous Drug Use. Washington, DC: The National Academies Press. doi: 10.17226/1195.
×
Page 273
Suggested Citation:"4 Facilitating Change in Health Behaviors." National Research Council. 1989. AIDS, Sexual Behavior, and Intravenous Drug Use. Washington, DC: The National Academies Press. doi: 10.17226/1195.
×
Page 274
Suggested Citation:"4 Facilitating Change in Health Behaviors." National Research Council. 1989. AIDS, Sexual Behavior, and Intravenous Drug Use. Washington, DC: The National Academies Press. doi: 10.17226/1195.
×
Page 275
Suggested Citation:"4 Facilitating Change in Health Behaviors." National Research Council. 1989. AIDS, Sexual Behavior, and Intravenous Drug Use. Washington, DC: The National Academies Press. doi: 10.17226/1195.
×
Page 276
Suggested Citation:"4 Facilitating Change in Health Behaviors." National Research Council. 1989. AIDS, Sexual Behavior, and Intravenous Drug Use. Washington, DC: The National Academies Press. doi: 10.17226/1195.
×
Page 277
Suggested Citation:"4 Facilitating Change in Health Behaviors." National Research Council. 1989. AIDS, Sexual Behavior, and Intravenous Drug Use. Washington, DC: The National Academies Press. doi: 10.17226/1195.
×
Page 278
Suggested Citation:"4 Facilitating Change in Health Behaviors." National Research Council. 1989. AIDS, Sexual Behavior, and Intravenous Drug Use. Washington, DC: The National Academies Press. doi: 10.17226/1195.
×
Page 279
Suggested Citation:"4 Facilitating Change in Health Behaviors." National Research Council. 1989. AIDS, Sexual Behavior, and Intravenous Drug Use. Washington, DC: The National Academies Press. doi: 10.17226/1195.
×
Page 280
Suggested Citation:"4 Facilitating Change in Health Behaviors." National Research Council. 1989. AIDS, Sexual Behavior, and Intravenous Drug Use. Washington, DC: The National Academies Press. doi: 10.17226/1195.
×
Page 281
Suggested Citation:"4 Facilitating Change in Health Behaviors." National Research Council. 1989. AIDS, Sexual Behavior, and Intravenous Drug Use. Washington, DC: The National Academies Press. doi: 10.17226/1195.
×
Page 282
Suggested Citation:"4 Facilitating Change in Health Behaviors." National Research Council. 1989. AIDS, Sexual Behavior, and Intravenous Drug Use. Washington, DC: The National Academies Press. doi: 10.17226/1195.
×
Page 283
Suggested Citation:"4 Facilitating Change in Health Behaviors." National Research Council. 1989. AIDS, Sexual Behavior, and Intravenous Drug Use. Washington, DC: The National Academies Press. doi: 10.17226/1195.
×
Page 284
Suggested Citation:"4 Facilitating Change in Health Behaviors." National Research Council. 1989. AIDS, Sexual Behavior, and Intravenous Drug Use. Washington, DC: The National Academies Press. doi: 10.17226/1195.
×
Page 285
Suggested Citation:"4 Facilitating Change in Health Behaviors." National Research Council. 1989. AIDS, Sexual Behavior, and Intravenous Drug Use. Washington, DC: The National Academies Press. doi: 10.17226/1195.
×
Page 286
Suggested Citation:"4 Facilitating Change in Health Behaviors." National Research Council. 1989. AIDS, Sexual Behavior, and Intravenous Drug Use. Washington, DC: The National Academies Press. doi: 10.17226/1195.
×
Page 287
Suggested Citation:"4 Facilitating Change in Health Behaviors." National Research Council. 1989. AIDS, Sexual Behavior, and Intravenous Drug Use. Washington, DC: The National Academies Press. doi: 10.17226/1195.
×
Page 288
Suggested Citation:"4 Facilitating Change in Health Behaviors." National Research Council. 1989. AIDS, Sexual Behavior, and Intravenous Drug Use. Washington, DC: The National Academies Press. doi: 10.17226/1195.
×
Page 289
Suggested Citation:"4 Facilitating Change in Health Behaviors." National Research Council. 1989. AIDS, Sexual Behavior, and Intravenous Drug Use. Washington, DC: The National Academies Press. doi: 10.17226/1195.
×
Page 290
Suggested Citation:"4 Facilitating Change in Health Behaviors." National Research Council. 1989. AIDS, Sexual Behavior, and Intravenous Drug Use. Washington, DC: The National Academies Press. doi: 10.17226/1195.
×
Page 291
Suggested Citation:"4 Facilitating Change in Health Behaviors." National Research Council. 1989. AIDS, Sexual Behavior, and Intravenous Drug Use. Washington, DC: The National Academies Press. doi: 10.17226/1195.
×
Page 292
Suggested Citation:"4 Facilitating Change in Health Behaviors." National Research Council. 1989. AIDS, Sexual Behavior, and Intravenous Drug Use. Washington, DC: The National Academies Press. doi: 10.17226/1195.
×
Page 293
Suggested Citation:"4 Facilitating Change in Health Behaviors." National Research Council. 1989. AIDS, Sexual Behavior, and Intravenous Drug Use. Washington, DC: The National Academies Press. doi: 10.17226/1195.
×
Page 294
Suggested Citation:"4 Facilitating Change in Health Behaviors." National Research Council. 1989. AIDS, Sexual Behavior, and Intravenous Drug Use. Washington, DC: The National Academies Press. doi: 10.17226/1195.
×
Page 295
Suggested Citation:"4 Facilitating Change in Health Behaviors." National Research Council. 1989. AIDS, Sexual Behavior, and Intravenous Drug Use. Washington, DC: The National Academies Press. doi: 10.17226/1195.
×
Page 296
Suggested Citation:"4 Facilitating Change in Health Behaviors." National Research Council. 1989. AIDS, Sexual Behavior, and Intravenous Drug Use. Washington, DC: The National Academies Press. doi: 10.17226/1195.
×
Page 297
Suggested Citation:"4 Facilitating Change in Health Behaviors." National Research Council. 1989. AIDS, Sexual Behavior, and Intravenous Drug Use. Washington, DC: The National Academies Press. doi: 10.17226/1195.
×
Page 298
Suggested Citation:"4 Facilitating Change in Health Behaviors." National Research Council. 1989. AIDS, Sexual Behavior, and Intravenous Drug Use. Washington, DC: The National Academies Press. doi: 10.17226/1195.
×
Page 299
Suggested Citation:"4 Facilitating Change in Health Behaviors." National Research Council. 1989. AIDS, Sexual Behavior, and Intravenous Drug Use. Washington, DC: The National Academies Press. doi: 10.17226/1195.
×
Page 300
Suggested Citation:"4 Facilitating Change in Health Behaviors." National Research Council. 1989. AIDS, Sexual Behavior, and Intravenous Drug Use. Washington, DC: The National Academies Press. doi: 10.17226/1195.
×
Page 301
Suggested Citation:"4 Facilitating Change in Health Behaviors." National Research Council. 1989. AIDS, Sexual Behavior, and Intravenous Drug Use. Washington, DC: The National Academies Press. doi: 10.17226/1195.
×
Page 302
Suggested Citation:"4 Facilitating Change in Health Behaviors." National Research Council. 1989. AIDS, Sexual Behavior, and Intravenous Drug Use. Washington, DC: The National Academies Press. doi: 10.17226/1195.
×
Page 303
Suggested Citation:"4 Facilitating Change in Health Behaviors." National Research Council. 1989. AIDS, Sexual Behavior, and Intravenous Drug Use. Washington, DC: The National Academies Press. doi: 10.17226/1195.
×
Page 304
Suggested Citation:"4 Facilitating Change in Health Behaviors." National Research Council. 1989. AIDS, Sexual Behavior, and Intravenous Drug Use. Washington, DC: The National Academies Press. doi: 10.17226/1195.
×
Page 305
Suggested Citation:"4 Facilitating Change in Health Behaviors." National Research Council. 1989. AIDS, Sexual Behavior, and Intravenous Drug Use. Washington, DC: The National Academies Press. doi: 10.17226/1195.
×
Page 306
Suggested Citation:"4 Facilitating Change in Health Behaviors." National Research Council. 1989. AIDS, Sexual Behavior, and Intravenous Drug Use. Washington, DC: The National Academies Press. doi: 10.17226/1195.
×
Page 307
Suggested Citation:"4 Facilitating Change in Health Behaviors." National Research Council. 1989. AIDS, Sexual Behavior, and Intravenous Drug Use. Washington, DC: The National Academies Press. doi: 10.17226/1195.
×
Page 308
Suggested Citation:"4 Facilitating Change in Health Behaviors." National Research Council. 1989. AIDS, Sexual Behavior, and Intravenous Drug Use. Washington, DC: The National Academies Press. doi: 10.17226/1195.
×
Page 309
Suggested Citation:"4 Facilitating Change in Health Behaviors." National Research Council. 1989. AIDS, Sexual Behavior, and Intravenous Drug Use. Washington, DC: The National Academies Press. doi: 10.17226/1195.
×
Page 310
Suggested Citation:"4 Facilitating Change in Health Behaviors." National Research Council. 1989. AIDS, Sexual Behavior, and Intravenous Drug Use. Washington, DC: The National Academies Press. doi: 10.17226/1195.
×
Page 311
Suggested Citation:"4 Facilitating Change in Health Behaviors." National Research Council. 1989. AIDS, Sexual Behavior, and Intravenous Drug Use. Washington, DC: The National Academies Press. doi: 10.17226/1195.
×
Page 312
Suggested Citation:"4 Facilitating Change in Health Behaviors." National Research Council. 1989. AIDS, Sexual Behavior, and Intravenous Drug Use. Washington, DC: The National Academies Press. doi: 10.17226/1195.
×
Page 313
Suggested Citation:"4 Facilitating Change in Health Behaviors." National Research Council. 1989. AIDS, Sexual Behavior, and Intravenous Drug Use. Washington, DC: The National Academies Press. doi: 10.17226/1195.
×
Page 314
Suggested Citation:"4 Facilitating Change in Health Behaviors." National Research Council. 1989. AIDS, Sexual Behavior, and Intravenous Drug Use. Washington, DC: The National Academies Press. doi: 10.17226/1195.
×
Page 315

Below is the uncorrected machine-read text of this chapter, intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text of each book. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

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

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.

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

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

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

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 . . . . . . . . .

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

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

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

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

FACILITATING CHANGE | 269 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~.

270 ~ LIMITING THE SPREAD OF HIV The individual goes through a series of psychological processes that range from being exposed to information, paying attention to it, comprehending the message, developing beliefs, making decisions, repeating and learning from the process of developing beliefs and making (recisions, and, finally, acting. Most media campaigns fo- cus on information transmission rather than on decision making or action. Several other social learning principles must be considered in crafting media material to effect behavioral change. Because belief is influenced by the perceived trustworthiness of the source of informa- tion, source credibility is particularly important when the ideas being presented are new or controversial (Green and McATister, 1984~. De- cisions to act can be influenced by displays of incentives, by the values attached to proposed actions, and by messages that enhance self-confidence. At the community level, program goals are more likely to be adopted if their presentation is preceded by messages that arouse awareness and interest among members of that com- munity. Again, experimentation will be necessary to find the best strategies for implementing these theories. Social marketing (the application of marketing techniques to so- cial problems) provides tools3 that will influence the acceptability of new ideas and products. An ideal strategy would be one that develops the right product, uses the right promotions strategy, puts the product in the right place for the right audience, and makes it available at the right price (Kotler and Zaltman, 1971~. Sev- eral community-based programs, including the San Fiancisco AIDS Foundation program, have used such approaches for AIDS preven- tion campaigns. In the San Ffancisco case, an advertising agency was hired to conduct focus groups and prepare newspaper adver- tisements promoting safer sex among gay men. The themes stressed by the agency were the electiveness of safer sex practices, individ- ual and community responsibility for appropriate action, and the recent changes in the community's norms and values to support safer sex. One poster promoted condom use: a photograph of a condom, watch, and pocket change was accompanied by the message, "It takes nine cents and twenty seconds to save a life" (Communication Technologies, 1987:Appendix C). At the same time, condoms were being promoted and distributed at gay events, workshops on safer sex, bars, and checkout counters at gay department stores (Pappas, 3For example, condoms packaged for women and available in stores on the same shelves as feminine hygiene products.

FACILITATING CHANGE ~ 271 1987~. Questions remain, however, about the effectiveness of so- cial marketing tools in solving problems of health promotion; many studies have used them in combination with other intervention tech- niques, and there have been few careful studies that have been able to isolate the effects of social marketing techniques on individual health behavior. The TOM/NAS AIDS committee recommended "continued at- tention to the development of policies to foster the use of condoms" (IOM/NAS, 1988:8~. Unquestionably a highly desirable outcome, in- creasing the acceptability of condoms in this country is nevertheless an objective that offers some interesting marketing problems. Poli- cies regarding conclom advertisements vary. As discussed in Chap- ter 7, television executives have been reluctant to air condom ad- vertisements, although public health announcements that include information about condoms have been accepted and aired. The net- works say they are afraid their audiences will be offended by such commercial presentations. Yet there is an apparent lack of consis- tency in this concern for viewers' sensibilities, as ads for feminine hygiene products have been accepted, and several popular television series have included fairly explicit sexual scenes. Moreover, public opinion polls do not indicate that the public would be more offender! by condom ads than they are by other advertisements. The broadcast media are an important too] that should be mo- bilized (to the extent that it is reasonable ant! feasible) to assist in preventing the further spread of HIV infection. With their unparal- leled capacity to reach and influence individuals, the media should be encouraged and helped in whatever ways are necessary to play their unique, vital role in halting this epidemic. The committee recommends that television networks present more public service messages on those behaviors associated with HIV transmission ant} practical measures for interrupting the spreac! of infection. The committee also recommences that television networks accept condom adver- tisements. Risk Perception For an inclividual to be motivates! to take action against AIDS (or any other clisease), the disease must be perceived as a personal risk with serious consequences (Rosenstock, 1960; Janz ant! Becker, 1984~. A person who does not believe that the disease in question is serious or

272 ~ LIMITING THE SPREAD OF HIV that he or she couch contract it is unlikely to undertake preventive action. There is a large body of information on risk perception and risk analysis that could be brought to bear on the design and implementa- tion of AIDS information and education campaigns.4 How statements of risk are interpreted clepencis on an individual's perceptions of the value associated with avoiding the health problem in question, the quality of information about intervention strategies, and the avail- able incentives and preferences for action (Lave, 1987~. Programs that do not attend to variations in risk perception are less likely to be successful in motivating individuals to act. Researchers have seen an association between knowledge about AIDS and perceived risk (DiClemente et al., 1988~. Thus, the aware- ness of HIV infection in a local {V drug-using population may increase the perception of risk among drug users and therefore the likeli- hood of appropriate action. However, it should be noted that very high rates of local infection could reinforce the notion that a single episode of sharing would inevitably lead to infection. An individual who strongly suspects that he or she is already infected may be less willing to undertake difficult changes in behavior. Such a fatalistic perspective could undermine behavioral modification efforts. The subjective assessment of personal risk levels does not al- ways correlate with more objective assessments. A 1983 survey of homosexual men from the San Francisco area recruited subjects from bathhouses (before they were closed) and bars, and through adver- tisements and professional organizations (McKusick et al., 1985~. The bathhouse and bar groups had a very high level of awareness of AIDS, and there was extensive knowledge of risk factors reported throughout this sample; these groups also reported the highest rates of sexually transmitted diseases and bad more evidence of HIV in- fection than clid other groups. Yet despite their knowledge of risk factors, many respondents continued anonymous sexual contacts and other high-risk sexual behavior. Tncleed, 65 percent of those in the bathhouse group saicT they hacT already made all the changes in their lives necessary to adapt to the threat of AIDS, and half believed they were less susceptible to AIDS than were (unspecified) others. Empirical studies of other health problems confirm the notion that people tend to report themselves to be less at risk than their peers for a variety of threats (Weinstein, 1987~. 4For more information, see the forthcoming National Academy of Sciences report, Im- proving Risk Communication, which summarizes the complex literature and research experience in risk perception and risk management.

FACILITATING CHANGE ~ 273 It appears that people estimate future risk by extrapolating from past events in their life (Weinstein., 19873. Under this system, if a problem has not yet occurred, it is unlikely to be a future threat. This optimistic bias (the notion that "it can't happen to me" ~ is par- ticularly strong in adolescence, as illustrated by teenagers' responses to learning that they are pregnant (Brooks-Gunn and Furstenberg, in press). However, adults are also unrealistically positive in their assessment of future risk. There are several possible reasons for such optimistic outlooks. One is denial (in the case of serious risk). For example, 45 percent of heterosexual men and 65 percent of heterosexual women from a national sample who reported nine or more sexual partners in the past year inclicated that they had never purchased condoms. Almost 60 percent rated their personal risk of contracting AIDS at the lowest possible level of the interview's risk scale (Turner et al., in press). Other possible reasons for unrealistically optimistic assessments of risk are the enhancement of self-esteem or the avoidance of embar- rassment or stigma (in the case of a preventable risk). For instance, it may be so difficult for men who engage in same-gender sex to recognize it as gay or homosexual behavior that they deny the HIV- associated risks. In adclition, cognitive error (for low-frequency risk) or lack of experience among adolescents and immature adults may ac- count for unfounded optimism about risks. Many adolescent females underestimate the risk of pregnancy; presumably, they would also underestimate the likelihood of contracting a disease such as AIDS. For these reasons, and the others noted above, the committee rec- ommencIs that programs to initiate and sustain changes in risk-associatec! behavior take into account how the targeted population perceives anct understancIs risk. Adoption and Diffusion of Innovations Empirical applications of the concepts of adoption and diffusion of innovations have identified certain factors that influence the likeli- hood that inclivicluals will accept new ideas, technologies, products, recommended practices, and other innovations. These factors include inclivicluals' characteristics (e.g., membership in communication net- works, the influence of opinion leaders), the characteristics of the innovation itself, and the social climate into which the innovation is to be introduced (Rogers, 1962~. The planned introduction of a new idea, program, or policy (i.e., an innovation) must take these factors into account prior to communicating or spreading (i.e., the process

274 ~ LIMITING THE SPREAD OF HIV of diffusion) the innovation to members of a social system over time (Rogers and Adhikarya, 1980~. Some new tools ant! ideas are more likely than others to be ac- ceptable to particular groups. If alternative approaches are available, the one that is most consistent with ongoing, accepted practices in a group should be emphasized. If no alternatives exist, steps should be taken to modify any negative perceptions of the proposed strategy on the parts of opinion leaders and the target audience. Organiza- tional and social impediments to adoption should be identified and removed, whenever possible. To facilitate the adoption of innova- tions, adequate funding, staff, and expertise should be proviclecT, and representatives from the broad spectrum of the groups that make up the target population should be encouraged to participate in the design and implementation of the program. The literature on the characteristics of adopters emphasizes the critical role of "opinion leaders." These are individuals who occupy central positions in communication networks and are recognized as expert (having knowledge and experience) and trustworthy in areas that are relevant to the particular innovation in question. In general, they tend to be younger and better educated than their peers; they tend to be more "cosmopolitan" (i.e., they regularly Took beyond their local interests and groups to learn what is new, they react more magazines and newspapers, etc.~; and they are often consulted for advice about new things. Finally, they are usually among the first individuals to try the innovation and thus are in a unique position either to recommend or discourage its further diffusion among their friends ant! colleagues (Becker, 1970~. Rogers (1962) finds that in assessing an intervention, individuals are more likely to take into account the opinion of those of their peers who have already adopted it than they are to accept the research findings of experts. Peers serve as models of behavior that can be imitated by others from the same social network. Diffusion can be viewed as a multistep process new information influences opinion leaders, who then go on to influence others who, in turn, influence still others, and so forth. Consequently, it may be important to identify opinion leaders an] concentrate on them the available resources for change.5 A more (lynamic process suggests that individuals are affects] directly (e.g., by the mass medial an] 50pinion leaders can be identified with sociometric techniques for example, asking a sample Of individuals from the group to be influenced to name two or three persons to whom they would turn for advice and information about the relevant innovation.

FACILITATING CHANGE ~ 275 by opinion leaders at the same time. This model wouIc! require ad- dressing both the external sources of messages as well as the opinion leaders. There are at least two approaches that individuals who intro- duced new concepts and products (so-callecl change agents) can em- ploy to increase the likelihood of an innovation's adoption: (1) use resources that will actually improve the innovation or (2) use per- suasion that will change the perceptions of it (Becker, 1970~. In a number of instances, successful campaigns in the past have changer! both the physical characteristics and the perceptions of interventions. For example, alarming increases in gonorrhea rates in Sweden led to a massive multifaceted campaign to promote condom use. Informa- tion and statistics on the disease were provided to the general public in a comprehensible manner while posters, brochures, and T-shirts hailed the arrival of new styles of condoms in bright colors and attrac- tive containers. Condom sales subsequently increased by more than 2 million in two years, and gonorrhea rates clecTined precipitously in Sweden at the same time they were increasing in other European countries. Consumer attitudes about condoms moved rapidly toward more acceptability among a variety of consumers, including young people and women (Ajax, 1974; Darrow, 1987; Potts, no (late). The failure to act to prevent the acquisition or spread of HIV infection cannot be blamed exclusively on individuals. Communica- tion problems, cultural ant! religious barriers, poor access to health resources and prevention services, community-level embarrassment, apathy, and misunderstanding have all contributed to the spread of HIV infection among some groups, especially minorities.6 The tragic increase in the prevalence of infection within minority groups illus- trates some of the problems that are associates! with the introduc- tion, acceptance, and use of new concepts and techniques to prevent disease. The design ant! implementation of successful programs to facilitate behavioral change shouic! take into account existing organi- zations in minority communities and prevailing social environments. Finally, those who promote change should become aware of the organizational and social environments that might impede the adop- tion and diffusion of icleas or practices (Greer, 1977~. For example, it may be necessary to provide existing organizations with increased resources (money, staff, or expertise) or to create new organizations. At the community level, it may be important to involve a wide va- riety of interest groups in the persuasive efforts to achieve a broad 6 See S. G. Boodman, "Hispanic Culture Redefines AIDS Fight: Communication Prob- lems, Moral Traditions Hinder Efforts," The Washington Post, December 28, 1987:A1.

276 ~ LIMITING THE SPREAD OF HIV base of acceptance for a new practice. Various types of people may be needed: those who are different from the community may be helpful in teaching (being perceived as competent); those who are like the community may be better at persuading (being perceived as trustworthy) or serving as models for new behaviors (being perceived as alike). The committee-recommends that innovative approaches to AIDS prevention programs be introclucec} in a planned manner that reflects wel];-established principles about the adoption ant} diffusion of new ideas. Specifically, (1) opinion leaders of target populations should be identified and incorporated into the flow of influence to maximize credibility and persuasiveness in the target audience; (2) a new program should be carefully as- sessed prior to implementation for characteristics that might impede its acceptance, and steps should be taken to alter those characteris- tics; and (3) strategies for change should be designed to reflect the organizational and social environments into which the new program is to be incorporated. MOTIVATING AND SUSTAINING BEHAVIORAL CHANGE Once the attention of a targeted audience has been captured through appropriate messages, there remains the task of getting people to act. Social and behavioral science research offers some guidance: . To begin behavioral change, people must be motivated; they must also believe that the changes being proposer! will do some good, and they must believe that they have a reasonable chance of successfully accomplishing those changes. Moreover, the proposed changes should be consistent with the in(livi~luaT's existing beliefs and values. . People often need assistance and support to change un- healthy behaviors, and many will not be completely successful in adhering to new behavior patterns. . It is often easier to get people to modify a behavior than to eliminate it. · Incremental changes and modifications, rather than global life-style changes, are more realistic goals for most people.

FACILITATING CHANGE ~ 277 · Offering choices among alternative behaviors for change is often more effective than rigidly prescribing a single behavior. People at risk for AIDS are less likely to attempt a complete al- teration of their behavior than they are to adopt protective measures that allow them to pursue their Tong-standing goals and interests in life. Thus, for many, conforms will be more acceptable than absti- nence; for some IV drug users, the sterilization of injection equipment may be more acceptable than detoxification or methadone treatment. Although "heroic" efforts to achieve raclical changes in behavior are appearing and provide dramatic stories, the reality is that, for most people, attempts to achieve major life-style or global changes will probably fail. Thus, for many individuals, strategies that seek to modify behav- ior rather than to achieve global behavioral change are more likely to succeed. Examples abound to support this point; to take just two: gout sufferers will more readily take a daily pill of allopurinol than adopt draconian diets, and some {V drug users will mollify their injection behavior rather than attempt to give up drugs en- tirely. Furthermore, successful modification of behavior will not be achieved through one treatment or by one exposure to an interven- tion program. Significant Tong-term behavioral change will require continuous support as new behaviors evolve over time. Thus, the committee recommencis that programs to facilitate behav- ioral change be approached as long-term efforts, with multi- ple ant! repeated strategies to initiate and sustain behavioral change over time. In the sections that follow, the committee reviews some of the factors that motivate behavioral change to reduce the risk of HIV infection, inclucling perceived self-efficacy, altruistic motives, and knowledge of antibody status. Because HIV infection is a fatal threat for which there is no biomedical "magic bullet," it will be necessary to maintain behavioral changes for an indefinite period, perhaps for a lifetime. Therefore, the committee also considers the problems asso- ciatec3 with sustaining behavioral change and assesses the adequacy of the change that has occurred to date. Self-Efflcacy People who consciously change their behavior and maintain such change must believe that (1) a particular behavior will result in a

278 ~ LIMITING THE SPREAD OF HIV desired outcome (i.e., outcome expectations), and (2) they are capa- ble of executing that behavior (i.e., efficacy expectations) (Bandura, 1977; Strecher et al., 1986~. Perceived ability is not necessarily con- gruent with actual past performance. Rather, it is the perception of one's abilities or self-efficacy that is important in an individual's assessment of whether or not she or he can execute specific behaviors in specific situations. This means that expectations of one's capa- bility or self-efficacy are variable and can be molded. The concept of self-efficacy has been used in programs to stimulate new health behaviors (e.g., initiate contraceptive use), inhibit existing behaviors (e.g., stop cigarette smoking), and disinhibit behaviors (e.g., resume sex after a heart attack) (Strecher et al., 1986~. Programs that focus on self-efficacy help individuals change their behavior by building their sense of competency and by teaching them the necessary skills. Strategies based on self-efficacy were originally designed to pre- vent the use of tobacco and have been adapted to drug-use preven- tion; they are now being applied to AIDS education efforts. Effec- tive smoking prevention programs have been designed around the principles of a social influence model that identifies messages and arguments in favor of smoking from peers, adults, and the media, and teaches teenagers how to counter those messages (Polich et al., 1984~. The intent of these programs is twofold: (1) to raise the level of general social skills (including expression, conversation, and assertiveness) and specific social skills related to the target behav- iors, and (2) to promote self-efficacy. Teaching skills to resist both subtle and explicit pressures to smoke from peers and the media has been shown to delay the onset of smoking among junior high school students and thus reduce the number of smokers by 30 to 60 percent (Durell and Bukoski, 1984; Polich et al., 1984~. Program activities have been led by classroom teachers and trained peers; the curricula presented by peers appear to have more impact on smoking behavior (Battjes, 1985~. There is differential success reported among younger adolescents who have not yet begun to smoke or who are only ex- perimenting with tobacco (Battjes, 1985~. More research is needed to understand the program's effects on different groups, especially minority adolescents. The use of condoms will also depend on an individual's sense of empowerment whether that person perceives himself or herself as capable of making the necessary behavioral changes to reduce risk. Notions of capability affect whether people will consider changing behaviors, what actions they choose, how much effort they apply to a situation, how long they persevere, how well change is maintained,

FACILITATING CHANGE ~ 279 and the amount of discomfort associated with making a behavioral change. Expectations of self-efficacy vary with three aspects of an indiviclual's self-perception: magnitude, strength, and generality. Magnitude refers to how capable a person believes himself or herself to be: if expectations are Tow, he or she will attempt only simple tasks. Strength refers to an inctividuaT's perception of the probability of successfully completing a task. Generality refers to taking a sense of efficacy from one task to others (Strecher et al., 1986~. The repe- tition of clifficult behaviors that are found to be protective enhances perceptions of self-efficacy and reduces defensive behavior. If percep- tions of self-efficacy are deficient, situations may not be managed in accordance with what the indiviclual knows to be effective. Empirical studies of homosexual men and {V drug users have found that higher levels of self-efficacy contributed to reducing high- risk behavior and increasing activity associates! with Tower levels of risk (Catania et al., 1988~. In a study of homosexual men, self- efficacy was found to be the variable most powerfully associated with level of risk activity (McKusick et al., 1987~. Other studies support the importance of self-efficacy in the adoption of safer sex behaviors (Joseph et al., 1987b). Among {V drug users recruited through detoxification treatment centers, self-efficacy was also associated with increased condom use (Catania et al., 1988~. Altruism Not all behavior reflects self-interest: altruism prevails in more sit- uations than is generally recognized. People have a strong tendency to identify with "their" group and to behave for its benefit; thus, the altruism displayed by those who reduce or eliminate high-risk behaviors is quite unclerstandable. Studies of diverse groups of gay men (Coates et al., l98Sa) have shown that those who are seropos- itive take more precautions against spreading the virus than those who are seronegative (who presumably are protecting themselves). Similar altruism has been demonstrated among {V drug users: some of the behavioral changes among {V drug users have been made to protect sexual partners and trusted needIe-sharing partners (Des Jariais, 1987~. HIV Antibody Testing There are important indiviclual and societal benefits to be derived from making voluntary HIV testing and counseling available on (le- mand to all who wish to know their antibody status. For example,

280 ~ LIMITING THE SPREAD OF HIV people who know their serologic status have been able to change some risk-associated behaviors; in addition, the knowledge of seropositiv- ity can lead to early recognition and treatment of life-threatening infections. Before the availability of any treatment for HIV infection, individuals concerned about the stigma and discrimination associ- atecT with antibody testing argued that the risks associated with testing outweighed the benefits. Now, however, with the possibil- ity that AZT (zidovudine) may be used for the treatment of early stages of HIV infection, testing, in conjunction with counseling and treatment for both HIV and opportunistic infections, can provide real benefits to infected individuals. Moreover, if voluntary antibody testing is not provided through alternative test sites to all who seek it, some individuals may feel compelled to use the blood-banking system as a testing venue, thus increasing the risk of contaminating the blood supply. HIV antibody testing has been found to be valuable in chang- ing some risk-associatecl behaviors in specific populations. More is known about the effects of testing among homosexual and bisexual men than about its effects among IV drug users, adolescents, or women at high risk of HIV infection. In general, studies have found positive behavioral effects associated with antibody testing among homosexual men in the United States, Canada, and Europe (Farthing et al., 1987; Fox et al., 1987b; Go~frie(1 et al., 1987; Willoughby et al., 1987; Coates et al., l98Sa; McCusker et al., 1988~. Yet there are other studies that have not found an association between knowing a positive test result ant! reducing risk-associated behavior (Doll et al., 1987; Pesce et al., 1987; Soucy, 1987~. In two studies, homosex- ual men who learned that they were seropositive were more likely to eliminate or decrease unprotected insertive anal intercourse than either seronegative men or seropositive men who did not know their antibody status (Fox et al., 1987b; McCusker et al., 1988~; however, in one study (McCusker et al., 1988), an awareness of test results was not associated with a decrease in unprotected receptive anal intercourse. Studies of the effects of testing on the behavior of ho- mosexual men (Fox et al., 1987a; McCusker et al., 1988) have been confouncled by the fact that seropositive men reported higher initial levels of most risk-associated behaviors at the outset of the study than did seronegative men, thus leaving more room for change. Of the limited number of studies in this country that have looked at the effects of HIV antibody testing on the behavior of {V drug users, all have shown consistent findings of reduced risk-taking be- havior following testing anti counseling (Casa(lonte et al., 1986, 1988;

FACILITATING CHANGE ~ 281 Cox et al., 1986~. {V drug users who were found to be seropositive reported more risk reduction than those who were seronegative. In acicTition, more change was seen in relation to the reduction or elim- ination of injection or to the sharing of injection equipment than was seen in sexual behavior. Some of the moves to more responsi- ble behavior came at considerable cost, including the dissolution of previously stable intimate relationships (Des JarIais, 1987~. Psychiatric morbidity associated with HIV testing has been a continuing issue of concern. Unfortunately, the limited studies that have been conducted report divergent findings. In one small study of 15 seropositive {V drug users recruited from methadone clinics in New York City, learning of a positive antibody status was not associated with serious psychological sequelIae (Casadonte et al., 1988~. A separate study of 66 pregnant women from the New York City area (Cancellieri et al., 1988) compared 25 seropositive drug users with 41 seronegative drug users. The study found increased feelings of guilt regarding the health of the unborn child in the seropositive women, together with anxiety when clrug-related symptoms were confused with HIV-related symptoms. Notification of test results was associated with the increased use of crack in both seropositive and seronegative women, which in turn led to paranoid psychotic episodes along with suicidal or homicidal behavior. Other studies illuminate additional problems associated with antibody testing. In one large survey of homosexual men (Lyter et al., 1987), the anticipation of psychological difficulties in dealing with a positive test result was the most common reason for refusing to learn about test results among those who had volunteered for HTV screening and had undergone extensive pretest counseling. Those who declined to be informed of their results were more likely to be young, nonwhite, and less educates! then those who agreed to know their results. In another study, seropositive men were more likely than seronegative men to report a break-up of their primary relationships (Coates et al., 1987~. Finally, a study of suicides in New York found alarmingly high rates among men with AIDS.7 Marzuk and colleagues (1988) found that men aged 20-59 with AIDS were 36 times more likely to commit suicide than men in the same age group who were not diagnosecl with AIDS. Despite the fact that public health officials recommend testing to encourage and support behavioral change, both this committee and the IOM/NAS AIDS committee find that further studies are 7Because the suicides documented among these men were obvious and for the most part violent, these rates are thought to underestimate the true level.

282 ~ LIMITING THE SPREAD OF HIV necessary to assess the impact of testing on behavioral change and psychiatric morbiclity, inclucling suicide. Research is needed to deter- mine why change occurs and how it is sustained in some individuals but not in others. Moreover, more knowledge is needed about how individuals in various at-risk groups decide whether to be tested. Part of the process surely includes weighing the risks of discrimina- tion (including the Toss of housing and insurance benefits) and the psychological distress associated with testing against its benefits. It is to be hoped that ciata from the CDC community demonstration and AIDS prevention projects noted earlier in this chapter will help fill these and other gaps in knowledge. New studies of the impact of serologic testing on risk-associated behavior will have to take into account the potential effects of di~er- ential participation in testing programs. On the one hand, in~lividu- als who are more concerned about their health may be more likely to seek testing and counseling for HIV infection or to undergo diagnostic evaluations more frequently than those who are less concerned about their health. On the other hand, individuals who know or suspect they are infected may be less likely to seek testing. Data from a serologic testing program (conducted in an STD clinics showed that seropositive inclividuals were more likely than seronegative persons to decline testing (Hull et al., 1988~. Clearly, it will be important to ascertain the extent and direction of self-selection bias in future studies. In no case, however, will testing be a panacea to prevent the spread of HIV infection, and it should not be the centerpiece of a health education program. Motivating, directing, and sustaining behavioral change should involve multiple strategies, with antibody testing as but one of the available means to achieve these goals. In addition, the problems that attend! the whole issue of antibody testing must be addressed. Institutional support, including the pro- vision of counseling and the guarantee of confidentiality, is needed to maximize the effectiveness of testing. Legal protection against discrimination and guarantees of humane treatment will also need to be put in place at the federal level. At present, however, from a pub kc health perspective, it is indefensible not to have testing available for those indivicluals who believe it will benefit their capacity to al- ter risk-associated behaviors. The committee recommends that anonymous HIV antibody testing with appropriate pre- and posttest counseling be made available on a voluntary basis for anyone desiring it. This recommendation concurs with that of the IOM/NAS AIDS committee (IOM/NAS, 1988~.

FACILITATING CHANGE ~ 283 Sustaining Behavioral Change Even when clesired change has occurred, there remains the problem of sustaining the changed behaviors over time. Considerable variation occurs in the length of time behavioral change will persist. High relapse rates have been reported in studies of a variety of health behaviors, although a critical review of experimental studies and their methodologies indicates that the problem of relapse has sometimes been overstated (Green et al., 1986~. For chronic health threats (e.g., HIV infection), a lifelong adherence to health-promoting behaviors (in this case, safer sex and safer injection behaviors) is necessary. It is therefore important to understand the factors associated with relapse and its prevention. "Temptation"—that is, availability in the environment—is com- monly believed to be the cause of relapse. Yet careful studies have shown that negative emotions such as stress, depression, and anxiety are the most common precursors of relapse. In ac3dition, alcohol or drugs may contribute to relapse; the combination of al- coho] or drugs with sex has been associated with high-risk activities among homosexual and bisexual men (Stall et al., 1986~. Although it is not known with any certainty whether the probability of lapsing is constant over time (Brownell et al., 1986), there are clearly psy- chological, environmental, and social factors that affect it. Learned coping responses, including skills training and relapse rehearsal, can lead to increaser! perceptions of self-efficacy and decrease the proba- bility of relapse (MarIatt, 1982~.8 Relapse prevention involves a self-management technique to help individuals either to refrain from a specific set of behaviors or to limit the occurrence of those behaviors. It includes a number of components: a conscious rethinking of the skills needed to resist risk-associated activity, relapse action and planning, behavioral con- tracting ant! rehearsal, and the mastery of new skills (Mantel!, no date). The technique is based on principles of social learning the- ory and combines skills training and cognitive intervention (MarIatt, 1982~. Originally developer! to manage addictive behaviors, relapse prevention is suitable for impulse control and the control of indulgent behaviors that require immediate gratification ant! are followed by delayed negative consequences. Many different strategies are used in relapse prevention; current HIV intervention programs, for ex- ample, are evaluating the efficacy of diaries for gay and bisexual 8For addictive behaviors, such as heroin use, there are also physiological issues that must be addressed to prevent relapse.

284 ~ LIMITING THE SPREAD OF HIV men to help them monitor the cognitive, social, and emotional an- tecedents of their high-risk behaviors (Coxon, 1986~. Other inter- ventions that protect against relapse may also help begin desired behavioral change. The length of an intervention program can affect the stability of behavioral change. In evaluating programs, it is important to distinguish between short-term and Tong-term prevention strategies. Sometimes there may be a tradeoff between expedient intervention strategies that result- in short-term changes in behavior and the slower, more clifficult programs that target Tong-term education and life-styTe changes to achieve congruence between behavior and the values, beliefs, and other attributes of the individual. Long-term drug treatment provided through therapeutic communities ant! short- term detoxification for {V drug use illustrate the two poles of this continuum of intervention length. (Unfortunately, the available data are not adequate to make definitive statements about the relative efficacy of Tong-term versus short-term drug treatment programs.) Drug treatment programs are obvious points for reaching IV drug users at risk of HIV infection and are effective in decreasing the frequency of infection, thus decreasing the likelihood of spreading AIDS. It is obvious, however, that an {V drug user must first have access to treatment if treatment is to have an effect. Currently, there are waiting lists for IV drug treatment programs in every major urban area in the country (IOM/NAS, 1988~. In Chapter 3, the committee recommends expanding drug treatment programs to accommodate anyone wanting treatment. In(lividuals who are motivated to take action need assistance to do so; they should be provided with programs to change risk-associated behavior and to sustain those changes. As states! in the previous chapter, serving the diverse neecis of disparate populations is apt to require multiple strategies. Moreover, sustained treatment contact is needed: a single experience with an intervention program is usually insufficient to effect lasting change. The common belief that one slip necessarily lea(ls to complete relapse is not substantiated by research in relapse prevention. The incorrect picture that has been fostered! by this notion may have come from focusing only on those who have relapsecl while not taking into account those who have not. It is particularly important to overcome the idea of "one fatal slip" among {V cirug users. As Des JarIais has noted: Given the exigencies of daily life for an IV drug user, it is unlikely that the new risk reduction behavior can always be maintained.

FACILITATING CHANGE ~ 285 Thus there must also be an additional belief that the occasional slip in risk reduction behavior does not negate the need for continuing risk reduction. (1987:12) It is unreasonable to expect that changes in risk-associated be- havior will be constant over an individual's lifetime. Both the in- dividual and the environment in which he or she lives are dynamic. The grave consequences of HIV infection require continued efforts to facilitate change in those behaviors associated with risk and to support change that has already occurred. Therefore, the commit- tee recommends that programs consider the psychological, social, biological, and environmental factors that may affect relapse; learned coping responses, including skills training and relapse rehearsal, should be taught to increase percep- tions of self-efflcacy. It is not yet clear how to influence the behavior of those individ- uals who persist in high-risk activities despite intervention efforts. The lessons that have been learned from smoking cessation programs indicate that even long-term educational efforts are sometimes inef- fective with persistently noncompliant groups. As discussed earlier in this chapter, more education does not inevitably lead to more change. Nevertheless, some approaches have been seen to offer the potential for influencing persistent behavior. Increasing a person's level of self-efficacy appears to be helpful. Programs to heighten individuals' awareness of the capacity of drugs and alcohol to im- pair judgment, especially in sexual situations, may also facilitate risk reduction. Combining approaches offers additional possibilities. In a ranclomized trial of a multifaceted face-to-face program for ho- mosexual men with long histories of high-risk activities, significant risk reduction was seen after 12 weeks of education, cognitive self- management training, and the development of strong social support systems (Kelly et al., 1987a). In addition, there are forces greater than the indiviclual (e.g., peer support and supportive social con- ditions) that need to be mobilized in oder to evoke and sustain appropriate behaviors; some of these forces are discussed later in this chapter. Assessing Change There is a notion that change is only significant or "real" if it has oc- curred in all targeted individuals and is permanent. Those who insist on so absolute a definition of change are unrealistic, and they will be eternally disappointed in the actual achievements of risk-takers

286 ~ LIMITING THE SPREAD OF HIV (and in the social scientists who design the intervention programs to facilitate those achievements). It is highly unlikely that such a stan- dard for behavioral change can be met sufficiently widely to make it a satisfactory program goal. As stated earlier, the modification of behavior and incremental change are usually easier to achieve than global change; in a(ldition, any change that has occurred may be difficult to maintain. A more reasonable and appropriate standard of judgment can be formulated as the question: Is the change that has aIreacly occurred sufficient to reduce the spread! of HIV infec- tion within a community, thereby decreasing the likelihood that a risk-taking person will encounter an infected individual? Unfortunately, there is limited information available on the dis- tribution of sexual and cirug-use behaviors (see Chapters 2 and 3) against which behavioral change can be measured. (Without such information, it is also difficult to target resources and programs; it is impossible to monitor program effects.) For some parts of the United States, appropriate current data simply do not exist. The available self-reported data on behavioral change show irregular patterns over time and across groups. For example, data from a longitudinal study of homosexual and bisexual men from San Ffancisco (Ekstranct and Coates, 1988) indicated that 33.9 percent of the respondents reported unprotected receptive anal intercourse in 1985; only S.3 percent con- tinued to report this practice in 1987 (T. J. Coates, University of California at San Francisco, personal communication, August 1988~. Yet there is strong concern that the behavioral modifications demon- strated in homosexual men from urban epicenters of the epidemic may not have occurred among gay men from rural areas or from urban areas that are thought to have Tow infection rates (Coates et al., l98Sb). Data from a number of studies give support to the belief that safer sex practices have not been adopted equally throughout the country. . Between May and December 1986, 65 percent of men participating in a large prospective, longitudinal study of homosexual men in Pittsburgh reported at least one episode of unprotected anal intercourse (Val~liserri et al., 1987~. . Homosexual men surveyed in Mississippi in 1987 re- ported an average of 19.7 partners in the past year with whom they had experienced unprotected receptive anal intercourse (Kelly et al., 1987a). . Of men recruited through a gay support organization in New Mexico in 1985, 67 percent reported that they

FACILITATING CHANGE ~ 287 practiced unprotected anal intercourse (C. C. Jones et al., 1987~. In 1986, 21 percent of men interviewed in Boston re- ported anal intercourse without the use of concloms (McCusker et al., 1988~. Even in New York City, an epicenter of the epidemic, homosexual men surveyed in 1985 reported using con- doms only 20 percent of the time they engaged in anal intercourse (Martin, i987~. As noted in Chapter 2, the incidence of STDs has been used as a surrogate marker for sexual behaviors associated with HTV infection. The uneven declines shown in gonorrhea and syphilis incidence data confirm the abovementione(1 self-reports of persisting high-risk sex- ual behavior. Although STD incidence has declined in San Fiancisco, Atlanta, New OrIeans, San Diego, and Denver, increases in syphilis have been seen in Miami, Newark, Houston, Dallas, and Boston (Coates et al., l988b). Chancroid is a sexually transmitter! disease that has been implicated as a cofactor for HIV infection in Africa. Since 1981 numerous outbreaks of chancroic3 have been reported in the United States, and it has become endemic in several areas includ- ing urban areas in Florida, California, and New York. Between 1971 and 1980, a mean of 878 cases of chancroid was reported annually in the Uniter! States; in 1986, 3,418 cases were reported (Schmitt et al. 1987). There are some ciata to indicate that behavioral change has also occurred! among IV drug users, albeit with variation across locations. A sample of IV drug users recruited through methadone maintenance programs in New York City in 1984 reported behavioral change to reduce the risk of contracting AIDS: approximately 30 percent reported the increased use of clean or new injection equipment and reduced needle-sharing (Friedman et al., 1986~. In addition, although no change in needIe-sharing behavior was seen between 1985 and 1987 in a sample of {V drug users recruited from a drug treatment center in San Francisco (Becker and Joseph, 1988), the proportion that reported it usually or always sterilized with bleach increased from 6 percent to 47 percent over this period (Chaisson et al., 1987~. Much less is known about the behavior of IV drug users who live in areas that have no active research programs. Even in areas in which intervention programs have been established, complete risk- reducing change is unlikely to have occurred throughout the at-risk population. Moreover, lit tie is known about how existing change is maintained over time.

288 ~ LIMITING THE SPREAD OF HIV Impediments to Inclividual Action: The Example of Condom Use The principles of behavioral change discussed above may be difficult to implement. These principles presume an empowered, active indi- vidual rather than a passive one, as well as realistically achievable paths of action. The following example may be helpful in clarifying some of the obstacles people may encounter when they attempt to change their behavior.- (A broader discussion of barriers to action is presented in Part Ill of this report.) A male high school student has heard that AIDS is a cleacITy sexually transmitted disease and that condoms may be helpful in preventing it. Being sexually active, he is reluctant to abandon a behavior that has been pleasurable. However, being quite sensible besides, he is not prepared to continue to take life-threatening risks. There are several questions he might well be expected to ask himself: Where do ~ get condoms? How do T negotiate the purchase with the local pharmacist? How do T figure out when and how to put a condom on? What clo T do if my partner doesn't want me to use them? Answering these questions is apt to require information, skills, practice, and a sense that one is capable of doing these things. The answers to these and other questions apparently etude many adolescents. A survey of black mate adolescents in gracles 7 through 12 from an urban area found that more than half thought they needed parental permission to purchase condoms (S. D. Clark et al., 1984; Grieco, 1986~. Almost half (43 percent) said the embarrass- ment involved in purchasing condoms inhibited their use. Of those students who reported using condoms, there were more who had ob- tained them from another person than from a store. Twelve percent reporter! stealing their first condom. Homosexual men have also reported cultural and practical bar- rers to condom use. In a study of gay men from the Pittsburgh area, the following perceptions of condoms were noted: they spoil sex (22 percent); they are embarrassing to buy (18 percent); they are found objectionable by sexual partners (16 percent); they are not readily available (22 percent); and they are used only by heterosexuals for contraceptive purposes (26 percent) (Valdiserri et al., 1987~. When men who "always" used condoms for insertive anal intercourse were compared with men who "never" used them, nonusers tended to be younger, less educated, less concerned about risk, less convinced of condom efficacy in preventing the spread of HIV, and more likely to have used alcohol or other drugs during sex (Valdiserri et al., 1988~. Indeed, the health education literature is replete with ex- amples of motivated individuals who nevertheless do not undertake

FACILITATING CHANGE ~ 289 recommended behavioral changes because they perceive numerous barriers to be associated with these actions (Janz and Becker, 1984~. The use of condoms to prevent sexually transmitted HTV infec- tion requires both the belief that condoms will prevent the spread of infection and the social and practical skills to acquire and use them. The question of condom- efficacy in the prevention of STDs in par- ticular, infection from HIV—has fueled the debate about whether condoms are a reasonable method of AIDS prevention. It is obvi- ously desirable and wise to caution potential users about the possible failure of concloms ant! the associated risks of such failure; it is also important, however, to consider the manner in which such a warning is given and the possible negative impact of exaggerated risk and of being led astray by perceived authorities. The following quotation comes from Parade magazine ("Special Intelligence Report," April 24, 1988:6), which is distributed in Sunday newspapers to households throughout the country. Warning! People who use condoms to prevent the spread of sex- ually transmitted diseases, such as AIDS, gonorrhea and syphilis, should know that they do not provide loom protection. In recent tests, 12% of the condoms made in the U.S. and 21% of those made abroad failed. The Food and Drug Administration tests condoms by submitting them to federal water-leakage standards in the lab. If more than four condoms out of 1000 are found de- fective, the FDA rejects the entire batch from which the samples have been drawn. Imported condoms consistently show a higher failure rate than domestic brands. Unfortunately, there is virtually no scientific data on the failure rate of condoms as used by humans. Last April, the FDA wrote condom manufacturers explaining that, as a result of HIV infec- tion, "it has become very important that users be fully aware that latex condoms provide protection, but do not guarantee it, and that protection is lost if condoms are not used properly." Properly used or not, a defective condom is, of course, worthless. This information is only partly correct and very misreading. The article claimed that 12 percent of domestic concloms fail; in fact, 12 percent of batches fait (CDC, 1988a). A batch is rejected (i.e., fails) if 4 of 1,000 (0.4 percent) of condoms do not pass a water leakage test, a test that may or may not mimic the stresses and strains of in vivo use. Moreover, foreign manufacturers with two or more batches that fait to meet FDA standards are placed on an automatic detention list; their products are cletained at the port of entry and are not distributec3 throughout the country (CDC, 1988a). Without doubt, there is some risk of breakage (and therefore infection) associated with condom use, although such risk is difficult to estimate. Nevertheless, it is clear that intercourse (vaginal or anal) using a condom is much safer than

290 ~ LIMITING THE SPREAD OF HIV intercourse without one. Consequently, in the case of the Parade article, the "warning" may well do more harm than good in reducing the spread of HIV infection. In its brochure, "AIDS and the Education of Our Children," the U.S. Department of Education stressed three phrases in its one- page section on condoms and AIDS: (1) the use of condoms can reduce but by no means eliminate the risk of contracting AIDS; (2) condoms can and do fail; and (3) maintaining strict moral standards is the most appropriate- way to avoid AIDS (U.S. Department of Education, 1987:16~. Focusing on the risk of condom failure in this way can lead to feelings of hopelessness and frustration, which in turn can lead to unprotected intercourse. Indeed, messages that stress the failure of condoms rather than their capacity to protect have been shown to clissuacle young adults from believing that condoms are an effective means of preventing HIV infection.9 It is clear, however, that protected intercourse, although not perfectly safe, is still safer than unprotected intercourse. SOCIAL SUPPORT FOR BEHAVIORAL CHANGE Individuals do not act in a vacuum: rather, action occurs in a social environment. Thus, if AIDS prevention programs are to be successful, they must take into account several important facts about the social factors that affect individual change. First, people are less likely to behave in ways that will incur the disapproval of others in their social group; people tend to conform to the "shoulds" and "oughts" of behavior specified in the norms of their community. (For example, behavioral change reported by homosexual men has been influenced by changes in the accepted stanl(lards and expectations for sexual behavior [i.e., normative shifts] in this group.) Second, some social anti community structures foster healthy behaviors and behavioral change; others inhibit them. (Tt is sensible to expect that anonymous testing, in contrast to other formats of testing, will yield more credible information and may also lead to desirable changes in behavior.) The identification and mobilization of social factors that support behavioral change are thus extremely important components of AIDS prevention programs. Programs that seek to 9Approximately 100 Yale University students were assigned to one of two groups re- ceiving logically equivalent but differently worded messages on condom failure. They were asked: "Should the government allow this condom to be advertised and sold as an effective method for preventing the spread of AIDS?" Almost 90 percent of the students who were told that condoms were 95 percent effective answered yes; only 42 percent of the students who were told that condoms had a 5 percent failure rate concurred with the statement (Dawes, 1988~.

FACILITATING CHANGE ~ 291 change behavior must inevitably confront the diverse and complex social forces that motivate and shape the behaviors at issue. Family, Group, and Community Beliefs There is increasing evidence that social support has an effect on the health status of individuals. Such support appears to be especially important in the management of chronic disease or in situations in which long-term behavioral change is required to prevent or amelio- rate disease (Becker, 1985~. For example, family support has been shown to be important in cuing and reinforcing appropriate behav- iors for obesity, hypertension, arthritis, and coronary heart disease (Becker, 1985; Morisky et al., 1985~. Families and other groups can affect an indiviclual's adherence to prescribed behaviors by provid- ing material, cognitive, and psychological support. The greater the compatibility of family roles and beliefs, the greater the support for health behaviors and the greater the likelihood that the individual will initiate and sustain them. Social support comes in many forms, ant! it can affect individ- ual action in many ways. In the early days of the AIDS epidemic, for instance, gay men turned to their communities for information about the disease and for an interpretation of relevant information. Yet social support for health behavior goes beyond the provision and interpretation of information, and this broader definition im- plies the need for aciclitional resources and the possibility of other problems. For example, the services needed to prevent and treat drug use require federal, state, and local resources,-the appropriation and coordination of which may be problematic. The current shortage of treatment slots and the establishment of fees to enter treatment con- stitute socially erected barriers to prevention. An acIditional barrier may be a community's resistance to locating programs in the local neighborhood. A number of the factors that have contributed to the spread of infection among Hispanics (or Latinos) provide poignant examples of the failure of societal and community structures to support indiviclual action to prevent AIDS. Grass-roots Latino political organizations did not make AIDS a high-priority issue early in the epidemic, nor did they claim to represent homosexual Latino men. Indeed, the high level of stigma associated with homosexuality in the Hispanic family and community is thought to have led to the denial of same- sex orientation and susceptibility to AIDS that has been seen among Latino men. The risk of abandonment by family and friends appears

292 ~ LIMITING THE SPREAD OF HIV real to Hispanic men who may have had sex with other men.~° In addition, support from larger societal structures has been limited. Minority populations in the United States have received fewer health resources and enclurec3 greater morbidity and mortality from a range of health problems. AIDS is yet another health threat that will differentially affect Latino and other minority communities (Fullilove, 1988; Peterson and Bakeman, 1988~. Subgroups of women also suffer from the lack of social support to prevent AIDS. Cultural constraints can inhibit women from taking a more active role in bringing condoms to a sexual relationship (Mantel! et al., in press). For example, Latino gender roles make it difficult for some women even to broach the subject of sex or condoms. Moreover, condoms interfere with reproduction and are therefore at ocIds with cultural ideals of virility and womanhood (Mantel! et al., in press). Even within a Tong-standing intimate relationship, a woman may not have sufficient power to effect change. Messages and programs that place the burden of condom use on women without parallel education efforts for men are not reasonable when the culture equates such be- havior among women with prostitution or moral laxness. Programs that focus exclusively on women give them the responsibility for pro- tecting themselves and their offspring from AIDS, but many women do not have sufficient power to prevent sexual transmission of this disease. Social forces can also modify perceptions and expectations, how- ever, which in turn can motivate and sustain behavioral change. Ffiends may report conficlentially a very pleasurable sexual expe- rience that involved the use of a condom; they may also reinforce the notion that others expect protected intercourse. Moreover, as Catania ant! coworkers note: "Belief in our abilities to accomplish change may be influenced by observing that people similar to us can successfully accomplish change" (1988:14~. The responses of others are particularly important in the case of {V drug use. Peer approval is a significant component in the initial use of IV drugs and is also a factor in the sharing of injection equips meet. It is logical, therefore, to consider peer approval as a potential strategy to reinforce risk-reducing behaviors. Indeed, data from one study in New York City indicated that the participation of friends in risk-reducing activities was the strongest predictor of behavioral change among IV drug users (FYiedman et al., 1987~. In addition, a study of methadone patients from the New York City area (Des 10See C. McGraw, "Lack of Effort to Combat AIDS in Latino Community Criticized," Los Angeles Times, February 26, 1988:II1. iiSee S. G. Boodman, "Hispanic Culture Redefines AIDS Fight: Communication Prob- lems, Moral Traditions Hinder Efforts," The Washington Post, December 28, 1987:A1.

FACILITATING CHANGE ~ 293 JarIais, 1987) showed that change was occurring along the lines of friendship groups ant! not among isolated individuals, indicating the important role of peer support in initiating and sustaining behav- ioral change. A sense of group identity and social community among homosexual men has also supporter! measures to prevent the spread of AIDS. Perceptions that one's peers were reducing risk-associated behavior have been shown to be correlated with individuals' reports of change in their own behavior (Joseph et al., 1987a). Common life-styles, attitudes, and beliefs form a strong basis for group iclen- tity, and field observations of communities of gay men (Coates and Greenblatt, in press) have shown that the sense of group identity and social community is very important in leading people to take protective measures against the spread of HIV infection. Normative beliefs also affect what an individual will do to prevent infection. The theory of reasoned action (Ajzen and Fishbein, 1980) proposes that the intention to act depends in part on subjective normative beliefs about what others think one shouts! or should not do. Behaviors that are considered the norm or that convey social approval provide a reward, a sense of benefit, to the individual who behaves in such a fashion. Similarly, unacceptable behavior can be inhibited by the predicted social disapproval of such action. The response of individuals to the perceived normative climate will affect their behavior: people develop notions about what others think of their behavior, and their subsequent actions reflect some sense of how important this is to them. Thus, for example, if the use of sterile injection equipment becomes normative within the IV drug- using population, individual users will fee! pressured to sterilize their works. Community-I,eve} Intervention Programs Community-leve] approaches to prevent HIV infection provide infor- mation, skills training, and a social environment that supports and sustains individual behavioral changes. In their efforts to change health-relate(1 behaviors, community-level programs bring together a number of diverse program components. They can also direct intervention strategies and the flow of information through exist- ing structures and groups, thus influencing a broa(ler audience than would be reached by more individual efforts. Community-leve! programs are designed to produce enough change in enough people to prevent the spread of infection and to alter norms that are relevant to the behaviors associated with risk. They create a social environment that reminds the individual that safer behavior is viewed as preferable to risky behavior. There are

294 ~ LIMITING THE SPREAD OF HIV two important points of impact. First, community-level interven- tions can reach a critical mass of individuals, providing information, motivation, and skills training. Second, by working through a variety of local agencies, changes in norms can be achieved. If normative be- havior has changed, it increases the likelihood that, for example, sex partners will expect to engage in low-risk behavior. If a critical mass has been reached, motivated, and changed, and if community norms have shifted, it is less likely that any given individual will indulge in high-risk behavior. "The objective is to create a sum greater than the parts through synergistic action around community-wide AIDS prevention events and activities" (Coates et al., l98Sb:22~. Communities can be defined by various criteria they may con- sist of individuals who share behavioral patterns (e.g., TV drug users or homosexual men); they may have a common racial, ethnic, or sexual identity; they may share a common geographic area or or- ganization (e.g., a school or prison). RegarcIless of the definition, intervention strategies should take into account the leaclers and or- ganizations of the community in the design of intervention programs. Authority figures and trusted opinion leaders can be important allies in achieving health goals. Although the initial stimulus for action may come from outside (for example, from the public health de- partment or a university-based research program), it must still be accepted by and incorporated into community structures. The com- mittee agrees with Coates and Greenblatt's (in press) statement that "change may require ideas ant! technology from the outside, but adoption, maintenance, and adaptation require the explicit colIab- oration of individuals and agencies from within the community." The committee recommencis that, to the extent possible, community-level interventions to prevent the spread of HIV infection address simultaneously information, motivational factors, skills, prevailing norms, and methods for diffusing innovation. Community-level intervention methods have been successfully applied to the prevention of a range of diseases, including cardio- vascular disease and cancer. Annual evaluation data from the well- designed Stanford Three-Community Study (Farquhar et al., 1977) indicated that communities exposed to a media-based campaign reducecl hypertension, bloocT cholesterol, and cigarette use by ap- proximately 25 percent; individuals who were given additional skills training and social support reduced their risk by approximately 30 percent. Most of those reporting change had maintained it for three years. In another instance, a community-base<] program to reduce teenage pregnancy (modeled on the Stanford program) was able to clelay the age of initial intercourse and increase the consistent use of

FACILITATING CHANGE ~ 295 contraceptives among teenagers who were sexually active (Vincent et al., 1987~. It is hoped that evaluation data from CDC-supported community demonstration projects currently under way in Dallas, Denver, Albany, New York City, Seattle, Chicago, and Long Beach will help to identify the primary factors associated with facilitating and maintaining behavioral change to prevent HIV infection. Community-level attempts to prevent drug use take into account the environment in which that behavior occurs. Such approaches have relied on information campaigns to communicate the adverse effects of cirug use anti to motivate people to refrain from using drugs; they have also involved the formation of collaborative and cooperative relationships among parents, schools, and community agencies to heighten concern about the problems associated with drug use and to take steps to alter organizations (e.g., "head shops" ~ and situations that facilitate drug use (Durell and Bukoski, 1984~. A program in California caller! Parents Who Care provides support to adolescents by giving ([rug-free parties and cooperatively setting guidelines for curfews and social activities (Polich et al., 1984~. The San Fiancisco area offers an excellent mode] of community- leve! intervention. Very early in the epidemic, the San Fiancisco AIDS Foundation began a community-based HIV risk reduction pro- gram. A nonprofit corporation, the Stop AIDS Project, was formed to work with grass-roots gay organizations. Because many gay men had already reported knowledge of AIDS and change in relevant behaviors, the focus of the Stop AIDS program activities moved be- yond individual change to social and cultural change that included raising individual awareness of peer support for safer sex practices and promoting further normative change in the local community. Changes that had already occurred among gays were emphasized to show the larger group that a shift in norms was occurring. The coop- eration and participation of leaclers in the gay community facilitated education efforts and lent credibility to the project's activities. The Stop AIDS project has now broadened its approach to the problem by reaching out to other risk groups and by enlisting other organizations in efforts to prevent further spread of infection. The University of California at San Ffancisco, through its AIDS Health Project, and Pacific Mental Health Services, through Operation Con- cern, joined this endeavor to provide health consultation and support groups for those at risk. The Instituto Familiar cle la Raza and the Bayview Hunter's Point Foundation assisted with outreach activities to minority communities ant! education efforts. The Women's AIDS Network and the California Prostitutes Education Project are ad- dressing the needs of women at high risk of HIV infection. Another part of the San Fiancisco community-level program provided AIDS

296 ~ LIMITING THE SPREAD OF HIV prevention education to IV drug users and relied on a number of organizations and outreach workers to contact substance abusers on the street and in outpatient and inpatient treatment facilities (Doll and Bye, 1987~. Independent research projects in the San Fiancisco area have found substantial decreases in the number of men engaging in high- risk sexual behavior. Because many AIDS-related activities have occurred simultaneously in San Fiancisco, it is difficult to discover a causal relationship between particular elements of the community- basec3 program and specific outcomes. However, there are indications that change occurring in San Fiancisco during the program's opera- tion is apt to be related to community-based efforts. Almost 7,000 homosexual anct bisexual men attended at least one small group meeting on safer sex practices; this number is thought to represent approximately 10 percent of the local gay population. A 1986 tele- phone survey found that 86 percent of homosexual and bisexual men interviewed were aware of the media campaign. More men remem- berec! specific messages about sex than about drugs. Twelve percent had attended at least one educational activity (Doll and Bye, 1987~. The San Fiancisco experience highlights the following seven ele- ments of a successful community-basec3 program: 1. strong leadership from within the targeted community; 2. market research to identify appropriate messages and communication channels to reach the target audience; 3. programs to inform and motivate the target audience; 4. activities to facilitate social and cultural change; 5. use of multiple channels of communication; 6. grass-roots participation; and 7. research documenting baseline levels of high-risk behav- ior and behavioral change, noting, where possible, the factors related to a failure to change (Communication Technologies, 1987~. In the case of AIDS, fostering community norms that allow those at risk to avail themselves of help is critical in controlling the spread of HIV infection. To empower the individual, it is necessary to empower the community, which in turn may require changes in institutions and structures. Institutional factors, such as legal and religious sanctions, can foster community norms and structures that either facilitate or impede individual action, and those institutions that operate in and have credibility with the community must be user! in efforts to change human behavior. Schools, churches, health care providers, the media, and workplaces are important venues for affecting health behavior. AnalYses of local resources can identify potential links to the local

FACILITATING CHANGE ~ 297 population and may provide clues to the best ways to reach specific groups. Ideally, the objectives and priorities for community-based programs shout be established through a process that includes input from the groups that make up that community (Green and McAlister, 1984~. Impecliments to Effecting Behavioral Change As noted earlier in this chapter, there are sometimes substantial barriers to implementing the strategies that have been designed to change human health-related behavior. For example, people often hold incorrect stereotypical notions about the problem and about those at risk. These problematic perceptions slow progress in pre- venting further infection because they frequently lead to operational- ization of poor ideas and tend to retard reasoned action. Prejudice and stigma (see Chapter 7) have caused some people to believe that certain groups are incapable of changing their behavior, but data from surveys of IV drug users, prostitutes, and homosexual men Lo not support this notion. In general, it is important to point out that the groups at highest risk of infection in this epidemic also respond most favorably to the conditions under which all people respond best that is, supportive economic, political, and social conditions. Clearly, there are variations in health and other behaviors across ethnic and racial groups; yet there are also common threads linking all people that should not be overlooked. In-Groups Versus Out-Groups: Creating Distance From Risk Many people believe that individuals who engage in high-risk behav- ior are quite different from everyone else, and they therefore conclude that risk-taking individuals will not respond to intervention strate- gies designed to halt the spread! of HIV infection. This exaggerated sense of difference between oneself or one's group (in-group) and others (out-group) has limited effective interventions in the AIDS epidemic. Four important phenomena may operate when the per- ceptions of in-groups are compared with those of out-groups: (1) people tend to see in-groups as superior (ethnocentrism); (2) they tend to perceive in-groups as more complex and heterogeneous than out-groups (out-group homogeneity); (3) they tend to exaggerate the differences between their own group and other groups (contrast and accentuation effects); and (4) they tent! to perceive events in a man- ner that is consistent with the expectations and goals of their group (assimilation) (Dawes et al., 1972; Rothbart et al., 1984~. These phenomena have an impact on how problems are definer! ant! solved and on how people are perceived and treated.

298 ~ LIMITING THE SPREAD OF HIV The operation of these phenomena can result in distorted per- ceptions of minorities and their risk of HIV infection, as illustrated in the following example. Minority communities in the United States have suffered a disproportionate burden of infection (Sabatier, 1988~. In a 1987 Washington Post editorial, "AIDS: The Real Danger . . ." (June 7:B7), social critic George F. Will clid not find it surprising that blacks and Hispanics account for disproportionate numbers of cases of AIDS: "After all, many people are caught in the culture of urban poverty precisely because they have never been given the basic skills of social competence: they do not regulate their behavior well, least of all in conformity with public-health bulletins." The distinc- tion that Mr. Will makes between poor, urban ethnic minorities and what he calls "the general heterosexual population" heightens the reader's perceptions of the differences between groups. The committee believes it is counterproductive to focus on cliffer- ences that are not related to behavioral change. To prevent further infection, people have to change risk-associated behavior; to begin to make appropriate behavioral changes, people must recognize that AIDS is a potential problem for them personally. Therefore, to lay blame, to label those at risk as socially, economically, or behaviorally inferior, is to alienate people who are seeking to understand their personal susceptibility and to discourage them from assessing their risk. In addition, to portray the problem as one that primarily af- fects minority populations deflects attention away from the need for nonminorities to take preventive action. It is vital to dispel the belief that indivi(luals who engage in high- risk behaviors are so different from most of the population or live with so high a level of psychopathology that they cannot be motivated by the same concerns or goals as others in the population and are there- fore not likely to be influencer! by any of the intervention strategies that the behavioral sciences have to offer. Although there are cer- tainly important differences between out-groups and in-groups, these differences can be identified and taken into account when planning interventions. Moreover, too strong a focus on such differences may negate those similarities that are bound to exist. There is no doubt that many factors affect the differential responses people have to one strategy or another. Still, exaggerating the differences between in-groups and out-groups will prevent an appropriate assessment of personal susceptibility and can generate a sense of hopelessness. IVDrugUsers An example of this hopelessness is the public's perception that IV drug users are unable to alter their drug and sexual behaviors to

FACILITATING CHANGE ~ 299 prevent either the acquisition or spread of the disease. There is a pervasive sense that drug users are self-destructive and uninterested in their own health and that they therefore cannot be expected to be concerned about the health of others. Although social organizational constraints and the physiology of addiction make changes in behavior clifficult for this at-risk population, data show that some TV drug users have already taken action to protect their own health and that of others. Skeptics might question the reliability of self-reported data col- lectec! from {V drug users, but there are other, perhaps more ob- jective, indicators of behavioral change. In New York City,- as more and more addicts have become aware of the risk posed by used in- jection equipment, the market for sterile illicit needles and syringes has been growing. For those who cannot give up their drug habit, rising numbers are trying to inject drugs in a safer fashion. Of 22 illicit needle sellers surveyed in New York City, 18 reported an in- crease in sales over the past year; 4 specifically mentioned AIDS as the cause for increased demand (Des JarIais and FYieciman, 1987~. Sadly, as discussed in the previous chapter, some of this demand is being met on the black market with counterfeit sterile injection equipment. Almost one-half of those selling needles reported occa- sionally repackaging used equipment for resale as new. Other drug dealers have been using new works as a marketing device for bags of heroin (Des JarIais, 1987~. These data highlight both the strength of the clemand for clean injection equipment and the dangers of relying on illicit markets for distribution. It is clear, however, that many IV drug users want to and can change some of their behavior, and the social barriers to such change should be removed. Female Prostitutes Considerable concern has also been expressed about the role that female prostitutes may play in spreading HIV infection. The link between multiple sexual partners and increased risk for AIDS was established in the homosexual population. Many people fear that prostitutes (who by definition have multiple sex partners) will not adopt safer sex practices with their clients and will therefore be the conduit through which HIV infection will spread to the heterosexual population. Yet the existing data on prostitutes do not support this concern (see Chapter 2~. The threat that prostitutes pose to any given heterosexual contact appears to be greater in personal relationships than in paying ones. The cultural values that surround intimate relationships, including notions of love and trust, do not

300 ~ LIMITING THE SPREAD OF HIV foster conclom use. Unsafe sex may be a part of the definition of a personal relationship for women who work in the sex industry. The term women in the sex industry has been coined to describe the diverse group of women who exchange sex for money, goods, or services (see discussion of prostitution in Chapter 2~. A survey of these women (Cohen, 1987) found that important prerequisites to AIDS intervention efforts includecl program designs that reflected the needs and perceptions of the target population and outreach to those in need through relationships based on caring, respect, and honesty. The design phase of this survey permitted input from the target population; respondents asked that they not be treated impersonally (as patients are often treated) or as objects of intellectual or ethical curiosity. Researchers who have made an impartial, informer! effort to un~lerstancl the needs of this population feel that, in return, they have benefited from their subjects' increased participation and frankness (Cohen, 1987~. As is the case with needle sterilization among {V drug users, women in the sex industry who are at risk for AIDS are more likely to modify their behavior than to make global charges in their life- styles. Clearly, the threat of further HIV transmission posed by prostitutes could be removed by eliminating prostitution. However, this is unlikely to occur as long as there is a clemand for the services offered by women in the sex industry and as long as women perceive that such employment is the best or only kind available to them. Therefore, effective prevention programs must understand and make appeals to the real goals of the targeted population, and the social barriers to implementing such programs should be removed. It should not be assumed that the goals held by those proposing change are necessarily those of the individuals to be reached. Rather, there is a need to interact with the group to determine what these goals are. Innovative ant} Controversial Approaches to Behavioral Change In its recent report, the IOM/NAS AIDS cot ttee concluded that "the HIV epidemic should prompt a reexamination of the fiscal and institutional barriers that impede effective public health efforts in all program areas related to the control of HIV infection" (IOM/NAS, 1988:62~. The threat posed by HIV infection does not permit the luxury of proceeding as with other diseases; this is not business as usual. Therefore, for some behaviors and in some populations, dramatic, innovative steps will be needed to prevent the spread of infection.

FACILITATING CHANGE ~ 301 Two such innovative approaches to facilitating behavioral change both of which are sources of controversy are the provi- sion of sterile needles for individuals who persist in {V drug use and intensive school sex education programs. The committee finds both of these approaches to be promising; nevertheless, it concludes that systematic, well-designed program evaluations (and planned pro- gram variations) are needed to determine the effectiveness of these strategies in preventing disease. Sterile Needle Programs There is no controversy about whether sterile needles help to prevent the spread of AIDS among {V drug users. Rather, debate centers on whether sterile needles would be used if they were maple available and whether programs to make them available would have harmful side effects (e.g., prolonging drug use or increasing its rate) that wouicT outweigh their benefits. The committee fincis no convincing evidence that current legal restrictions decrease drug use and no evidence (from other countries) that easing access to injection equipment increases the number of new drug users or the levels of drug use among existing {V drug users. To ciate, needle distribution programs in this country are currently in the planning stage; therefore, no data are currently available on the effect of this approach among IV drug users in the United States. The belief that IV drug users would not protect themselves by using sterile needles is best expressed by a 1988 editorial written by Tottie Ellis for USA Today. The editorial, entitled "Clean NeecIles Idea Is Menace to Society," states: "To assume that anyone who is so irresponsible as to get on heroin would then become sensible enough to use clean needles or sterilize them is as contradictory as a cat with wings" (February 9:10A). The belief expressed in this statement is that a single behavior (IV drug use) is diagnostic of a global per- sonaTity characteristic (irresponsibility) that implies with certitude an entire set of other behaviors. Yet almost all research on the subject challenges the existence of global personality characteristics. The inconsistent arguments that a sterile needle program would be ineffective because irresponsible people who do not care about their health would not use it ant! because it would encourage drug use appear to be based more on in-group/out-group prejudice than on logic. In countries in which sterile needle programs have been imple- mented, IV drug users have taken advantage of their offerings (Des i2For a review of the concept of global personality, see Shweder (1979~.

302 ~ LIMITING THE SPREAD OF HIV JarIais and Hunt, 1988~. An estimated 50 percent of IV drug users in Amsterdam have used its "needle exchange program" (Buning et al., 1988~. As discussed in the previous chapter, data from Amsterdam (Buning, 1987), where neecIle exchange programs have been in place for several years and the sale of injection equipment is legal, indi- cated no increase in the number of {V drug users; they clip indicate an increase in the demand for treatment. There is also evidence that the program led to a decrease (from almost 90 percent to less than 50 percent) in the percentage of IV drug users who injected more than once a day (Des JarIais, 1987~. It is important to note, however, that the provision of sterile needles has been insufficient to prevent the spread of HIV and hepatitis among {V drug users in Amsterdam. Controlled experiments are required to assess the impact of ster- ile needle programs in this country. Careful evaluation will be needed to provide evidence of the effect of such programs on the initiation of new {V drug users and on the drug-use patterns of those who are already injecting drugs. The committee recognizes that instituting sterile needle programs will not be easy; it will take money, exper- tise, scientific review, and care in execution as well as public and political support. Moreover, it will take time. It is highly unlikely that any one study of needle exchange programs will be definitive; multiple efforts, using planned variations of approaches in different populations with appropriate evaluation, will be needled to build a sound base of knowledge about this innovative strategy. Thus, the committee recommends that well-designed, staged trials of sterile needle programs, such as those requested in the 1986 Institute of Meclicine/National Academy of Sciences report Confronting AIDS, be implemented. Education Programs for Teenagers The committee focuses on teenage sexual behavior because a sub- stantial number of adolescents are sexually active and have dismal rates of consistent contraceptive use and alarmingly high rates of STDs. The relevant data that are summarize<] below are presented in cletaiT in Chapter 2. Sexual experimentation without the benefit of barrier contraceptives (i.e., concloms) and a history of STDs inclicate that adolescents are also at risk for HIV infection. The fact that there have been few documented cases of AIDS among adolescents is in part a function of the lengthy time between acquisition of the infection and the diagnosis of AIDS. Data from the 1983 National Longitudinal Survey of Youth (Moore et al., 1987:Appendix Table 1.4) found that, by the end of adolescence (age 19), 83 percent of all young men and 74 percent

FACILITATING CHANGE 1 3o3 of all young women have engaged in sexual intercourse. Many peo- ple believe that very early onset of sexual intercourse is a problem seen only among disadvantaged youths that middle-cIass and non- minority aclolescents do not engage in intercourse. Although it is true that minority youth are more likely than nonminority youth to have had intercourse as teenagers, the difference between black and white never-married girls reporting intercourse has decreased since 1971 (Moore et al., 1987:Appendix Table 1.2~. American teenagers, in contrast to their peers in other industri- alized countries, are notoriously poor contraceptive users hi. B. Jones et al., 1985~. Approximately half of all teenagers do not use contra- ceptives the first time they have sexual relations, and there is often irregular or no use after the first intercourse (ZeInik and Shah, 1983; Moore et al., 1987:Appendix Table 2.1~. This lack of contraceptive use results in substantial rates of pregnancy among young women. In a sample of sexually active female aclolescents who reported never using contraception, 48 percent of whites and 52 percent of blacks reported a premarital first pregnancy within 24 months of experienc- ing first intercourse (Moore et al., 1987:Appendix Table 3.5~. Even among those who reported that they always used a contraceptive method, premarital pregnancies occurred in approximately 10 per- cent of young women in the sample within two years of the onset of intercourse. Excluding homosexual men and prostitutes, sexually active teen- age girls have the highest rates of gonorrhea, cytomegalovirus, chIa- mydia, and pelvic inflammatory disease of any age/sex group (Bell and Hein, 1984; Cates and Raugh, 1985; Mosher, 1985~. The risk factors for STDs in adolescence include early onset of intercourse and no or irregular contraceptive use. There are several ways to alter the high rates of STDs and un- intencled pregnancies among aclolescents and the behaviors that can transmit HIV. The TOM/NAS AIDS committee found that "school- based educational programs are an essential part of eiTorts to increase awareness of the risk of HIV and to combat the spread of infection" (IOM/NAS, 1988:66~. The Presidential Commission on the Human Immunodeficiency Virus Epidemic (1988) concurred. This commit- tee has considered two important strategies for preventing infection in the adolescent population: school-basecl sex education programs and school-based clinics. An often-cited concern about providing sex education is the in- tuitive and generally untested notion that sex education leads to sexual activity (Hayes, 1987~. If teenagers have not learned about sex, the argument goes, then they will not engage in it. Does sex education precipitate or encourage sexual behavior? There is little

304 ~ LIMITING THE SPREAD OF HIV evidence to support this notion. Large-scale evaluations of school- based programs in the United States suggest that sex education does not promote early sexuality (ZeInik and Kim, 1982; Furstenberg et al., 1986~. However, these programs do appear to increase knowI- ecige about reproduction, especially in younger adolescents, and they may even promote contraceptive use among sexually active teens (although variations in program design and implementation and few large-scare evaluations make the interpretation of these data more difficult) (Kirby, 1984~. In Western Europe, where youths receive much more extensive sexual education rates of sexual activity are no higher than those reported in the United States, but rates of con- traceptive use are higher and rates of teenage pregnancy are Tower hi. B. Jones et al., 1985~. Another concern about school-based sex education programs sur- rouncis the belief that parents will not accept sex education outside the home for their children. Parents report being very concerned that their offspring become sexually responsible adults; many also report that they are very uncomfortable talking about reproductive and sexual issues with their children (Brooks-Gunn, 1987~. In addition, although sex education was once believed to be solely the province of the family, the responsibility for sex education has in fact shifted in part to the school system. In the early l980s, three quarters of all school districts provided some sex education (Kirby and Scales, 1981~. The specter of HIV infection may increase the aIrea(ly high proportion of parents wishing to have sex education in the schools. In a recent national survey by Harris, virtually all parents (94 percent) wanted AIDS education in schools.~3 Given the virtual unanimity among parents to include AIDS education in school curricula, why does the controversy surrounding such programs persist? The crux of the problem seems to be whether frank, explicit instruction will be allowed. Existing sex education programs are neither intensive nor extensive. Guttmacher's (1981) survey of school districts revealed that three quarters of the schoo] districts surveyed provident reproductive information, but only one quarter of them included the recluction of sexual activity and teenage childbearing in their goals. In addition, most sex education programs are short (10 hours or less); fewer than 10 percent of all students have taken comprehensive programs of 40 hours or more (Kirby, 1984~. 13A 1988 Children's Magazine article ("When AIDS Comes to School," a special report from Rodale Press) reported that 94 percent of parents responded that schools should take special steps when Harris pollsters asked them the following question: "In schools where NO child is suspected of having AIDS or carrying the AIDS antibodies, should the school take special steps to educate teachers and students about the disease, or are no special steps necessary?"

FACILITATING CHANGE ~ 305 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.

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

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

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. REFERENCES Ajax, L. (1974) How to market a nonmedical contraceptive: A case study from Sweden. In M. H. Redford, G. W. Duncan, and D. J. Prager, eds., The Condom: Increasing Utilization in the United States. San Francisco: San Francisco Press, Inc. Ajzen, I., and Fishbein, M. (1980) Understanding Attitudes and Predicting Social Behavior. Englewood Cliffs, N.J.: Prentice-Hall. Bandura, A. (1977) Self-efficacy: Toward a unifying theory of behavioral change. Psychological Review 34:191-215. Battjes, R. J. (1985) Preventing adolescent drug abuse. International Journal of the Addictions 20:1113-1134.

FACILITATING CHANGE ~ 309 Becker, M. H. (1970) Sociometric location and innovativeness: Reformulation and extension of the diffusion model. American Sociological Review 35:267-282. Becker, M. H. (1985) Patient adherence to prescribed therapies. Medical Care 23:539- 555. Becker, M. H., and Joseph, J. G. (1988) AIDS and behavioral change to reduce risk: A review. American Journal of Public Health 78:394-410. Bell, T., and Hein, K. (1984) The adolescent and sexually transmitted diseases. In K. K. Holmes, P. A. Mardh, P. S. Sparling, and P. J. Wiesner, eds., Sexually Transmitted Diseases. New York: McGraw-Hill. Brandt, A. M. (1987) No Magic Bullet. New York: Oxford University Press. Brooks-Gunn, J. (1987) Pubertal processes and girls' psychological adaptation. In R. Lerner and T. T. Foch, eds., Biological-Psychosocial Interactions in Early Adolescence. Hillsdale, N.J.: Lawrence Earlbaum Associates. Brooks-Gunn, J., and Furstenberg, F. F. (In press) Adolescent sexual behavior. American Psychologist. Boyer, C. B., Brooks-Gunn, J., and Hein, K. (1988) Preventing HIV infection and AIDS in children and adolescents: Behavioral research and intervention strategies. American Psychologist 43:958-964. Brownell, K. D., Marlatt, G. A., Lichtenstein, E., and Wilson, G. T. (1986) Under- standing and preventing relapse. American Psychologist 41:765-782. Buning, E. C. (1987) Prevention Policy on AIDS Among Drug Addicts in Amsterdam. Presented at the Third International AIDS Conference, Washington, D.C., June 1-5. Buning, E. C., Hartgers, C., Verster, A. D., et al. (1988) The Evaluation of the Needle/Syringe Exchange in Amsterdam. Presented at the Fourth International AIDS Conference, Stockholm, June 12-16. Cancellieri, F. R., Holman, S., Sunderland, A., Fine, J., Bihari, B., and Landesman, S. (1988) Psychiatric and Behavioral Impact of HIV Testing in Pregnant Drug Users. Presented at the Fourth International AIDS Conference, Stockholm, June 12-16. Casadonte, P. P., Des Jarlais, D. C., Smith, T., et al. (1986) Psychological and Behavioral Impact of Learning HTLV-III/LAV Antibody Test Results. Presented at the Second International AIDS Conference, Paris, June 23-25. Casadonte, P. P., Des Jarlais, D. C., Friedman, S., and Rotrosen, J. (1988) Psycho- logical and Behavioral Impact of Learning HIV Test Results in IV Drug Users. Presented at the Fourth International AIDS Conference, Stockholm, June 12-16. Catania, J. A., Kegeles, S. M., and Coates, T. J. (1988) Towards an Understanding of Risk Behavior: The CAPS' AIDS Risk Reduction Model. University of California at San Francisco. Cates, W., Jr., and Raugh, J. L. (1985) Adolescents and sexually transmitted diseases: An expanding problem. Journal of Adolescent Health Care 6:1-5. Centers for Disease Control (CDC). ~ 1988a) Condoms for prevention of sexually transmitted diseases. Morbidity and Mortality Weekly Report 37:133-137. Centers for Disease Control (CDC). (1988b) Guidelines for effective school health education to prevent the spread of AIDS. Morbidity and Mortality Weekly Report 37(Suppl. S-2~. Chaisson, R. E., Osmond, D., Moss, A. R., Feldman, H. W., and Bernacki, P. (1987) HIV, bleach, and needle sharing (letter). Lancet 1:1430. Check, W. A. (1987) Beyond the political model of reporting: Nonspecific symptoms in media communications about AIDS. Reviews of Infectious Diseases 9:987-1000.

310 ~ LIMITING THE SPREAD OF HIV Clark, N. M. (1987) Social learning theory in current health education practice. In W. B. Ward, S. K. Simonds, P. D. Mullen, and M. H. Becker, eds., Advances in Health Education and Promotion, vol. 2. Greenwich, Conn.: JAI Press, Inc. Clark, S. D., Zabin, L. S., and Hardy, J. B. (1984) Sex, contraception, and parenthood: Experience and attitudes among urban black young men. Family Planning Perspectives 16:77-82. Coates, T. J., and Greenblatt, R. M. (In press) Behavioral change using interventions at the community level (draft). In K. K. Holmes, P A. Mardh, P. S. Sparling, and P. J. Wiesner, eds., Sexually Transmitted Diseases. New York: McGraw-Hill. Coates, T. J., McKusick, L., Morin, S. F., Charles, K. A., Wiley, J. A., Stall, R. D., and Conant, M. D. (1985) Differences Among Gay Men in Desire for HTLV-III/LAV Antibody Testing and Beliefs About Exposure to the Probable AIDS Virus: The Behavioral AIDS Project. Presented at the Annual Meeting of the American Psychological Association, Los Angeles, August. Coates, T. J., Morin, S. F., and McKusick, L. (1987) Behavioral consequences of AIDS antibody testing among gay men. Journal of the American Medical Association 258:1889. Coates, T. J., Stall, R. D., Kegeles, S. M., Lo, B., Morin, S. F., and McKusick, L. (1988a) AIDS antibody testing: Will it stop the AIDS epidemic? Will it help people infected with HIV? American Psychologist 43:859-864. Coates, T. J., Stall, R. D., and Hoff, C. C. (1988b) Changes in Sexual Behavior Among Gay and Bisexual Men Since the Beginning of the AIDS Epidemic. Background paper prepared for the Health Program, Office of Technology Assessment, U.S. Congress, Washington, D.C. Cohen, J. B. (1987) Three Years' Experience Promoting AIDS Prevention Among 800 Sexually Active High Risk Women in San Francisco. Presented at the National Institute of Mental Health/National Institute on Drug Abuse Research Workshop on Women and AIDS, Bethesda, Md., September 27-29. Cohen, J. B. (No date) Condom Promotion Among Prostitutes. University of California at San Francisco. Communication Technologies. (1987) A Report on Designing an Effective AIDS Pre- vention Campaign Strategy for San Francisco. San Francisco: Communication Technologies. Cox, C. P., Selwyn, P. A., Schoenbaum, E. E., et al. (1986) Psychological and Behavioral Consequences of HTLV-III/LAV Antibody Testing and Notification Among Intravenous Drug Abusers in a Methadone Program in New York City. Presented at the Second International AIDS Conference, Paris, June 23-25. Coxon, A. P. M. (1986) Report of a Pilot Study: Project on Sexual Lifestyles of Non-heterosexual Males. Social Research Unit, University College, Cardiff, U.K. Darrow, W. W. (1987) Condom Use and Use-Effectiveness in High-Risk Populations. Presented at the CDC Conference on Condoms in the Prevention of Sexually Transmitted Diseases, Atlanta, Gal, February 20. Dawes, R. M. (1988) Measurement Models for Rating and Comparing Risks: The Con- text of AIDS. Presented at the conference, Health Services Research Methods: A Focus on AIDS, sponsored by the Health Services Research and Demon- stration Grants Review Committee of the National Center for Health Services Research and Health Care Technology Assessment and the University of Arizona, Department of Psychology, Tucson, June 2-4. Dawes, R. M., Singer, D., and Lemons, F. (1972) An experimental analysis of the contrast effect and its implications for intergroup communication and the indirect assessment of attitude. Journal of Personal and Social Psychology 21:281-295.

FACILITATING CHANGE ~ 311 Dawson, D. A., Cynamon, M., and Fitti, J. E. (1988) AIDS knowledge and attitudes for September 1987: Provisional data from the National Health Interview Survey. In Advance Data from Vital and Health Statistics, No. 148. DHHS Publ. No. (PHS) 88-1250. Hyattsville, Md.: Public Health Service, National Center for Health Statistics. Des Jarlais, D. C. (1987) Effectiveness of AIDS Educational Programs for Intravenous Drug Users. Background paper prepared for the Health Program, Once of Technology Assessment, U.S. Congress, Washington, D.C. Des Jarlais, D. C. (1988) HIV Infection Among Persons Who Inject Illicit Drugs: Problems and Progress. Presented at the Fourth International AIDS Conference, Stockholm, June 12-16. Des Jarlais, D. C., and Friedman, S. (1987) HIV infection among intravenous drug users: Epidemiology and risk reduction (editorial review). AIDS 1:67-76. Des Jarlais, D. C., and Hunt, D. E. (1988) AIDS and intravenous drug use. AIDS Bulletin, National Institute of Justice, U.S. Department of Justice. DiClemente, R. J., Zorn, J., and Temoshok, L. (1986) Adolescents and AIDS: A survey of knowledge, attitudes, and beliefs about AIDS. American Journal of Public Health 76:1443-1445. DiClemente, R. J., Boyer, C. B., and Mills, S. J. (1987) Prevention of AIDS among adolescents: Strategies for the development of comprehensive risk-reduction health education programs. Health Education Research 2:287-291. DiClemente, R. J., Boyer, C. B., and Morales, E. S. (1988) Minorities and AIDS: Knowledge, attitudes, and misconceptions among black and Latino adolescents. American Journal of Public Health 78:55-57. Doll, L. S., and Bye, L. L. (1987) AIDS: Where reason prevails. World Health Forum 8:484-488. Doll, L. S., Darrow, W., O'Malley, P., Bodecker, T., and Jaffe, H. (1987) Self-Reported Behavioral Change in Homosexual Men in the San Francisco City Clinic Cohort. Presented at the Third International AIDS Conference, Washington, D.C., June 1-5. Durell, J., and Bukoski, W. (1984) Preventing substance abuse: The state of the art. Public Health Reports 99:23-31. Edwards, L., Steinman, M., Arnold, K., and Hakanson, E. (1980) Adolescent pregnancy prevention services in high school clinics. Family Planning Perspectives 12:6-14. Ekstrand, M., and Coates, T. J. (1988) Prevalence and Change in High Risk Behavior Among Gay and Bisexual Men. Presented at the Fourth International AIDS Conference, Stockholm, June 12-16. Emmons, C. A., Joseph, J. G., Kessler, R. C., et al. (1986) Psychosocial predictors of reported behavior change in homosexual men at risk for AIDS. Health Education Quarterly 13:331-345. Farquhar, J. W., Wood, P. D., and Breitrose, I. T. (1977) Community education for cardiovascular health. Lancet 1:1191-1195. Farthing, C. F., Jessen, W., Taylor, H. L., Lawrence, A. G., and Gazzard, B. G. (1987) The HIV Antibody Test: Influence on Sexual Behavior of Homosexual Men. Presented at the Third International AIDS Conference, Washington, D.C., June 1-5. Flay, B. R. (1987) Mass media and smoking cessation: A critical review. American Journal of Public Health 77:153-160. Fox, R., Ostrow, D., Valdiserri, R., VanRaden, B., and Polk, B. F. (1987a) Changes in Sexual Activities Among Participants in the Multicenter AIDS Cohort Study. Presented at the Third International AIDS Conference, Washington, D.C., June 1-5.

312 ~ LIMITING THE SPREAD OF HIV Fox, R., Odaka, N. J., Brookmeyer, R., and Polk, B. F. (1987b) Effect of HIV antibody disclosure on subsequent sexual activity in homosexual men. AIDS 1:241-246. Friedman, S. R., Des Jarlais, D. C., and Sotheran, J. L. (1986) AIDS health education for intravenous drug users. Health Education Quarterly 13:383-393. Friedman, S. R., Des Jarlais, D. C., Sotheran, J. L., Garber, J., Cohen, H., and Smith, D. (1987) AIDS and self-organization among intravenous drug users. International Journal of the Addictions 22:201-219. Friedman, S. R., Sotheran, J. L., Abdul-Quader, A., Primm, B. J., Des Jarlais, D. C., Kleinman, P., Mauge, C., Goldsmith, D. S., El-Sadr, W., and Maslansky, R. (1988) The AIDS epidemic among blacks and Hispanics. Milbank Quarterly 65(Suppl. 2~:455-499. Fullilove, R. E. (1988) Minorities and-AIDS: A review of recent publications. Multi- cultural Inquiry and Research on AIDS 2:3-5. Furstenberg, F. F., Moore, K. A., and Peterson, J. L. (1986) Sex education and sexual experience among adolescents. American Journal of Public Health 75:1331-1332. Godfried, J. P., VanGriensven, G., Tielman, R. A. P., Goudsmit, J., VanDerNoordaa, J., DeWolf, F., and Coutinho, R. A. (1987) Effect of HIVab Serodiagnosis on Sexual Behavior of Homosexual Men in the Netherlands. Presented at the Third International AIDS Conference, Washington, D.C., June 1-5. Green, L. W., and McAlister, A. L. (1984) Macro intervention to support health be- havior: Some theoretical perspectives and practical reflections. Health Education Quarterly 11:322-339. Green, L. W., Wilson, A. L., and Lovato, C. Y. (1986) What changes can health promotion achieve and how long do these changes last? The trade-offs between expediency and durability. Preventive Medicine 15:508-521. Greer, A. L. (1977) Advances in the study of diffusion of innovation in health care organizations. Milbank Memorial Fund Quarterly: Health and Society 55:505-532. Grieco, A. (1986) Cutting the Risks for STDs. Winter Park, Fla. Guttmacher, A. (1981) Teenage Pregnancy: The Problem Hasn't Gone Away. New York: Alan Guttmacher Institute. Hayes, C. D., ed. (1987) Risking the Future: Adolescent Sexuality, Pregnancy, and Childbearing, vol. 1. Washington, D.C.: National Academy Press. Hochhauser, M. (1987) Readability of AIDS Educational Materials. Presented at the Annual Meeting of the American Psychological Association, New York, August. Hull, H. F., Bettinger, C. J., Gallaher, M. M., Keller, N. M., Wilson, J., and Mertz, G. J. (1988) Comparison of HIV-antibody prevalence in patients consenting to and declining HIV-antibody testing in an STD clinic. Journal of the American Medical Association 260:935-938. Institute of Medicine/National Academy of Sciences (IOM/NAS). (1988) Confronting AIDS: Update 1988. Washington, D.C.: National Academy Press. Janz, N. K., and Becker, M. H. (1984) The health belief model: A decade later. Health Education Quarterly 11:1-47. Job, R. F. S. (1988) Effective and ineffective use of fear in health promotion campaigns. American Journal of Public Health 78:163-167. Jones, C. C., Waskin, H., Gerety, B., et al. (1987) Persistence of high-risk sexual activity among homosexual men in an area of low incidence of the acquired immunodeficiency syndrome. Sexually Transmitted Diseases 14:79-82. Jones, J. B., Forrest, J., Goldman, N., Henshaw, S., Lincoln, R., Rosoff, J., Westoff, C., and Wulf, D. (1985) Teenage pregnancy in developed countries: Determinants and policy implications. Family Planning Perspectives 17:53-63.

FACILITATING CHANGE ~ 313 Joseph, J. G., Montgomery, S. B., Kessler, R. C., et al. (1987a) Behavioral Risk Reduction in a Cohort of Homosexual Men: Two Year Follow-up. Presented at the Third International AIDS Conference, Washington, D.C., June 1-5. Joseph, J. G., Montgomery, S. B., Emmons, C. A., Kessler, R. C., Ostrow, D. B., Wortman, C. B., O'Brien, K., Eller, M., and Eshleman, S. (1987b) Magnitude and determinants of behavioral risk reduction: Longitudinal analysis of a cohort at risk for AIDS. Psychological Health 1:73-96. Kelly, J. A., St. Lawrence, J. S., Hood, H. V., et al. (1987a) Behavioral Interventions to Reduce AIDS Risk Activities. University of Mississippi Medical Center. Kelly, J. A., St. Lawrence, J. S., Brasfield, T. L., and Hood, H. V. (1987b) Relationship Between Knowledge About AIDS and Actual Risk Behavior in a Sample of Homosexual Men: Some Implications for Prevention. Presented at the Third International AIDS Conference, Washington, D.C., June 1-5. Kirby, D. (1984) Sexuality Education: An Evaluation of Programs and Their Elects. Santa Cruz, Calif.: Network Publications. Kirby, D., and Scales, P. (1981) An analysis of state guidelines for sex education instruction in public schools. Family Relations 31:229-237. Kotler, P., and Zaltman, G. (1971) Social marketing: An approach to planned social change. Journal of Marketing 35:3-12. Lashley, K. S., and Watson, J. B. (1922) A Psychological Study of Motion Pictures in Relation to Venereal Disease Campaigns. Washington, D.C.: U.S. Interdepart- mental Social Hygiene Board. Lave, L. B. (1987) Health and safety risk analyses: Information for better decisions. Science 236:291-295. Lyter, D. W., Valdiserri, R. O., Kingsley, L. A., Amoroso, W. P., and Rinaldo, C. R. (1987) The HIV antibody test: Why gay and bisexual men want or do not want to know their result. Public Health Reports 102:468-474. Mantell, J. E. (No date) Prevention of HIV Infection Among Women: Issues and Recommended Initiatives. Gay Men's Health Crisis, New York City. Mantell, J. E., Schinke, S. P., and Akabas, S. H. (In press) Women and AIDS prevention. Journal of Primary Prevention. Marlatt, G. A. (1982) Relapse prevention: A self-control program for the treatment of addictive behaviors. In R. B. Stuart, ea., Adherence, Compliance and Generalization in Behavioral Medicine. New York: Brunner/Mazel. Martin, J. L. (1987) The impact of AIDS on gay male sexual behavior patterns in New York City. American Journal of Public Health 77:578-581. Marzuk, P. M., Tierney, H., Tardiff, K., Gross, E. M., Morgan, E. B., Hsu, M. A., and Mann, J. J. (1988) Increased risk of suicide in persons with AIDS. Journal of the American Medical Association 259:1333-1337. McCusker, J., Stoddard, A. M., Mayer, K. H., Zapka, J., Morrison, C., and Saltzman, S. P. (1988) Effects of HIV antibody test knowledge on subsequent sexual behaviors in a cohort of homosexually active men. American Journal of Public Health 78:462-467. McKusick, L., Horstman, W., and Coates, T. J. (1985) AIDS and sexual behavior reported by gay men in San Francisco. American Journal of Public Health 75:493-496. McKusick, L., Coates, T. J., Wiley, J. A., Morin, S. F., and Stall, R. (1987) Prevention of HIV Infection Among Gay and Bisexual Men: Two Longitudinal Studies. Presented at the Third International AIDS Conference, Washington, D.C., June 1-5.

314 ~ LIMITING THE SPREAD OF HIV Moore, K. A., Wenk, D., Hofferth, S. L. ted.), and Hayes, C. D. (ed.) (1987) Statistical appendix: Trends in adolescent sexual and fertility behavior. In S. L. Hofferth and C. D. Hayes, eds., Risking the Future: Adolescent Sexuality, Pregnancy, and Childbearing. Vol. 2, Working Papers and Statistical Appendixes. Washington, D.C.: National Academy Press. Morisky, D. E., DeMuth, N. M., Field-Fass, M., Green, L. W., and Levine, D. M. (1985) Evaluation of family health education to build social support for long-term control of high blood pressure. Health Education Quarterly 12:35-50. Mosher, W. D. (1985) Reproductive impairments in the United States, 1965-1982. Demography 22:415-430. Office of Technology Assessment (OTA). (1988) How Effective Is AIDS Education? A staff paper in OTA's Series on AIDS-Related Issues, Health Program. Office of Technology Assessment, Washington, D.C. Pappas, L. S. (1987) Promoting Condoms for Gay Men. Presented at the CDC Conference on Condoms in the Prevention of Sexually Transmitted Diseases, Atlanta, Gal, February 20. Pesce, A., Negre, M., and Cassuto, J. P. (1987) Knowledge of HIV Contamination Modalities and Its Consequence on Seropositive Patients' Behavior. Presented at the Third International AIDS Conference, Washington, D.C., June 1-5. Peterson, J., and Bakeman, R. (1988) The epidemiology of adult minority AIDS. Multicultural Inquiry and Research on AIDS 2:1-2. Polich, J. M., Ellickson, P. L., Reuter, P., and Kahan, J. P. (1984) Strategies for Controlling Adolescent Drug Use. Santa Monica, Calif.: Rand Corporation. Potts, M. (No date) Using Controversy to Promote Condoms. Family Health Interna- tional, Research Triangle Park, N.C. Pratt, W. F., and Hendershot, G. E. (1984) The use of family planning services by sexually active teenagers. Population Index 50:412-413. Presidential Commission on the Human Immunodeficiency Virus Epidemic. (1988) Report of the Presidential Commission on the Human Immunodeficiency Virus Epidemic. Washington, D.C.: Government Printing Office. Reuben, N., Hein, K., Drucker, E., Bauman, L., and Lanby, J. (1988) Relationship of High-Risk Behaviors to AIDS Knowledge in Adolescent High School Students. Presented at the Annual Research Meeting, Society for Adolescent Medicine, New York City, March 24-27. Rogers, E. M. (1962) Diffusion of Innovations. New York: Free Press. Rogers, E. M., and Adhikarya, R. (1980) Diffusion of innovations: An up-to-date review and commentary. In D. Nimmo, ea., Communication Yearbook 3. New Brunswick, N.J.: Transaction Books. Rosenstock, I. M. (1960) What research in motivation suggests for public health. American Journal of Public Health 50:295-302. Rothbart, M., Dawes, R., and Park, B. (1984) Stereotyping and sampling biases in intergroup perception. Pp. 109-134 in J. R. Eiser, ea., Attitudinal Judgment. New York: Springer-Verlag. Sabatier, R. (1988) Blaming Others: Prejudice, Race, and Worldwide AIDS. Wash- ington, D.C.: The Panos Institute. Schmid, G. P., Sanders, L. L., Blount, J. H., and Alexander, E. R. (1987) Chancroid in the United States. Journal of the American Medical Association 258:3265-3268. Shweder, R. A. (1979) Rethinking culture and personality theory: A critical examina- tion of two classical postulates. Ethos (Fall):255-278. Soucy, J. (1987) Human Immunodeficiency Virus Antibody Disclosure and Behav- ior Change. Presented at the Annual Meeting of the American Psychiatric Association, Chicago, Ill., May 9-14.

FACILITATING CHANGE ~ 315 Stall, R., Wiley, J., McKusick, L., et al. (1986) Alcohol and drug use during sexual activity and compliance with safe sex guidelines for AIDS: The AIDS behavioral research project. Health Education Quarterly 13:359-371. Strecher, V. J., DeVellis, B. M., Becker, M. H., and Rosenstock, I. M. (1986) The role of self-efficacy in achieving health behavior change. Health Education Quarterly 13:73-91. Sutton, S. R. (1982) Fear-arousing communications: A critical examination of theory and research. In J. R. Eiser, ea., Social Psychology and Behavioral Medicine. New York: John Wiley & Sons. Turner, C. F., Miller, H. G., and Barker, L. (In press) AIDS research and the behavioral and social sciences. In R. Kulstad, ea., AIDS 1988: A Symposium. Washington, D.C.: American Association for the Advancement of Science. U.S. Department of Education. (1987) AIDS and the Education of Our Children: A Guide for Parents and Teachers. Washington, D.C.: U.S. Department of Education. Valdiserri, R. O., Lyter, D., Callahan, C., et al. (1987) Condom Use in a Cohort of Gay and Bisexual Men. Presented at the Third International AIDS Conference, Washington, D.C., June 1-5. Valdiserri, R. O., Lyter, D., Leviton, L. C., Callahan, C. M., et al. (1988) Variables influencing condom use in a cohort of gay and bisexual men. American Journal of Public Health 78:801-805. Vincent, M., Clearie, A. F., and Schluchter, M. D. (1987) Reducing adolescent pregnancy through school and community-based education. Journal of the American Medical Association 257:3382-3386. Watters, J. K. (1987) Preventing Human Immunodeficiency Virus Contagion Among Intravenous Drug Users: The Impact of Street-Based Education on Risk Behavior. Presented at the Third International AIDS Conference, Washington, D.C., June 1-5. Weinstein, N. D. (1987) Unrealistic optimism about susceptibility to health problems: Conclusions from a community-wide sample. Journal of Behavioral Medicine 10:481-500. Willoughby, B. M., Schechter, T., Boyko, W. J., Craib, K. J. P., Weaver, M. S., and Douglas, B. (1987) Sexual Practices and Condom Use in a Cohort of Homosexual Men: Evidence of Differential Modification Between Seropositive and Seronegative Men. Presented at the Third International AIDS Conference, Washington, D.C., June 1-5. Winkelstein, W., Samuel, M., Padian, N. S., et al. (1987) The San Francisco Men's Health Study. III. Reduction in human immunodeficiency virus transmission among homosexual/bisexual men, 1982-1986. American Journal of Public Health 77:685-689. Zabin, L. S., Hirsch, M. B., Smith, E. A., Strett, R., and Hardy, J. B. (1986) Evaluation of a pregnancy prevention program for urban teenagers. Family Planning Perspectives 18:119-126. Zelnik, M., and Kim, Y. J. (1982) Sex education and its association with teenage sexual activity, pregnancy, and contraceptive use. Family Planning Perspectives 14:117-126. Zelnik, M., and Shah, F. K. (1983) First intercourse among young Americans. Family Planning Perspectives 15:64-70.

Next: 5 Evaluating the Effects of AIDS Interventions »
AIDS, Sexual Behavior, and Intravenous Drug Use Get This Book
×
Buy Hardback | $90.00
MyNAP members save 10% online.
Login or Register to save!
Download Free PDF

The AIDS virus is spread by human behaviors enacted in a variety of social situations. In order to prevent further infection, we need to know more about these behaviors. This volume explores what is known about the number of people infected, risk-associated behaviors, facilitation of behavioral change, and barriers to more effective prevention efforts.

  1. ×

    Welcome to OpenBook!

    You're looking at OpenBook, NAP.edu's online reading room since 1999. Based on feedback from you, our users, we've made some improvements that make it easier than ever to read thousands of publications on our website.

    Do you want to take a quick tour of the OpenBook's features?

    No Thanks Take a Tour »
  2. ×

    Show this book's table of contents, where you can jump to any chapter by name.

    « Back Next »
  3. ×

    ...or use these buttons to go back to the previous chapter or skip to the next one.

    « Back Next »
  4. ×

    Jump up to the previous page or down to the next one. Also, you can type in a page number and press Enter to go directly to that page in the book.

    « Back Next »
  5. ×

    To search the entire text of this book, type in your search term here and press Enter.

    « Back Next »
  6. ×

    Share a link to this book page on your preferred social network or via email.

    « Back Next »
  7. ×

    View our suggested citation for this chapter.

    « Back Next »
  8. ×

    Ready to take your reading offline? Click here to buy this book in print or download it as a free PDF, if available.

    « Back Next »
Stay Connected!