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4 Facilitating Change in Health Behaviors This chapter summarizes some of the major findings of research that has been undertaken to understand how to facilitate change in human behavior to prevent disease and promote health.) Special attention has been given to the way this research relates to altering the behaviors associated with the transmission of HIV infection. At the beginning of its study, the committee had hoped that factors clearly associated with altering HIV-related behaviors could be identified by examining evaluations of existing AIDS prevention programs. Unfortunately, although considerable behavioral change has been documented among the individuals who reported engaging in high-risk behavior, much less attention has been paid to under- standing how and why those changes occurred. There has been little useful evaluation of the few major intervention programs that have been undertaken, and there have been even fewer studies that com- pared the efficacy of alternative interventions (Office of Technology Assessment, 1988~. Consequently, the committee has had to rely on a more basic analysis of intervention strategies, using principles of human behavior established through empirical research in the social and behavioral sciences, to suggest useful programs to prevent the spread of HIV infection. 1 there are many literatures that report empirical findings of behavioral studies that have attempted to modify individuals' health-related behaviors (e.g., promotion of seat belt use, participation in screening and immunization programs, compliance with prescribed regimens). However, because of the many unique features surrounding the behaviors involved in the transmission of HIV, this chapter emphasizes only those principles of behavior and research findings that appear to be most directly related to the behaviors that can transmit HIV. 259

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260 ~ LIMITING THE SPREAD OF HIV AIDS intervention programs have been established out of the need and desire to act quickly. The tremendous effort that has al- reacly been expended to halt the spread of infection is laudable; nevertheless, the committee has concluded that much more could be accomplished. Well-designed research programs and effective inter- vention strategies are-needect to maximize the likelihood of progress. Furthermore, the design of such activities must take into considera- tion a wicle range of conceptual and empirical research approaches, derived from the various fields that make up the social ant! behav- ioral sciences. There are also methodological issues that must be addressed. (These are discussed in detail in the next chapter.) Much is understood about human behavioral change and about messages and their effectiveness. Yet the application of these ideas to spe- cific groups typically can be undertaken in more than one way, and rarely is theory strong enough to tell us in advance which method will be the more effective. This state of knowlecige leads to two central methoclological principles: (1) the practice of using planned variations in messages, programs, and campaigns should be standard! in AIDS intervention programs, and (2) a plan for evaluating the comparative success of the variations should be a critical component of any intervention. Only in this manner can the most effective in- terventions be rapidly and reliably determined. To "streamline" the preparation of educational materials and intervention programs by choosing a single, "best-we-think-we-can-do" product is to delay the identification of effective intervention strategies. Two fundamental themes can be seen in the principles of behav- ior presented in the following pages: 1. For behavior to change, individuals must recognize the problem, be motivated to act, and have the knowledge and skills necessary to perform the action. 2. To increase the likelihood of action, impediments in the social environment must be removed or weakened and inducements for change provided whenever possible. By focusing on facilitating change in risk-associated behavior, the committee does not wish to impute a diminished importance to maintaining those behaviors that are not associated with risk. Clearly, the best way to prevent IV cirug-associated HTV transmis- sion is to prevent the use of drugs. However, intravenous use of illicit cirugs is a Tong-standing problem in U.S. society; it has resisted pre- vention efforts to date and is unlikely to disappear in the foreseeable future. Sexual behavior must also be considered in realistic terms.

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FACILITATING CHANGE | 261 Although social norms present sexual abstinence as a lauciable goal for the aclolescent population and monogamy as an appropriate sta- tus for adults, the data presented in Chapter 2 clearly show that the realities of sexual behavior are not always consistent with the norms. Changing the behavior of individuals is important in the management of many health problems; it is critical in the prevention of AIDS. Motivating anti sustaining change in risk-associated intimate and addictive behaviors are not easy; they will require a continued com- mitment to diverse and, at times, innovative approaches. Yet there is much reason to be hopeful about the potential for success of behav- ioral interventions to prevent the spread! of HIV infection. A wealth of research on health behavior indicates that indivicluals are certainly capable of undertaking changes in important areas of conduct; in- deecI, substantial changes in individual behavior have already been reported among homosexual men and IV drug users in response to the AIDS epidemic (Becker and Joseph, 1988; Office of Technology Assessment, 1988~. Surveys of IV drug users from the New York City area indicate high levels of awareness and knowledge about AIDS, increased demand for treatment, and substantial changes in needIe- sharing practices and the sterilization of injection equipment (Des JarIais, 1987~. The variations in the amount and types of change that have been reported across groups and by geographic location should not detract from the substantial modifications made by those at greatest risk of this fatal disease. As Becker and Joseph have noted, "in some populations of homosexual/bisexual men, this may be the most rapid and profound response to a health threat which has ever been documented" (1988:407~. In this chapter the committee identifies factors that are likely to help an individual alter risk-associated behaviors and sustain healthy ones. Providing accurate, appropriate, and effective information is the logical starting point for any health program. Education plays an important role in facilitating behavioral change, allaying unnec- essary fears, and reducing discrimination. However, as the commit- tee's discussion of education programs indicates, information alone is generally insufficient to alter behavior. Therefore, the chapter also provides an analysis of the strategies needed to motivate in(livi~luals to change unhealthy behaviors and to sustain healthy ones. Because the behaviors of interest are enacted in social situations, the final sec- tions of the chapter include discussions of the social support needed to facilitate health behavior and the existing social impediments that

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262 ~ LIMITING THE SPREAD OF HIV hinder change in individual behavior and the implementation of HIV prevention programs. EDUCATION PROGRAMS For behavior to change, individuals must unclerst end the risks they incur by engaging in that behavior. In this section, the committee reviews the role of education programs in preventing HIV infection, including the behavioral mollifications that increased knowledge can reasonably be expected to accomplish. The remainder of the section focuses on three aspects of such programs that have- particular rele- vance for AIDS prevention: (1) the content of health messages and, especially, the level of fear evoked by the message; (2) the role of the merlin in purveying health messages ant! the effect of risk percep- tion on taking appropriate action; and (3) the problems associate<] with the introduction and adoption of new ideas and technologies, including antibody testing. The Role of Education ant! Knowledge in Preventing the Spread of HIV Infection Information is necessary but often insufficient by itself to effect be- havioral change. Consequently, the association between knowledge and facilitating behavioral change is of particular interest to interven- tion planners. Empirical studies have found knowledge about HIV and its transmission to be of varying importance in effecting and sus- taining behavioral change (Emmons et al., 1986; Kelly et al., 1987b). Becker and Joseph (1988) postulate that there may be a "threshold" effect: beyond a certain level, increases in knowledge or changes in attitude may not increase changes in behavior. Alternatively, an indirect relationship may exist between knowledge and attitudes, on the one hand, and behavior, on the other; another possibility is that intervening variables may link these factors. Yet the uncertainties surrounding the role of information in behavioral change do not oh viate the need for this basic element of health programs: it would be unconscionable not to provide accurate, comprehensible information about HIV and AIDS. Thus, the logical starting point for any AIDS education program is the provision of information. General information about AIDS, including facts about the causative virus and routes of transmis- sion, has been successfully disseminated through posters, pamphlets, radio and television, word-of-mouth, community communications

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FACILITATING CHANGE ~ 263 networks, and, recently, a brochure from the Public Health Service, which was mailed to every househoIcl in the United States. AIDS is very much on the public's mind. In national surveys, approxi- mately 90 percent of respondents reported seeing, hearing, or reacting something about AIDS within the last week (Dawson et al., 1988~; in public opinion polis,-almost all respondents knew that AIDS is caused by a virus that is transmitted through sexual behaviors or shared injection equipment (Turner et al., in press). The public also holds numerous erroneous- beliefs, however, and questions persist about the role of kissing and toilet seats in the transmission of HIV. It is important, therefore, to understand how to provide additional information. As AIDS education efforts continue, more attention must be di- rected toward how the material is presented. Print and broadcast media offer the economy of reaching many people with a unified message. However, face-to-face communication for hard-to-reach in- clividuals (e.g., {V drug users) is also needed to clarify questions, deal with fear or inertia, ant! facilitate access to needed goods and services. It must be recognized by those designing education programs that access to mainstream sources of information for minority groups and others may be limited by Tower levels of eclucational achievement and a limited capacity to comprehend messages in English. Information must be delivered in a manner that is comprehensible and relevant to the audience it is intended to reach. Clearly, this requirement will en- tai] providing written and spoken messages in the different languages and idioms of the various ethnic, racial, social, age, and sexual ori- entation groups that make up the national population. Much of the currently available information on AIDS and HIV transmission floes not fulfill these criteria. An analysis of 16 educational brochures on AIDS prevention found that, on the average, they were written at a 14th-grade (second year of college) reading level (Hochhauser, 1987~. This is clearly unsatisfactory. There is also a need in AIDS education for frank exchange that allows no misunclerstanding. Clear, explicit language is required; yet its use in AIDS education continues to be impeded by the pervasive American reticence about discussing sexual behavior (see Chapter 7~. The results of such reticence and the lack of straightforward com- munication are seen in the misconceptions that remain about HTV transmission. For example, the use of the expression "exchange of bodily fluids" in early information campaigns left many people with unsubstantiated concerns about the risk associated with kissing; oth- ers may not have understood this term to include the presem~nal and

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264 ~ LIMITING THE SPREAD OF HIV vaginal fluids present during foreplay. Many adolescents continue to believe that HIV infection can be acquired through casual contact, such as shaking hands or simply being near someone with AIDS (Di- Clemente et al., 1986, 1988; Reuben et al., 1988~. In some instances, the lack of clear information encourages continued risk-associatec! behavior. Some IV drug users, for example, still believe that water is sufficient for sterilizing injection equipment; others believe infected individuals can be identified by their appearance. Moreover, homo- sexual men who believed they had successfully "fought off" the virus (as one would fight off the flu- by mounting an antibody response) were more likely to report continued participation in high-risk sex- ual activities than men who had a clearer, more accurate sense of whether or not they were infected (Coates et al., 1985~. In other instances, misinformation impedes desirable behavior. Among the general population, more than one quarter of a national sample (26 percent) believed that a person could get AIDS from donating blood (Dawson et al., 1988~. Mocles of information dissemination are another aspect to be considered in providing AIDS education. An example of the use of a spectrum of networks to disseminate AIDS messages is the program created by the San Ffancisco AIDS Foundation in the early years of the epidemic (Communication Technologies, 1987~. One component involved advertising campaigns that were designed to reach large numbers of people: ads urging safer sexual practices and providing information about AIDS were placed in newspapers and magazines, on billboards, ant! in buses and other forms of public transportation. They were also carried on television and radio. To achieve greater visibility and acceptability in the local gay population, a widely dis- tributec3 and controversial poster featured two nude men embracing with the caption, "You Can Have Fun and Be Safe, Too" (Com- munication Technologies, 1987:11~. Later communications used the theme, "The Best Defense Against AIDS Is Information" and tar- geted a broader population. Pamphlets published in the languages spoken in the community were (distributed through the mail, in the streets, at public forums, and through health care facilities. (These materials included "Can We Talk?," a brochure for homosexual men that has been translated and copied around the world.) A project to provide anonymous antibody testing with counseling was also implemented, anti appeals to provide protection through anti~lis- crimination legislation were promoted. The program also attempted to teach safer sex skills and en- hance the erotic attractiveness of safer sex. One project, called . . . . . . . . .

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FACILITATING CHANGE ~ 265 "Bartenders Against AIDS," provided information on AIDS preven- tion to local bartenders and included training on how to support safer sex among customers (Communication Technologies, 1987:17~. Small group meetings were helcT in individuals' homes and elsewhere (the Stop AIDS Project-) to clarify the guidelines of safer sex practices and produce commitment to their use through face-to-face interac- tion and discussions. Over time, the design of the campaign was altered, based on the findings of marketing research. In addition, pamphlets anct flyers were updated regularly to reflect new material and epiclemiological findings and to reach new audiences. Founda- tion personnel collaborated with journalists to assist in the process of creating informative, accurate articles. The community-level programs noted above are supported and complemented by educational efforts at the federal level. CDC is the lead agency for AIDS prevention programs in the Public Health Service. It supports a range of extramural information and education activities and selected intramural efforts, including . a multimillion-dolIar school education program; . a national hot line; . a multimedia advertising campaign whose slogan is "America Responds to AIDS"; a national clearinghouse for printed AIDS information available to the public on request; . multimillion-(lollar cooperative agreements with the 50 states, 5 territories, and 4 other locales to support com- munity task forces, hot lines, and antibody testing and counseling; and . community demonstration projects to disseminate in- formation, promote change in social norms and risk- associated behavior, and provide antibody testing anct counseling. . As cletailed later in this chapter, there is clearly more to influenc- ing health behavior than the provision of information, as has certainly been seen in smoking and drug prevention campaigns. To change be- havior, at a minimum, indivi(luals need to perceive that they are personally at risk of acquiring a serious condition, that efficacious preventive actions can be undertaken, and that barriers to initiat- ing or continuing these preventive practices can be minimized or overcome (Janz and Becker, 1984~. Supportive environments ensure a quicker adoption and more consistent maintenance of behavioral change. Education, however, is the beginning. Various agencies in

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266 ~ LIMITING THE SPREAD OF HIV the public and private sectors have been making considerable efforts to provide information on the AIDS epidemic to the public. Federal efforts have been hampered by constraints on the use of language that can convey the AIDS prevention message frankly and explicitly. The committee finds that the gravity of this epidemic allows no room for misunderstanding. The committee recommends making in- formation available in clear, explicit language in the idiom of the target audiences The Function of Fear in Health Messages Information, prevention, and treatment programs for sexually trans- mitted diseases (STDs) for both the military ant! civilian populations have relied to varying extents on threatening messages that evoke high levels of fear. Similar tactics have been used in programs to prevent AIDS. (For example, such messages as "Bang Bang You're Dead" have been used to call attention to the fatal consequences of sexually transmitted HIV infection.) Whether these messages have been effective in changing behavior is not known because there have been no controller! studies or evaluations of their impact. Research suggests, however, that the efficacy of such a frightening and unin- forming message is doubtful. Messages designed to evoke high levels of fear or those that rely exclusively on threats may be intuitively appearing in the case of pre- venting a deadly disease, but they have been shown to be effective for most people only if coupled with advice about how behavioral change can reduce the threat (Sutton, 1982; Becker, 1985~. Anxiety alone does not necessarily lead to behavioral change. For example, in the syphilis campaign undertaken early in this century, the edu- cational messages crafted for the military sought to arouse fear in the troops (Brandt, 1987~. Knowlecige about STDs was measured in military inductees before and after STD prevention films (e.g., "Fit to Fight" and "Fit to Wind. Premovie and postmovie mea- surements revealed that these strategies changed general impressions about STDs (e.g., horror and fear were increased and persisted for weeks after the viewing), but knowledge and behavior did not change (LashIey and Watson, 1922~. During World War IT, however, when a prophylaxis program based on condoms and treatment was initiated, soldiers responded favorably. As many as 50 million concloms were accepted by soldiers each month, and rates of syphilis declined in this population over that time (Brandt, 1987~. Nevertheless, the lack of a systematic evaluation of the message and prophylaxis programs (a

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FACILITATING CHANGE ~ 267 shortcoming of most STD programs) foils any attempt to draw con- clusions as to what factors did or clid not work in reducing syphilis in this population. Like the military STD prevention programs, early drug preven- tion programs for youths were largely aimed at providing information ant! evoking fear (Polich et al., 1984~. The content of the message and the time devotee! to the presentation of information varied greatly across the programs, making it difficult to compare their relative effectiveness. Yet general trends in the findings that have been pro- duced indicate that knowledge alone floes not change drug-associatec! behaviors, nor do messages with high threat content. School-basec! programs that rely heavily on fear have not been successful, appar- ently because the fear is associated with a Tow-probability event and because there is a substantial time lag between risk-associated be- havior and adverse outcome (Des JarIais and FYiedman, 1987~. The assumption that teenagers would not use drugs if they were informed about the inherent dangers of drug use clid not take into account the social factors involved in initiating and sustaining drug-use behavior. Ideally, health promotion messages should heighten an individ- ual's perceptions of threat and his or her capacity to respond to that threat, thus moclulating the level of fear. Job (1988) has proposed five prescriptions for the role of fear in health education messages: 1. Messages containing elements of fear should be intro- ducec! before discussing the desired behavior. 2. The behavior or event that is associated with the risk should be perceived as real ant! likely to occur to the audience targeted for that message. 3. A reasonable, desirable alternative behavior that pro- tects against the undesired health problem should be offered. Attention to short-term benefits is desirable and can reinforce Tong-term behavioral change. 4. The level of fear invoked should be sufficient to cre- ate awareness of a potential problem but not so high as to evoke denial. Similarly, the fear level should be low enough that it can be effectiveIv managed bv the adoption of the desired behavior. 5. The resulting reduction in fear should be of such mag- nitude that it will reinforce the desired behavior and confirm its effectiveness. ~ ~7 ~ What is not yet known is how to introduce fear in the right way in a particular message intended for a particular audience. Acquiring

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268 ~ LIMITING THE SPREAD OF HIV that knowledge will require planned variations of AIDS education programs that are carefully executed and then carefully evaluated. The committee recommencIs that AIDS prevention mes- sages strike a balance in the level of threat that is conveyed. The level should be sufficiently high to motivate individuals to take action. However, it should not be so high that it paralyzes individuals with fear or causes them to deny their susceptibility. Fear-arousing health promotion messages must also provide specific information on steps that can be taken to protect the individual from the threat to his or her well-being. The Role of the Media The media play an important role in informing individuals about and alerting them to health risks. They can also help people develop rele- vant protective social skills (e.g., how to resist peer pressure without losing face, how to ask questions, how to receive information from authority figures) and technical skills (e.g., how to use a condom, how to sterilize a needled. In addition, the media influence and are influenced by the norms of the community. This committee concurs with the findings of the {OM/NAS AIDS committee (IOM/NAS, 1988) and the Presidential Commission on the Human Immunodefi- ciency Virus Epidemic (1988~; both of these bodies found that the gravity of HIV infection calls for an expanded use of the media in educational activities. Because of a lack of evaluation of AIDS media campaigns in the United States, little can be said about their impact on risk- associated behaviors. Yet there can be little doubt that the media play important roles in transmitting factual information and in help- ing to create a social climate conclusive to the successful change of health-related conduct. An obvious example is the use of the mass media in antismoking campaigns. Since 1973, adult per capita to- bacco consumption has fallen every year; it is presently at its lowest point in a century. There is general agreement that extensive, sus- tained mass merlin health promotion programs played an important role in this achievement (Flay, 1987~.2 2To date, evaluations have been conducted of 40 mass media campaigns that attempted to influence smoking behavior through broadcast information on health risks posed by cigarettes, printed information to promote smoking cessation (fact sheets, self-help man- uals, and hot lines), and self-help clinics. At follow-up intervals ranging from 3 to 12 months, the following mean percentages of participants had continued success in quit- ting smoking (the data are presented by type of cessation program): American Lung Association cessation manual, 3-4 percent; American Lung Association manual and

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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~.

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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.

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306 ~ LIMITING THE SPREAD OF HIV te(1 infections (Brooks-Gunn and Furstenberg, in press). Typically, other services are also provided, including physical examinations, treatment for illness and injury, immunization, and drug and alcohol programs. Most programs require parental consent, with blanket per- mission for all health services offered. Test results and consultations are confidential. Evaluations of school-based clinics are currently being con(lucted, with promising results reported for some programs (Edwards et al., 1980; Zabin et al., 1986~. Given the resistance ev- idenced in some communities, however, it remains to be seen how many school-based clinics will- be opened in the coming decade. The committee believes that such clinics require the systematic evalua- tion of planned variations to understand! in what settings and for which individuals these programs can promote contraceptive use and HIV prevention. The committee recommends that sex education be avail- able to both male and female students ant! that such educa- tion include explicit information relevant to the prevention of HIV infection. Comprehensive services for adolescents, both those offered in the community and in the school context, should include components that focus directly on the high-risk behaviors- unprotected sex and {V drug use that are associated with the spread of HIV infection. In focusing its attention on the problems associated with pre- venting HIV infection among aclolescents, the committee was not able to acIdress AIDS prevention outside the context of sex educa- tion and school-based clinics. Nevertheless, the committee recognizes that the majority of school-based AIDS education takes place outside these venues and that joint efforts involving the schools and commu- nities may hold the greatest promise for preventing HIV infection, other STDs, and unintended pregnancies (Vincent et al., 1987~. The CDC Guidelines for Effective School Health Education to Prevent the Spread of AIDS (CDC, l98Sb), as well as the Presiclential AIDS Commission, the Institute of Medicine, and other national health and education organizations, have recommended that AIDS educa- tion be integrated within a planned and comprehensive school health education program. Age-appropriate curricula that address HTV prevention, sex education, and drug prevention education have been proposer! for children in kindergarten through grade twelve. A com- prehensive school program that is integrated into community efforts is needed to prevent the unnecessary problems that result when cat- egorical efforts are developed in isolation and without broader public and administrative support. The committee finds health education for children of all ages, especially as it relates to HIV prevention, to

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FACILITATING CHANGE ~ 307 be a very important issue and one that it hopes to address in detail in future activities. THE ROLE OF PLANNED VARIATIONS AND EVALUATION It was the committee's hope that those factors clearly associated with altering sexual and drug-use behaviors could be identified by exam- ining the evaluation data of well-designed programs. Unfortunately, such data do not exist. There are self-reported data on relevant behavioral change: some {V drug users report changes in neecIle- sharing practices and increased sterilization of injection equipment, while some homosexual men report less unprotected anal intercourse. Yet little attention has been paid to understancling how and why these changes have occurred or the extent to which they have been instituted by different groups in different places. Altering the course of the AIDS epidemic will depend on an iter- ative process in which intervention programs are implemented, their effects assessed, and a new and better set of intervention programs designecl and implemented. Any intervention program is likely to involve many aspects, each of which would require choosing from a set of possible alternatives (there may be several choices available among target groups and approaches to them, media, program ma- terials, delivery modes, timing, and so forth). The "best" choice is not always clear for at least some of these aspects. This fact poses a strategic opportunity that should not be lost: progress in program improvement can be much accelerated by deliberately using two or more alternatives for some of the key choices. This strategy has been referred to in this chapter as planned variation. The com- mittee recommends that planned variations of key program elements be systematically and actively incorporated into the design of intervention programs at an early stage. There are great advantages to conditions in which several acl- missible variants can be tried out in parallel. First, some successful combination is more likely to emerge if several promising variants are used. Second, ideas that are actually inferior can be more promptly identified and dropped. Third, ideas that are actually superior can be more quickly recognized. Fourth, a broader understanding of what works and why it works can build up a systematic base of knowlecige. The principles of behavior discusser! in this chapter form the basis for selecting the most promising program variations. The committee recommencIs that the Public Health Service

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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.

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