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Applying Persuasion Strategies to Alter HIV-Relevant Thoughts and Behavior



Health communication strategies are at the core of both mass media campaigns and public health interventions conducted at the community level concerning the prevention of HIV/AIDS. They are often nested in complex contexts that prevent us from being able to identify the persuasive impact of a specific message. The authors attempt to account for an array of factors contributing to the persuasiveness of messages about HIV. The aim is to synthesize the psychological literature on persuasion and thus provide a conceptual framework for understanding message effects in HIV communications. This discussion concerns fear appeals, message framing, tailoring, cultural targeting, and additional factors pertaining to the message, source, and channel of the communication. Whenever possible, recommendations for further research are formulated. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Applying Persuasion Strategies to Alter HIV-Relevant Thoughts
and Behavior
Loraine Devos-Comby and Peter Salovey
Yale University
Health communication strategies are at the core of both mass media campaigns and
public health interventions conducted at the community level concerning the prevention
of HIV/AIDS. They are often nested in complex contexts that prevent us from being
able to identify the persuasive impact of a specific message. The authors attempt to
account for an array of factors contributing to the persuasiveness of messages about
HIV. The aim is to synthesize the psychological literature on persuasion and thus
provide a conceptual framework for understanding message effects in HIV communi-
cations. This discussion concerns fear appeals, message framing, tailoring, cultural
targeting, and additional factors pertaining to the message, source, and channel of the
communication. Whenever possible, recommendations for further research are formulated.
In view of the public health threat posed by
the HIV epidemic, government agencies have
invested considerable resources in mass media
campaigns aimed at informing the public about
this disease and its prevention. Numerous be-
havioral interventions have been implemented
as well among vulnerable subgroups of the pop-
ulation with the purpose of shaping health be-
haviors relevant to HIV prevention. Both mass
media and behavioral intervention strategies en-
tail a communication component: Information
is disclosed and transmitted by a source to po-
tential receivers with the purpose of persuading
and inducing behavior change.
In this article, we attempt to account for an
array of factors contributing to this communi-
cation goal. Our aim is not to provide an eval-
uation of media campaigns devoted to HIV/
AIDS; neither is it to conduct an exhaustive
review of complete intervention programs.
Rather, our approach consists of synthesizing
the psychological literature on persuasion to
provide a conceptual framework for under-
standing the particular effectiveness of certain
kinds of messages in HIV communications. We
also review evidence from the literature on
health promotion—and, when available, HIV
prevention—that supports these principles.
We first consider the use of threat appeals to
motivate HIV-preventive behaviors. We pro-
vide an overview of theoretical considerations
regarding the effectiveness of such appeals and
then discuss studies investigating the impact of
HIV communications based on threat. The sec-
ond section addresses the role of message fram-
ing in the promotion of various health behav-
iors. Few investigators have studied systemati-
cally the impact of gain and loss frames on the
persuasiveness of HIV-related messages. The
findings obtained in this area reveal the com-
plexity of HIV-relevant behaviors, notably with
respect to the perceived risk or uncertainty as-
sociated with them. They also underscore the
importance of matching the type of frame used
to individuals’ risk appraisals. In the third sec-
tion, we report research designed to match mes-
sages to characteristics of the population or
individuals targeted. The tailoring of informa-
tion about cancer prevention offers a good il-
Editor’s Note. Geoffrey Cohen served as the action editor
for this article.—PS
Loraine Devos-Comby and Peter Salovey, Department of
Psychology and Center for Interdisciplinary Research on
AIDS, Yale University.
Preparation of this article was supported by funding from
the National Institute of Child Health and Human Develop-
ment, by a Swiss National Science Foundation fellowship
awarded to Loraine Devos-Comby, and by National Insti-
tute of Mental Health Grant P01-MH/DA 56826 to Peter
Salovey. We thank Kim Blankenship, Diana Cordova, and
the members of the Health, Emotion, and Behavior Labo-
ratory for their comments on early versions of this article.
Correspondence concerning this article should be ad-
dressed to Loraine Devos-Comby or Peter Salovey, De-
partment of Psychology, Yale University, P.O. Box
208205, New Haven, Connecticut 065208205. E-mail: or
Review of General Psychology Copyright 2002 by the Educational Publishing Foundation
2002, Vol. 6, No. 3, 287–304 1089-2680/02/$5.00 DOI: 10.1037//1089-2680.6.3.287
lustration of what could be done in HIV com-
munications. In HIV/AIDS prevention, match-
ing so far has been limited mostly to cultural
targeting. Finally, we discuss additional factors
deserving greater attention in HIV-related mes-
sages. In all sections, we strive to identify the
areas needing further research and to provide
directions for this work. Overall, we intend to
underscore the contributions of theory drawn
from the persuasion literature to research on
HIV-relevant communications.
Fear and Threat Appeals
When and How Are Threat Appeals
Threat appeals had been used in persuasive
communication long before the ght against
HIV and AIDS became the focus of important
prevention efforts. The notion of threat appeals
refers to messages stressing harmful (physical,
social, psychological, or emotional) conse-
quences if a recommendation is not followed. It
is usually assumed that threat appeals induce
fear; therefore, they are frequently referred to as
fear appeals (however, this assumption has not
often been tested; Petty & Wegener, 1998).
Although threat is generally the antecedent of
fear, this emotional reaction is not necessarily a
systematic response to threat appeals.
Several hypotheses accounting for the role of
fear in persuasion have been proposed (Hale &
Dillard, 1995). According to the original hy-
pothesis (Hovland, Janis, & Kelley, 1953),
threat appeals produce fear or anxiety about the
negative consequences depicted in the message.
This emotional reaction prompts compliance
with the recommendations if the advocated be-
haviors are perceived as effective to avoid these
negative consequences. In these conditions, the
more fear arousing the message, the more ef-
fective the appeal. A second hypothesis (Janis
& Feshbach, 1953) involves the defensive
avoidance or resistance triggered by messages
that cause high levels of fear without providing
ways of avoiding the negative outcomes de-
picted. Under these circumstances, the stronger
the emotional reaction following threat appeals,
the greater the resistance to persuasion. A third
explanation for the role of fear in persuasion
attempts to reconcile the previous two hypoth-
eses (G. R. Miller, 1963). It posits a curvilinear
relationship between fear and persuasion: Fail-
ure to persuade is likely when levels of fear are
too low or too high; only intermediate levels
lead to persuasion. Two meta-analyses con-
ducted on studies testing the impact of threat
appeals showed that, overall, increases in fear
were associated with increased persuasion, a
conclusion consistent with the rst hypothesis
and at odds with the resistance and curvilinear
hypotheses (Boster & Mongeau, 1984; Sutton,
1982). However, the changes associated with
fear were observed with behavioral intentions
and only to a much smaller extent with actual
Other researchers have tried to dene the
conditions under which fear leads to persuasion.
For instance, according to Leventhal (1971),
threat appeals arouse the emotion of fear and the
motivation to manage this fear. At the same
time, threat appeals trigger the need to eliminate
the potential danger evoked by the message.
Thus, receivers may attempt to reduce the emo-
tion of fear (fear control) or to avoid the nega-
tive consequences depicted in the message (dan-
ger control). Only the latter would lead receiv-
ers to follow the recommendation. Although
this model raises an important distinction, it
does not specify the conditions under which
each motivation (fear control and danger con-
trol) would come into play.
Witte (1992) extended Leventhals (1971)
model by delineating these conditions. First,
both processes need some level of threat to be
activated (the message must engender substan-
tial fear, and the danger must be perceived as
such). In conditions of high fear, the extent to
which danger control operates depends on the
efcacy of the recommendation. If the message
contains an effective method of avoiding the
negative outcome, receivers will be motivated
to comply with it. If the message does not spell
out the means to avoid the undesirable conse-
quences, receivers will be motivated to control
their fear by engaging in emotion regulation.
The models reviewed thus far address the
emotional component of persuasion following
threat appeals. Protection motivation theory
(Rogers, 1983), on the other hand, describes the
cognitive components of effective threat ap-
peals. According to this framework, threat ap-
peals are effective to the extent that they con-
vince receivers that (a) the consequences are
very undesirable (severity of threat), (b) the
consequences represent a danger for them (vul-
nerability to the threat), (c) they can avoid the
negative outcome by following the recommen-
dation (response efcacy), and (d) they have the
ability to engage in the recommended behavior
(self-efcacy). According to protection motiva-
tion theory, the greater the extent to which a
message contains these four components, the
more effective it will be, irrespective of the
level of fear elicited.
Several pitfalls must be avoided when one is
using threat appeals (Petty & Wegener, 1998).
On one hand, individuals often tend to minimize
the likelihood that they will experience severe
outcomes because of self-protective motives.
On the other hand, if threat appeals are too
strong, they may elicit an intense emotional
reaction likely to reduce message processing. In
some cases, this lack of careful examination of
the message arguments may reduce persuasion.
Fear and Threat Appeals in HIV
Probably because of the deadly consequences
of AIDS and the serious threat posed by the
spread of HIV, the use of fear and threat appeals
has been a widespread strategy to motivate
HIV-preventive behaviors (Freimuth, Ham-
mond, Edgar, & Monahan, 1990). Evocations of
death and morbidity have been used commonly
to frighten people in the hope of increasing
feelings of vulnerability, concern, and willing-
ness to protect oneself from these outcomes. For
example, in a poster promoting abstinence dis-
tributed by the Connecticut Department of Pub-
lic Health, the macro-picture of a cell is de-
picted, along with the slogan AIDS eats your
cells, eats your soul, eats your heartprinted on
a red background. The New York State Depart-
ment of Health also used a threat appeal in a
black-and-white poster showing the feet of a
corpse lying on a gurney, a tag with the word
AIDS attached to the left big toe. The phrase
He didnt use a condomis printed at the top of
the poster. The purpose of these two billboards
clearly was to arouse fear.
Laypeople often perceive such appeals as
more effective in promoting HIV-preventive
behaviors than emotionally neutral messages
(Rhodes & Wolitski, 1990). Many designers of
mass media campaigns as well work on the
principle that to catch the attention of individ-
uals and initiate changes in health-threatening
habits, one has to shakeor shock them by
using fear-inducing messages. But does arous-
ing fear really improve the actual effectiveness
of HIV prevention messages? To our knowl-
edge, only a handful of studies have compared
HIV-relevant messages according to their level
of threat.
In two studies, LaTour and his colleagues
examined the responses of samples of college
students to two different advertisements (John-
son & LaTour, 1991; LaTour & Pitts, 1989).
The rst advertisement, sponsored by the Aus-
tralian Ministry of Health, was known as the
grim reaperadvertisement, and it evoked the
deadly consequences of AIDS along with a rec-
ommendation to use condoms (threat appeal).
The second advertisement, sponsored by the
United States Centers for Disease Control and
Prevention, featured a male speaker calmly dis-
cussing the need for using condoms to prevent
HIV infection (control condition). In compari-
son with the neutral message, the authors ob-
served an increase in arousal (tension and en-
ergy) following the threat appeal. Participants
reported greater liking and interest following
the threat appeal, but they also judged this mes-
sage more irritating and less appropriate than
the control advertisement. Because behavioral
intentions and behavior change were not mea-
sured, it is difcult to know the extent to which
the threat-induced arousal actually was effec-
tive in motivating desired action.
Fear arousal does not necessarily lead to the
adoption of health recommendations. In some
cases, it can produce the reverse effect, as illus-
trated by a study in which a cohort of Australian
gay men exposed to the grim reaperadver-
tisement subsequently reduced safer sex behav-
iors (Rosser, 1991). Although the study design
did not explore the mechanism by which this
dramatic effect occurred, the authors concluded
that images suggesting that no one can escape
contracting AIDS and that death is inevitable
for those who are HIV positive may have trig-
gered denial and helplessness.
One can assume that most people fear AIDS
at some level. Research among young adults
and teens has shown high levels of fear of AIDS
(Witte, 1992). However, this does not mean that
people feel personally vulnerable. In fact, most
people often downplay their own personal risk
relative to their perception of othersrisk (Sny-
der & Rouse, 1992). However, according to
protection motivation theory, threat appeals
need to create some level of personal vulnera-
bility or susceptibility if they are to be effective
(Rogers, 1983). In this regard, the role of AIDS
campaigns should be to elicit some level of
personal vulnerability instead of trying to in-
crease levels of fear. Research is needed to
determine how personal vulnerability can be
increased and how this translates into compli-
ance with recommendations. One way to
achieve this might be to heighten the personal
relevance of messages, for instance by cultural
targeting or by presenting a source similar to the
receivers (see later sections on targeting and
source factors).
However, arousing ones personal vulnerabil-
ity might be counterproductive if it is not ac-
companied by recommendations about how to
avoid the threat depicted in the communication.
In some cases, as personal vulnerability in-
creases, receivers engage in denial strategies.
For instance, one study showed that sexually
active participants who watched a lm carefully
crafted to foster feelings of vulnerability per-
ceived their risk of HIV infection as lower than
their peers in a control condition (Morris &
Swann, 1996). The lm increased the perceived
vulnerability of sexually active participants to
the point that they denied their risk as a way to
control fear. On the other hand, participants
who were sexually inexperienced and whose
initial level of personal vulnerability was glo-
bally low (because of the absence of past sexual
risks) were receptive to the vulnerability manip-
ulation: Their perception of personal risk of
HIV infection increased relative to their coun-
terparts in the control condition.
HIV prevention messages should provide re-
ceivers with actions that they perceive as feasi-
ble and effective. In that sense, interventions
aimed at teaching people how to negotiate safer
sex and how to use condoms are likely to in-
crease self-efcacy in regard to such behaviors.
However, many mass media campaigns relying
on fear appeals do not contain components en-
hancing self-efcacy in the behaviors promoted
(Kenny, 1990). For instance, the America Re-
sponds to AIDScampaign presented a hetero-
sexual couple walking with a child and a voice
and written message stating the slogan
AIDSProtect yourself and your familyGet
the facts.The message did not offer any con-
crete way to prevent the disease from destroying
ones family. Other campaigns have proposed a
solution that is not realistic or believable for
everyone: sexual abstinence. Although condom
use remains the best way for sexually active
individuals to prevent the sexual transmission
of HIV, Freimuth and her colleagues (1990), in
their content analysis of AIDS public service
announcements, found that only 18% of the
advertisements reviewed specically recom-
mended condom use to prevent AIDS.
What is the empirical evidence that efcacy
components added to HIV prevention messages
increase their effectiveness? We could nd only
two instances in which this question was inves-
tigated. In an experimental setting, men took
more condoms immediately after having
watched a fear-arousing public service an-
nouncement about AIDS if the message con-
tained the explicit recommendation to use
condoms to prevent HIV transmission (Struck-
man-Johnson & Struckman-Johnson, 1996).
However, the addition of the recommendation
had no effect on intention to use condoms with
sexual partners. Witte (1992) manipulated the
efcacy component more systematically. In
written messages presented to college students,
she either described condoms as highly efcient
in preventing HIV (high efcacy) or empha-
sized that condoms fail sometimes and high-
lighted the problems involved with their use
(low efcacy). Witte also simultaneously ma-
nipulated levels of threat and vulnerability (low,
medium, or high threat and vulnerability). She
measured self-reported condom use 6 weeks
later. The combination of high threat and vul-
nerability with high response efcacy resulted
in an effective persuasive message that led to
behavior change in the desired direction. How-
ever, threat appeals lacking ways to avoid the
negative consequences depicted in the message
produced a boomerang effect, in that partici-
pants were less likely to adopt the recom-
mended behavior. Witte did not investigate the
role of self-efcacy in persuasive HIV-relevant
messages. Insisting on the participantsability
to engage in the behavior might have increased
self-reported condom use.
Personality variables may also moderate the
impact of fear messages. Indeed, people react
differently to fear. Although Dinoff and Kowal-
ski (1999) did not manipulate the level of threat
posed by HIV-relevant messages, they distin-
guished people high and low in protection mo-
tivation on the basis of scales corresponding to
the four components of protection motivation
theory. People high in protection motivation
were more likely than people low in such mo-
tivation to obtain condoms immediately after
reading an HIV-related message. Thus, perceiv-
ing AIDS as a threat and feeling personally
vulnerable to it, but at the same time acknowl-
edging that there are ways to avoid HIV infec-
tion and feeling capable of engaging in preven-
tive behaviors, led participants to engage in a
prevention behavior. Moreover, fear appeals
might be more effective with people who are
realistic about evaluating risks than with people
who tend not to see or to deny a given risk
(Kenny, 1990). In this regard, the distinction
between monitoring and blunting (S. M. Miller,
1987, 1995) is relevant. This distinction per-
tains to two dimensions characterizing styles of
information seeking. When faced with a threat,
high monitors characteristically seek informa-
tion, whereas low monitors avoid it. High blunt-
ers typically try to distract themselves from the
source of the threat, whereas low blunters gen-
erally avoid distraction and show a behavioral
preference for threatening cues. Individual dif-
ferences in these styles of coping with threat are
likely to produce different patterns of reactions
to threat appeals used in HIV communications.
Finally, threatening health messages may
elicit other negative reactions along with fear.
The risk in trying to induce fear in an attempt to
persuade is that HIV prevention messages may
engender other unintended affective responses
such as anger or sadness. These various emo-
tions may in turn initiate different action ten-
dencies that may compete with or contribute to
persuasion. For instance, it has been shown that
participants experiencing a sad mood perceive
themselves as less able to carry out health-
promoting behaviors but as more vulnerable to
diverse negative health outcomes (Salovey &
Birnbaum, 1989). Threat appeals arousing sad-
ness as well, especially those calling upon death
or suffering, may be counterproductive in that
this state leads to decreased self-efcacy in
terms of the behavior promoted and, hence, a
greater reluctance to adopt safer behaviors de-
spite greater perceived vulnerability. Dillard
and his colleagues observed that threatening
public service announcements aimed at pro-
moting HIV-preventive behaviors elicited mul-
tiple emotions such as fear, surprise, sadness,
and puzzlement (Dillard, Plotnick, Godbold,
Freimuth, & Edgar, 1996). Fear and surprise
were associated with increased perceptions of
message persuasiveness; puzzlement seemed to
play against message acceptance, whereas in-
creases in sadness had no systematic effects.
Continued Need for Research on Threat
Appeals and HIV Prevention
More research is needed on the role of emo-
tionsin particular, fearelicited by HIV pre-
vention messages. Because amount of fear elic-
ited is a key factor in determining the persua-
siveness of messages, investigators should
assess the emotional reactions induced by HIV
prevention recommendations. They should also
examine the extent to which HIV-preventive
messages comply with the principles estab-
lished by the persuasion theories discussed pre-
viously. Specically, more attention should be
devoted to the relative contribution of the four
components distinguished by protection moti-
vation theory (Rogers, 1983). The correspon-
dence between levels of threat and behavior
change should be documented, and the moder-
ating role of self-efcacy in the behavior pro-
moted should be assessed.
Finally, one largely ignored issue concerns
the impact of threat appeals on feelings about
sexuality (Paalman & Sandfort, 1990). Do they
make people afraid of sex? If so, is it ethical to
generate such fear? Is it possible to promote
safer sex as something sensual? In short, how
can we communicate that sex is, in itself,
healthy, normal, and pleasurable and that HIV-
preventive messages are not aimed at ghting or
controlling sexuality as such but, rather, encour-
aging minimization of the risks involved?
Message Framing
Differential Influence of Positive or
Negative Wording
A growing body of research documents that
small changes in the wording of recommenda-
tions to motivate health behaviors may produce
signicant differences in their impact. In this
work, the persuasiveness of messages stressing
the costs of not performing the recommended
behavior (loss frame) and messages emphasiz-
ing the benets of following the recommenda-
tion (gain frame) is compared (Rothman &
Salovey, 1997). For instance, as a means of
promoting safer sex, one could stress the costs
of not using condoms through statements such
as If you dont use condoms you are at greater
risk of sexually transmitted diseases(attaining
an undesirable outcome, a loss frame) or If you
dont use condoms you decrease your chance of
staying healthy(not attaining a desirable out-
come, also a loss frame). A gain-framed mes-
sage promoting safer sex emphasizes the bene-
ts of using condoms: If you use condoms you
increase your chance of staying healthy(attain-
ing a desirable outcome) or If you use con-
doms, you are at lesser risk of sexually trans-
mitted diseases(not attaining an undesirable
outcome). As shown in this example, loss-
framed messages can be phrased in two distinct
ways: attaining an undesirable outcome or fail-
ing to attain a desirable outcome.
Similarly, gain-framed messages focus either
on attaining a desirable outcome or not attaining
an undesirable outcome (for similar distinc-
tions, see Brendl, Higgins, & Lemm, 1995; Wil-
son, Purdon, & Wallston, 1988). Although the
dimensions of action (attain vs. not attain) and
outcome (desirable vs. undesirable) represent
important conceptual distinctions (Rothman &
Salovey, 1997), empirical work has not gener-
ally shown differences between the two ways of
operationalizing loss or gain (Apanovitch, Mc-
Carthy, & Salovey, 2002; Detweiler, Bedell,
Salovey, Pronin, & Rothman, 1999). However,
as reviewed subsequently, gain-framed and
loss-framed messages do show systematic
Messages can be framed in gain versus loss
terms without affecting their substantive con-
tent. In the earlier example, the four messages
are factually equivalent: One should use con-
doms.That being said, which frame is more
effective in motivating individuals to adopt
healthy behaviors? Prospect theory enables us
to specify the conditions under which each type
of frame should be more effective (Kahneman
& Tversky, 1984; Tversky & Kahneman, 1981).
This theory proposes that people act to avoid
risks when they consider gains or benets and
that they are more willing to accept risks when
they consider costs as a way of avoiding the
loss. Loss frames are more persuasive when
individuals consider behavioral decisions that
they perceive as risky or uncertain, and gain
frames are more effective in promoting these
decisions when they are seen as involving little
or no risk. For instance, it has been shown that
when college students believed that people of
their age were at risk of coronary heart disease,
a loss-framed message increased their inten-
tions to obtain a blood cholesterol test relative
to a gain-framed message. When participants
believed that only older people were at risk, the
gain frame was more effective (Maheswaran &
Meyers-Levy, 1990; Meyerowitz, Wilson, &
Chaiken, 1991).
The extent to which one considers a specic
behavior as more or less risky depends also on
its goal: whether it is to prevent the onset of a
health problem or detect its development (Roth-
man & Salovey, 1997). Preventive behaviors
usually involve low risks, because they gener-
ally serve to maintain ones health and encom-
pass little uncertainty (e.g., using sunscreen,
eating healthy foods, or exercising). Consistent
with prospect theory, the advantage of gain
frames over loss frames has been shown in the
effects of messages promoting sunscreen use on
both intentions and actual behavioral outcomes
(Detweiler et al., 1999; Rothman, Salovey, An-
tone, Keough, & Martin, 1993).
On the other hand, detection (screening) be-
haviors can inform individuals of a health prob-
lem. Because of the uncertainty of their out-
come, these behaviors involve some risk (e.g.,
obtaining a mammogram involves the risk of a
tumor being found). These immediate risks may
overshadow the important long-term benets of
detection behaviors (i.e., obtaining treatment).
Consistent with prospect theory, loss-framed
messages should be more effective in promot-
ing them than gain-framed messages. This pre-
diction has been supported notably in the cases
of mammography use (Banks et al., 1995;
Schneider et al., 2001) and breast self-examina-
tion (Meyerowitz & Chaiken, 1987). Two ex-
periments systematically compared the impact
of message framing on the promotion of pre-
vention or detection behaviors relevant to the
same disease (Rothman, Martino, Bedell, Det-
weiler, & Salovey, 1999). Participants ex-
pressed greater intentions to engage in the pre-
ventive behaviors when the information was
gain framed than when it was loss framed; loss-
framed messages were more effective at encour-
aging the detection behaviors.
Messages that are framed in unexpected ways
(Smith & Petty, 1996) or that do not match
participantsexperiences or concerns (Tykocin-
ski, Higgins, & Chaiken, 1994) can be more
effective in that they can lead to greater scrutiny
or deeper message processing. For instance,
Tykocinski et al. (1994) found that college stu-
dents who were generally concerned about the
presence of negative outcomes were more will-
ing to comply with the advocacy when the ben-
ets of eating breakfast were claimed than when
the costs of not eating breakfast were stressed.
Conversely, participants concerned about the
presence of positive outcomes expressed greater
intentions to eat breakfast after reading loss-
framed information as opposed to gain-framed
information. The authors suggested that when a
framed message matches peoples current con-
cerns, they can effectively counterargue the
message, thus undermining its impact, whereas
messages mismatched to the general concern
orientation are harder to counterargue and there-
fore more persuasive.
Finally, the personal relevance of an issue or
ones involvement in it has an impact on fram-
ing effects. Several ndings seem to support the
idea that higher involvement with the target
issue leads to greater framing effects. For in-
stance, in one set of studies, only women were
affected differentially by framed messages pro-
moting skin cancer detection and prevention
(Rothman et al., 1993). Men, for whom this
disease is less of a concern, showed no differ-
ential sensitivity to framing (see also Meyero-
witz et al., 1991).
Framing Effects in the Context of HIV
To what extent can we extrapolate from the
ndings of research on sunscreen use or mam-
mography to make predictions about condom
use and HIV testing? Very little research has
examined message framing effects in the pro-
motion of HIV-relevant behaviors. One could
hypothesize that condom use, because it is a
preventive behavior, would be better promoted
by stressing its benets. For instance, one might
say If you use condoms, you will stay healthy,
you will feel peace of mind, or you will feel
more relaxed and comfortable during sex.Sim-
ilarly, because HIV testing is a detection behav-
ior, loss frames could be expected to be more
persuasive. In this case, one might say, If you
dont get tested for HIV, you may feel more
anxious because you may wonder if youre ill,
or you would not access critical medical treat-
ment that you would need if you were HIV
positive.A pair of studies illustrates these two
In one study, Linville, Fischer, and Fischhoff
(1993) examined the impact of frames in terms
of the success rate or failure rate of condoms on
intentions to use them. Although condom use is
the most effective way to prevent the sexual
transmission of HIV if one is sexually active,
condoms do not offer 100% protection, a fact
very often stated in prevention information.
How does priming the effectiveness rate of con-
doms versus their failure rate inuence individ-
ualsintentions to use condoms? When partici-
pants were told of the success rate of a partic-
ular condom brand, they reported more
intentions to use them than when the failure rate
was reported. These results support the notion
that gain frames are more effective in advocat-
ing preventive behaviors such as condom use.
The other study aimed to promote HIV test-
ing among a sample of African American
women (Kalichman & Coley, 1995). A video
presenting the potential costs and losses of not
being tested was found to be more effective than
messages omitting this information. Participants
who watched this video expressed a greater
intent to obtain testing and were more likely to
be tested within 2 weeks after the intervention.
Although this study illustrates the advantage of
using a loss-frame message as compared with
nonframed information, it did not test the supe-
riority of loss frames over gain-framed mes-
sages in promoting HIV testing.
If HIV testing is thought of simply as a de-
tection behavior, then loss-framed language
should be more persuasive. On the other hand,
HIV testing can be perceived as a more or less
uncertain behavior depending on how one ap-
praises ones own risk taking and exposure to
HIV. In the case of some people, HIV testing
involves a somewhat high level of uncertainty:
They are aware of the fact that they have en-
gaged in unsafe behaviors placing them at
greater risk of HIV. Prospect theory predicts
that messages stressing the costs of not obtain-
ing testing will be more effective in bringing
these individuals to accept the risk of nding
that one has HIV. For some individuals, re-
peated HIV tests may have a prevention func-
tion to the extent that they conrm that adequate
measures have been taken to avoid the virus.
For other people, HIV testing does not comprise
any risk at all because they perceive their pre-
vious behaviors as very safe. In the case of these
two groups, one can predict that messages em-
phasizing the benets of HIV testing will be
more persuasive.
We conducted a community-based experi-
ment to test this set of predictions (Apanovitch
et al., 2002). A sample of inner-city women
watched a video, framed either in gain or loss
terms, encouraging participants to obtain HIV
testing. Women who viewed HIV testing as a
behavior with a certain outcome were more
likely to have obtained testing within 6 months
after the intervention if they had seen a gain-
framed, rather than loss-framed, video. The op-
posite was true for participants who viewed
HIV testing as a risky behavior with uncertain
outcomes. These ndings support the notion
that individualsrisk appraisals moderate fram-
ing effects.
Moreover, in this study, we asked a subgroup
of women what they considered the most im-
portant reason to obtain testing for HIV. We
wanted to examine whether women who con-
strued HIV testing as primarily serving preven-
tion goals (i.e., preventing the spread of the
virus to others) were more inuenced by gain-
framed messages than women who construed
HIV testing as primarily serving the goal of
early detection for the purpose of medical treat-
ment. Six months after the intervention, women
who viewed HIV testing as a detection behavior
were more likely to obtain testing if they had
viewed loss-framed messages. Among the
women who viewed HIV testing as a prevention
behavior, gain-framed messages were more ef-
fective. These results illustrate the importance
of taking into account the meaning individuals
assign to the specic behaviors advocated.
Future Directions for Research on
Framing of HIV-Relevant Messages
The empirical evidence gathered to date in-
dicates that the distinction between prevention
and detection, although very useful, does not
always capture or reect individualsappraisals
of risk or uncertainty. The subjective perception
of risk is often at odds with the objective ben-
ets of the behavior advocated. For example,
important social, interpersonal, and personal
risks are often associated with condom use (e.g.,
risk of raising suspicion, offending a partner, or
making sex less enjoyable), which may under-
mine the long-term gains of using condoms.
According to prospect theory, condom use
would be better promoted by gain framing to the
extent that people view this behavior as involv-
ing low risk. However, if social, interpersonal,
and personal negative consequences of condom
use are salient for message receivers, loss
frames will be more effective in persuading
Because the meaning that individuals assign
to the behaviors advocated is likely to vary
notably in terms of risk appraisals, it would be
enlightening to investigate subjective values
and framing effects associated with behaviors
other than condom use and HIV testing. For
instance, public health practitioners may want
to promote the acquisition of condoms or the
negotiation of condom use in dyads. Condom
acquisition might involve more or less risk in
the eyes of individuals depending on whether
they are concerned about embarrassment or
negative evaluations from others (Devos-
Comby & Salovey, 2001). Condom negotiation
with sexual partners may involve interpersonal
risk: the risk of losing face with an important
other or losing a valued relationship (Afifi,
1999). The frames used to promote these spe-
cic behaviors would probably gain in persua-
siveness if they were matched to individuals
perceptions of risks associated with the
Another direction that deserves to be ex-
plored is the role of expectancies in regard to
framing (Smith & Petty, 1996). Which frames
about distinct HIV-relevant behaviors appear as
more natural or more expected? What effect
does frame congruency with expectancies have
on persuasiveness of the messages? To what
extent can we improve the distinct impact of
each frame by manipulating the expectancies in
the opposite direction? How does the general
focus on negative or positive outcomes inu-
ence framing effects in the context of HIV?
How does the personal relevance of the infor-
mation presented inuence the effectiveness of
messages stressing the benets or the costs of
HIV-relevant behaviors? Finally, one could ex-
amine to what extent HIV-related information
produces different affective reactions (such as
fear, sadness, or pride) that could moderate the
persuasiveness of message framing.
Targeted and Tailored
Health Communication
This section covers a recent trend in health
communication: the tailoring and targeting of
health messages. As noted by Kreuter and Skin-
ner (2000), the terms tailoring and targeting are
often used interchangeably. However, they refer
to two different audience segmentation strate-
gies for creating intervention materials or activ-
ities and developing health education programs
(Slater, 1995). Tailoring can be dened as any
combination of information or change strategies
intended to reach one specic person and based
on characteristics that are unique to that person
(Kreuter, Farrell, Olevitch, & Brennan, 2000).
These characteristics are thought to be related to
the outcome of interest and are derived from
individualized assessments. In other words, tai-
lored information is aimed to a particular person
and is built on individual-level factors related
to the health or behavioral outcome at stake
(Dijkstra & DeVries, 1999). Tailoring is achieved
by collecting data from participants on psycho-
social or behavioral factors and applying algo-
rithms (usually computerized) to process each
persons data and generate customized feedback
to meet the individuals specic needs (for a
review of existing computerized tailoring sys-
tems, see Bental, Cawsey, & Jones, 1999).
Targeting refers to the development of a sin-
gle intervention approach or health communi-
cation for a dened population subgroup that
takes into account characteristics shared by the
subgroups members. Typically, cultural vari-
ables based on demographic data (e.g., ethnic-
ity, gender, age, location, or education) are
used. Targeting of health communications and
interventions follows from the idea that the pop-
ulation is not monolithic, and information may
have different inuences on different subgroups
(Paalman & Sandfort, 1990). At the same time,
there is an assumption that sufcient homoge-
neity exists among members of subpopulations
to justify using the same communication with
all members (Kreuter, Strecher, & Glassman,
1999). Some investigators prefer the term cul-
tural tailoring to targeting when describing this
strategy (Pasick, DOnofrio, & Otero-Sabogal,
Targeting and tailoring can be conceived as
part of the same continuum corresponding to the
degree of match between a communication and
individual characteristics (Kreuter, Farrell, et
al., 2000). These two approaches nonetheless
differ from each other on important aspects
(Kreuter & Skinner, 2000): unit of assessment
(subgroups vs. individuals), type of data col-
lected (usually, demographic vs. psychosocial),
and use of the data collected (use of individual-
level data to characterize a subgroup vs. use of
individual-level data to intervene at the individ-
uals unique level). Studies suggest that target-
ing and tailoring are more effective than generic
comparison programs that do not take into ac-
count the characteristics of the populations in-
volved (Skinner, Campbell, Rimer, Curry, &
Prochaska, 1999). The next section focuses on
work investigating the benets of tailoring.
Most of this research has been applied to cancer
prevention. We then present research relevant to
HIV prevention. In the case of HIV/AIDS, ef-
forts to match information to participants have
focused on cultural targeting, rather than tailor-
ing, almost exclusively.
Tailoring Information: Advances in
Cancer Prevention
The literature on tailoring is characterized by
the diversity of the interventions conducted
(Rakowski, 1999; Skinner et al., 1999). Tai-
lored interventions and health communications
have been grounded in various models of health
behavior. The choice of a model as the founda-
tion of tailoring has direct implications for mes-
sage content and format and for the mediating
variables that are measured as psychosocial pre-
dictors of behavior change. Often, researchers
have combined variables from distinct models
for the tailoring of their interventions. For in-
stance, components of tailored communications
have been derived from the transtheoretical
model (Prochaska, DiClemente, & Norcross,
1992). In such cases, researchers match the in-
tervention strategy to the process of change
associated with each of the ve stages distin-
guished by the theory. Other tailored compo-
nents have been based on the health belief
model (Becker, 1974). This theory proposes
that people are most likely to take preventive
action when they perceive themselves at risk of
a serious negative outcome and when they per-
ceive more reasons for than impediments to
making the change. Thus, information is tai-
lored to individualsperceptions of risks, barri-
ers, and benets.
Also, the target of tailored interventions has
varied, including smoking cessation (Strecher,
1999), nutrition (Brug, Steenhuis, Van Assema,
Glanz, & DeVries, 1999; Campbell, Honess-
Morreale, Farrell, Carbone, & Brasure, 1999),
mammography (Skinner, Strecher, & Hospers,
1994), and physical activity (Bull, Kreuter, &
Scharff, 1999). Moreover, programs have var-
ied in terms of format (e.g., personal letters,
brochures, or newsletters), delivery channel
(e.g., mail, telephone, or videotape), message
source (e.g., health providers, peers, or univer-
sity researchers), number of variables on which
tailoring is based and number of possible mes-
sage combinations, amount of text and graphics
addressing each variable, writing and language
style, amount of tailoring, obvious versus im-
plicit tailoring, and number of tailored compo-
nents. Finally, intervention outcomes have been
measured on various dimensions, including
readability, reactions to materials, change in
attitudes, behavioral intentions, behaviors, mor-
bidity, and knowledge.
It is not easy to draw conclusions about the
efcacy of tailored interventions because of all
of the parameter variations that we have just
described. Nonetheless, Skinner and her col-
leagues (1999) summed up what can be learned
from this literature as follows. Tailored infor-
mation is more likely to be read, remembered,
and perceived as more relevant than comparison
communications (Brinberg & Axelson, 1990;
Brug, Glanz, Van Assema, Kok, & Van Breuke-
len, 1998; Skinner et al., 1994). Tailored infor-
mation may have an impact on knowledge about
and self-efcacy in the behavior promoted and
may motivate participants to move to the next
stage of change (Campbell et al., 1999). Tailor-
ing also may enhance the ability of interven-
tions to produce behavior change (Brug et al.,
1998; Bull et al., 1999; Rimer et al., 1994;
Skinner et al., 1994; Strecher et al., 1994).
Tailoring and Targeting HIV-Relevant
To our knowledge, only one study has ap-
plied tailoring techniques to HIV communica-
tions (Brown-Peterside, Redding, Ren, & Kob-
lin, 2000). Using an interactive computer-based
system, a sample of women responded to ques-
tions about their attitudes toward using con-
doms and their actual behavior. Immediately
after completing this questionnaire, participants
received tailored feedback based on their stage
of change regarding condom use (i.e., readiness
to use condoms). Almost half of the sample was
at an early stage of change, considering using
condoms but not actually using them consis-
tently. The results of the study illustrated that,
overall, attitudes were very positive toward the
feedback and the system. They also suggested
that traditional intervention strategies would be
appropriate only for individuals ready to use
condoms consistently, about one third of the
sample. However, the impact of stage-matched
feedback on HIV-relevant behaviors still re-
mains to be demonstrated.
A study published almost a decade ago rec-
ommended that HIV-relevant communications
be matched to behavioral and psychosocial fac-
tors such as actual and perceived risk (Snyder &
Rouse, 1992). Four groups of individuals were
distinguished. The unthreatenedgroup in-
cluded people who were not at risk for HIV and
who perceived themselves as such. Therefore,
they would not necessitate particular attention.
Panickedindividuals were not at risk but had
misconceptions about HIV, leading them to
overestimate their own vulnerability. Thus,
these individuals should be presented with in-
formational messages to correct misperceptions
leading to inappropriate prevention strategies.
Another group, the deniers,signicantly min-
imized the perception of their actual risks. Mes-
sages directed at deniers should contribute to
increasing feelings of vulnerability to the HIV
epidemic. Finally, gamblerswere individuals
who recognized their risks but felt inefcacious
in preventing AIDS, mistrusted condoms or did
not know how to initiate condom negotiation in
the relationship. To reach them, messages
should aim at increasing self-efcacy in pre-
venting HIV infection.
More research has been dedicated to target-
ing HIV communication. HIV researchers
mostly have embedded health information in
culturally relevant contexts. In comparison with
Anglos, ethnic minorities have been character-
ized by greater rates of misperceptions about
AIDS and by increased risks for HIV transmis-
sion (Kalichman, Hunter, & Kelly, 1992). This
may result partly from a lack of cultural and
personal relevance of AIDS prevention mes-
sages (Kalichman, Kelly, Hunter, Murphy, &
Tyler, 1993; Michal-Johnson & Bowen, 1992).
Cultural relevance, sensitivity, or targeting can
be achieved by manipulating the surface or deep
structure of messages (Resnicow, Soler, Braith-
waite, Ahluwalia, & Butler, 2000). The surface
structure refers to the match between informa-
tion and observable social and behavioral char-
acteristics of a target population. It implies us-
ing people, language, clothing, or music famil-
iar to, as well as preferred by, the target
audience. In contrast, deep structure targeting
reects how cultural, social, psychological, en-
vironmental, and historical factors inuence
health behaviors differently across ethnic
groups. This involves understanding how
members of the target population perceive the
cause of illnesses and determinants of health
These different levels of targeting have var-
ied effects on behavior change. Kalichman and
his colleagues (1993) targeted health communi-
cations by manipulating surface and deep struc-
ture cues. African American women were re-
cruited in low-income housing projects and
were randomly assigned to three conditions. In
a control condition, they watched a videotape in
which information was presented by the sur-
geon general and two White professional broad-
casters. In the second condition, cultural sensi-
tivity was manipulated at the surface structure
level, by matching the ethnicity and sex of the
presenters with participantscharacteristics. In
the third condition, cultural sensitivity was
manipulated at the deep structure level. The
videotape stressed culturally relevant values,
such as cultural pride, community concern, and
family responsibility. The presenters were the
same as in the second condition but dressed
more casually and spoke with less authority.
The informational content was identical in all
In comparison with the two other conditions,
deep structure targeting increased fear, anxiety,
concern, and perceptions of the presenters as
expressing more care and concern. No differ-
ences between targeting by the surface structure
condition and the control condition were ob-
served. All of the videotapes enhanced partici-
pantsHIV-related knowledge regardless of
type. In summary, targeting the information by
social values increased the personal relevance
of the information and produced stronger emo-
tional reactions, but it did not make the message
more persuasive. Moreover, because targeting
involved the simultaneous manipulation of sev-
eral contextual variables, it is difcult to iden-
tify the component of targeting to which the
effects observed could be attributed. However,
it appeared that simply using a source identical
to participants in terms of ethnicity and sex did
not produce differential effects relative to no
targeting at all.
Similar results were obtained in a study con-
ducted among a similar population (Kalichman
& Coley, 1995). Women who reported just after
watching the videotape that they intended to
obtain HIV testing were more likely to actually
get an HIV test when information was targeted
at the deep structure. However, in this study, the
most effective message differed from the other
two in an additional aspect: Information was
framed in loss terms, as described earlier.
Therefore, it is difcult to disentangle the spe-
cic contributions of cultural targeting at the
deep structure level and framing.
Herek and his colleagues (1998) also inves-
tigated the impact of cultural targeting. They
compared a culturally specic message with a
multicultural message. In a rst condition, the
videotape targeted a specic culture: Partici-
pantsethnic identity and community identi-
cation were made salient by manipulating the
communicators race and clothing and the mes-
sage content. In two other conditions, the mes-
sage was targeted at multiracial audiences by
discussing the problems posed by AIDS for
different ethnic groups, and it was delivered
either by an African American communicator or
a White man. Ratings of the message were
consistently more favorable for the African
American announcer delivering a culturally
specic message, whereas the multicultural
message delivered by the White communicator
was the least favorable. To some extent, the
multicultural message was better perceived if an
African American rather than a White man de-
livered it. Although the videotapes increased
participantsworries and perceptions of their
own risks, the type of message did not affect
these variables. Intentions to reduce risks or to
obtain HIV testing were not inuenced by the
Developing Research on Targeting and
Tailoring of HIV Communications
Several researchers have argued the case for
cultural sensitivity in HIV education (Markova
& Power, 1992; McDaniel, Isenberg, Morris, &
Swift, 1997; Michal-Johnson & Bowen, 1992).
The studies on HIV communications reviewed
here illustrate that cultural targeting, especially
when grounded in deep structure, increases the
relevance of the message and produces emo-
tional reactions to it. However, this alone does
not seem to motivate more distal outcomes such
as behavior change or intentions to engage in
safer behaviors. Moreover, the specic tech-
niques of targeting have not been investigated
systematically, and multiple variables are often
studied at the same time, preventing us from
clearly understanding the contributions of each
Furthermore, the benets of tailoring mes-
sages to current HIV-relevant behaviors should
be examined. Actual risks and perceived risks
appear to be key variables in this respect (Sny-
der & Rouse, 1992). For instance, one study
indicated that a signicant minority of college
students thinks in terms of pregnancy risk,
rather than risks of contracting sexually trans-
mitted diseases, when considering safer sex
(Witte, 1992). For these individuals, being on
birth control is reason enough not to use con-
doms. Obviously, messages promoting condom
use would be more persuasive if they were
tailored to these representations.
Other variables for tailoring could be derived
from theoretical models of behavior change. For
instance, Maibach and Cotton (1995) discussed
how the transtheoretical model (Prochaska et
al., 1992) could provide a framework to tailor
HIV-relevant messages. They gave instances of
specic messages aimed at each stage. Individ-
uals in precontemplation lack intentions to
modify their risk behavior and are more likely
to respond positively to messages that encour-
age self-examination rather than behavior
change. Messages aimed at them should ac-
knowledge the risks associated with multiple
partners and unprotected sex and endorse sev-
eral positive outcomes of monogamy and con-
dom use. People in contemplation are aware of
the need to practice a healthier behavior but are
not ready yet to take action. To reach individ-
uals at this stage, messages should address the
barriers to safer sex or use of clean needles.
People who are preparing for action often have
some experience with the new behavior and are
attempting to modify their behavior, experi-
ences, and environment in an effort to practice
the new behavior consistently. In this case, mes-
sages should reinforce appropriate behaviors.
Finally, to promote maintenance of healthy be-
haviors, messages should rene skills that will
help people avoid relapse.
Also, research efforts should investigate fur-
ther the mechanisms that need to be acted on to
enhance both targeted and tailored message ef-
fects (Abrams, Mills, & Bulger, 1999) and de-
termine the conditions under which these tech-
niques produce the most benets (Holt, Clark,
Kreuter, & Scharff, 2000). Skinner and her col-
leagues (1999) described the need for labora-
tory-based research and smaller scale studies, in
that they would permit greater manipulation of
variables and tailored components before the
launching of larger, community-based interven-
tions. This advice certainly applies to research
on targeting as well. Also, there is still a need
for investigation of the relative advantages of
tailoring versus targeting. In some cases, infor-
mation well matched to participants (by target-
ing or simply by chance) may be as effective as
the more complex tailoring (Kreuter, Oswald,
Bull, & Clark, 2000).
Finally, research should assess the cost-effec-
tiveness of tailored interventions as compared
with generic and targeted interventions. Al-
though tailoring is greatly facilitated by elec-
tronic technologies, tailored interventions, be-
cause they are often more intense and more
complex, may be more costly. On the other
hand, tailored interventions might be more cost-
effective because they successfully reach differ-
ent segments of the population. The trade-offs
among complexity, demand burden on partici-
pants, reach, efcacy, and cost-effectiveness
need to be evaluated (Abrams et al., 1999;
Kreuter et al., 1999).
Other Message, Source,
and Channel Factors
In our concluding remarks, we would like to
extend the scope of our discussion to include
additional factors whose role in HIV communi-
cations needs to be further investigated. These
communication parameters pertain to the mes-
sage, its source, and the channel (message for-
mat) by which information is transmitted.
Message Factors
The discrepancy between an advocated be-
havior and the receivers actual behavior affects
motivation to comply with the advocacy (Petty
& Wegener, 1998). The greater the discrepancy,
the more difcult it is to induce behavior
change. For this reason, a message promoting
abstinence would be less likely to generate com-
pliance among a population of sexually active
individuals than a message advocating condom
use. For this population, abstinence implies a
more radical change than condom use, which
builds on an existing behavior (sexual activity).
This point is illustrated in an HIV-education
study conducted among gay men in New Zea-
land (Robert & Rosser, 1990). The interven-
tions compared had differential effects on spe-
cic safer sex behaviors such as condom use,
monogamy, and avoidance of anal intercourse.
The explicitness of the recommendation also
deserves investigation. Ratzan and his col-
leagues (Ratzan, Payne, & Massett, 1994) re-
viewed public service announcements used in
the America Responds to AIDScampaign
and underscored the lack of clear messages re-
garding safer sex and high-risk behaviors (such
as drug use and same-gender sex). Although in
the case of sexual behaviors, the tendency might
be to adopt more implicit language so as to
avoid being offensive, evidence suggests that
explicit recommendations are needed to moti-
vate people to adopt prevention behaviors. In-
deed, it has been shown that participants were
more likely to acquire condoms immediately
after a public service announcement when the
message contained the explicit recommendation
to use condoms to prevent HIV transmission
than when it did not (Struckman-Johnson &
Struckman-Johnson, 1996). However, there
might be instances in which the use of very
explicit messages becomes counterproductive if
these communications arouse emotions such as
embarrassment toward the advocated behaviors.
Finally, research is needed examining the im-
pact of mixed messagesas compared with
unilateral messages. Mixed messages can be
dened as communications advocating two ap-
parently mutually exclusive behaviors, for in-
stance, abstinence and condom use (McGrath &
Strasburger, 1995). How do teenagers and
young adults receive these mixed messages, and
how do these communications affect their ac-
tual behaviors? Also, what is the best way to
promote use of condoms, given the knowledge
that they do not always provide 100% protec-
tion? Obviously, it is better to emphasize the
success rate of condom use rather than the fail-
ure rate (Linville et al., 1993). However, what is
the effect of stating or not stating the success
rate of condoms? Research is lacking on these
Source Factors
Is a message on HIV/AIDS persuasive to the
same extent whether it comes from the surgeon
general, a peer, or a celebrity? Research on
source variables in other areas has shown their
impact on persuasion. Source variables can be
dened as aspects of the person(s) or group(s)
presenting the persuasive appeal (Petty & We-
gener, 1998). Such factors pertain to source
expertise, popularity, or similarity to recipients.
HIV communications have used experts or
peers to present information, based on the as-
sumption that expertise or similarity will in-
crease persuasiveness. Sourcereceiver similar-
ity has also been used as a way to achieve
cultural targeting and increase personal rele-
vance. The psychological literature indicates
that source effects will occur in conditions of
low message scrutiny, that is, when people are
less motivated or able to process the message
content carefully (Petty & Wegener, 1998).
Researchers have examined the effect of ce-
lebrities disclosing their HIV-positive status
and endorsing health-relevant messages. Inter-
est in AIDS information, concern about the dis-
ease, and discussions of the disease among
friends increased after basketball star Magic
Johnson disclosed his seropositivity (Kalich-
man & Hunter, 1992), as did HIV counseling
testing requests (Tesoriero, Sorin, Burrows, &
LaChance-McCullough, 1995). Brown and Ba-
sil (1995) examined the mechanisms underlying
celebrity effects on attitudes and behaviors.
They distinguished between the simple fact of
knowing the celebritys HIV-positive status and
emotional involvement with the star. Mere
knowledge of Magic Johnsons HIV status was
not enough to account for increased concern or
intentions to reduce risk taking. Rather, emo-
tional involvement with the celebrity was the
key factor. It was signicantly related to per-
sonal concern about AIDS and intentions to
reduce high-risk sexual behaviors. Therefore,
the mechanism underlying celebrity effects on
persuasion may be identication: Audience
members who identify with celebrities seek to
be like them by adopting similar attitudes, be-
liefs, and behaviors.
Systematic comparisons between sources
varying in terms of expertise, similarity to re-
ceivers, popularity, or likeableness would help
determine the aspects of the communicators that
are most inuential. These effects should also
be considered in relation to the populations
studied: Which audiences are more sensitive to
involvement with or similarity to the source?
Who is more convinced by expertise? In which
circumstances are source effects the strongest?
Finally, use of personal stories of HIV-positive
individuals chosen because of their similarity to
receivers may entail the following pitfall: Such
communications may increase feelings of per-
sonal vulnerability to the point that individuals
may engage in fear-control processes (e.g., de-
nying their own risks for HIV) rather than in
danger-control processes (e.g., adopting safer
sex; see Morris & Swann, 1996).
Channel Factors
HIV information has been communicated
through all possible means: print materials, vid-
eotapes, mass media, and the Internet, to name
a few (see Perloff, 2001). We cannot address
cost-effectiveness considerations about differ-
ent channels used to communicate HIV-related
information, although this is an important factor
in deciding which type of communication to
favor. Rather, we aim to underscore a concep-
tual distinction that offers an interesting frame-
work for understanding the role of message
channel in persuasion (Petty & Wegener, 1998):
self-paced and externally paced presentation of
messages. A typical self-paced message is a
printed communication enabling the reader to
go back and read and reread anything if desired.
Externally paced communications, such as pub-
lic service announcements, do not allow receiv-
ers to control the pace of information delivery.
Self-paced communications lead to greater mes-
sage scrutiny, whereas externally paced mes-
sages, because they provide visual prompts, in-
crease the impact of peripheral persuasion cues
such as communicator credibility and likeable-
ness. Finally, the message channel in itself
could inuence the mode of information pro-
cessing. Indeed, certain types of presentations
may impress some people (who thus pay more
attention to the message or give more credit to
the content) but distract others (who thus do not
scrutinize the content of the communication).
Persuasion research is characterized by a dearth
of systematic analyses of channel effects. Be-
cause HIV communications have historically
used multiple channels to reach populations,
they certainly offer an arena to investigate such
determinants more rigorously.
A Plea for Theory-Driven HIV
Prevention Programs
In this article, we have reviewed literature
bearing on variables at the message and indi-
vidual levels. Our approach has consisted of
analyzing what can be done at a micro-level to
motivate individuals to engage in HIV preven-
tion behaviors. Our intention was not to under-
mine the importance of contextual factors. Ef-
forts to promote healthy practices should be
aimed at a structural level as well. In fact, both
levels should be targeted simultaneously to lead
to effective prevention. As an example, it is
useless to motivate people to use condoms if
condoms are not made easily available in stores,
clinics, prisons, schools, and so forth. On the
other hand, easy access to condoms does not
guarantee that people will use them; they have
to be convinced of their necessity. This article
has presented an overview of different tech-
niques to reach people at this latter level of
Our goal was to provide conceptual frame-
works that could be used to design effective
HIV communications and to stress the benets
of using theory-driven approaches. Without re-
search, prevention policies will only succeed by
accident(Paalman & Sandfort, 1990, p. 208).
To inuence behavior, one needs to rely on
scientic knowledge about persuasion strate-
gies, the nature of the behaviors targeted, and
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... pictures of sexually transmitted infections) while Journal of the Georgia Public Health Association, Vol. 1 No. 1, 2009 other times used to persuade behaviors (i.e. evoke fear of death in hopes of promoting condom use; Devos-Comby & Salovey, 2002;O'Grady, 2006;Slavin, Batrouney, & Murphy, 2007). Similarly, it has been argued that loss-framed messages that may discover a health concern are considered more persuasive compared to gain-messages that are aimed at preventing the onset of a health problem (Apanovitch, McCathy, & Salovey, 2003;Devos-Comby & Salovey, 2002;Rothman, Bartels, Wlaschin, & Salovey, 2006). ...
... evoke fear of death in hopes of promoting condom use; Devos-Comby & Salovey, 2002;O'Grady, 2006;Slavin, Batrouney, & Murphy, 2007). Similarly, it has been argued that loss-framed messages that may discover a health concern are considered more persuasive compared to gain-messages that are aimed at preventing the onset of a health problem (Apanovitch, McCathy, & Salovey, 2003;Devos-Comby & Salovey, 2002;Rothman, Bartels, Wlaschin, & Salovey, 2006). Despite the empirical literature that endorses the utility of such appeals (Devos-Comby & Salovey, 2002), the general public is less likely to decipher the intended audiences for such messages, thus continuing to perpetuate fear. ...
... Similarly, it has been argued that loss-framed messages that may discover a health concern are considered more persuasive compared to gain-messages that are aimed at preventing the onset of a health problem (Apanovitch, McCathy, & Salovey, 2003;Devos-Comby & Salovey, 2002;Rothman, Bartels, Wlaschin, & Salovey, 2006). Despite the empirical literature that endorses the utility of such appeals (Devos-Comby & Salovey, 2002), the general public is less likely to decipher the intended audiences for such messages, thus continuing to perpetuate fear. ...
Strategies to reduce acquired immunodeficiency syndrome (AIDS)‐related stigma are paramount to promoting effective HIV prevention. As in the case of HIV antibody testing, despite the benefits of early detection, links to care, and risk behavior modification, nearly 250,000 people are unaware of their HIV status. AIDS‐related stigma has impeded such efforts due to discrimination, ignorance and other forms of stigma. These issues related to stigma and HIV testing are magnified when placed in the context of the rural Deep South region of the United States, where the incidence of HIV/AIDS are growing at alarming rates. The purpose of this paper was to examine strategies to reduce AIDS‐related stigma that in turn promotes HIV testing as proposed by people living with HIV/AIDS (PLWHA) who reside in the Deep South. An exploratory descriptive qualitative research design was utilized. The sample consisted of 18 PLWHA. Data was collected using a focus group and individual, semi‐structured interviews. The analysis revealed the importance of ongoing education as a mediator between reducing stigma and promoting HIV testing. Other salient findings were related to reframing HIV/AIDS‐related health messages to reflect a sense of empowerment; the need to normalize testing; the use of less stigmatizing testing sites; and the continuance of anonymous HIV testing. This article is significant because it illuminates the challenges of HIV prevention in the Deep South, while also generating culturally‐sensitive strategies to counter these barriers.
... Hastings, Stead and Webb [20] suggested that ads that are causing to fear can cause to a chronic heightened anxiety and instead of preventing the danger, the ad can increase it. Also, fear and anxiety can cause to different effects such as sadness and confusion regarding the danger, and as a result the message is wrongly accepted [22]. ...
Full-text available
The warning ads on cigarette packs are well known almost in every country on the globe. The anti - smoking campaigns which are managed and directed by the governments include several types of warning: textual, pictorial and combined. This work will focus on the newest campaign in Germany, which combines the graphical and the textual warnings and will try to discuss the advantages, the disadvantages and the ethical issues of such type of warnings by an overview of the literature. Also, this paper will try to suggest alternative methods for health warnings on the packs that according to the literature may cause to the same or even improve the goals and its results. A new theoretical model will be suggested as well when the goal of this model is to provide a new point of view based on literature and previous researches about the effectiveness of the warnings among those who are heavy smokers and those who are not. However, this model is a theoretical one and is not proven yet in the field.
... However, Wallack (1984) posits that campaign success cannot be seen as effective unless institutions at macro level adopt the change in behavior reinforcing the intervention message. However, there does appear to be more agreement that true effectiveness should be measured by the change in behavior at the macro environmental levelsuch as in government institutions' practices and cultural processes (Cairns & Stead, 2009;Devos-Comby & Salovey, 2002;Wymer, 2011). This notion was originally mooted by Smith-McLallen and Fishbein (2008) who proposed that change at macro level should include factors that influence public policy and the wider society, and this has been recently supported by Truong (2016) and Wood (2016). ...
In India, breast cancer is the most commonly diagnosed type of cancer among women in cities and urban areas, yet women seek medical care extremely late due to lack of awareness about self-examination. This study explores the health marketing literature via signaling theory, to uncover the unique social, economic, cultural and institutional challenges and opportunities faced by health marketers and consumers in breast cancer awareness (BCA) in an emerging economy – India. An interpretive-inductive method, alongside a grounded theory approach via focus groups with medical professionals and interviews with women is employed. Findings reveal complex challenges at national, state and community levels which impact negatively on the reputation of India's health sector. Social marketing strategies could be leveraged to raise BCA via community health activists. Propositions are suggested and a conceptual framework is developed to assist health marketers to manage BCA in an emerging economy.
... & Salovey, 2003;Detweiler et al., 1999; also seeDevos-Comby & Salovey, 2002). ...
Features of advice messages have received considerable attention in prior research, but the framing of advice has remained underexplored. This study examined the influence of advice message framing (i.e., gain-framed message vs. loss-framed message) on recipients’ responses to advice in terms of evaluation of advice quality, facilitation of coping, and intention to implement advice. The mediating roles of regard for face and efficacy were also assessed. A total of 605 participants read and responded to a hypothetical conversation in which they received advice from a friend. Results indicated that gain-framed advice messages elicited higher evaluations of advice quality and higher perceptions of facilitation of coping in comparison with loss-framed advice messages. Recipient’s perceptions of the advice-giver’s regard for face mediated the impact of framing on evaluation of advice quality and facilitation of coping.
... Unlike other health behaviors, most sexual behaviors involve a partnerand areinherentlyinterpersonalinnature.Forinstance,the decision to have sex could pose different types of risk depending on whether aperson focuses primarily on potential coststo him-or herself (e.g., STI infection) or costs involving his or her sexual partner as well (e.g., uncomfortable discussions about condom use) (Devos-Comby & Salovey, 2002;Kiene et al., 2005). While knowledge of a potential sexual partner's sexual history could also alter the relative costs, benefits, and level of uncertainty involved in making a decision to have sex with that individual, how different message frames affect decision making with highand low-risk partners has not been investigated previously. ...
Full-text available
Messages that frame a target behavior in terms of its benefits (gain frame) or costs (loss frame) have been widely and successfully used for health promotion and risk reduction. However, the impact of framed messages on decisions to have sex and sexual risk, as well as moderators of these effects, has remained largely unexplored. We used a computerized laboratory task to test the effects of framed messages about condom use on young adults' sexual decision making. Participants (N = 127) listened to both gain- and loss-framed messages and rated their intentions to have sex with partners who posed a high and low risk for sexually transmitted infections (STIs). The effects of message frame, partner risk, participant gender, ability to adopt the messages, and message presentation order on intentions to have sex were examined. Intentions to have sex with high-risk partners significantly decreased after the loss-framed message, but not after the gain-framed message, and intentions to have sex increased for participants who received the gain-framed message first. Yet, participants found it easier to adopt the gain-framed message. Results suggest that loss-framed messages may be particularly effective in reducing intentions to have sex with partners who might pose a higher risk for STIs, and that message presentation order may alter the relative effectiveness of gain- and loss-framed messages on sexual decision making. Future studies should examine the precise conditions under which gain- and loss-framed messages can promote healthy sexual behaviors and reduce sexual risk behaviors.
Objective: Health decision making models propose that affective associations at both the implicit and explicit level and cognitive beliefs influence health behaviours. The current studies investigated whether affective or cognitive persuasive messages would lead to more positive implicit and explicit condom use attitudes and higher intentions among African American college women. Design: Participants (Study 1 N = 109; Study 2 N = 112) explicit attitudes were assess prior to watching a short video that contained either affective (e.g., safe sex is pleasurable) or cognitive messages (e.g., latex condoms are effective in preventing HIV) in favour of condom use. Main Outcome Measures: Following the video, participants completed the Affect Misattribution Procedure (AMP), a measure of implicit attitudes, explicit measures of condom use attitudes that assessed attitudes at the overall and component level, intentions to use condoms, and interest in receiving free sample of condoms. Results: Participants in the affective message condition reported more positive condom use attitudes on both the implicit and explicit measure, higher intentions to use condoms, and more interest in receiving free condoms than those in the cognitive message condition. Conclusion: These results suggest that affective messages may be more effective in changing condom use attitudes, which can be used in interventions to promote protective condom use behaviours.
The potential of pictorial and verbal metaphors to gain attention and enhance persuasion is considerable. Few scholars, however, have investigated the persuasive effects of metaphor in health messages. We applied a 2 × 2 factorial experiment to examine the effects of metaphor use (metaphor/literal) and message format (verbal/pictorial) on cognitive processing and persuasive outcomes of condom promotion messages. Results showed no significant differences in cognitive processing according to metaphor or format, but there were differences in attitudes and behavioral intentions according to metaphor and format, with literal and verbal messages performing best. Potential explanations for findings and implications for future research and health message design are discussed. Keywords: Condom Promotion, HIV Prevention, Message Design, Message Format, Metaphor
This chapter provides a review of theory and evidence concerning the relative persuasiveness of gain- versus loss-framed messages in health contexts, with particular attention to research surrounding proposed moderators of message framing effects, including type of health behavior advocated, message recipients' involvement with the health issue and approach/avoidance tendency, and desirability of the end-state emphasized in the message. The review suggests that several theoretical perspectives including prospect theory, dual-process theories, and regulatory focus theory have been used to explain message framing effects. It is argued that there has been a lack of effort to integrate the different theoretical perspectives into a broader framework based on which the relative effects of message framing can be understood. The chapter concludes with an assessment of the current state of research and directions for future studies.
Dieses Kapitel stellt internetbasierte Risikokommunikation aus psychologischer Perspektive dar. Es wird beleuchtet, wie sich drei Eigenschaften des Internets (Reichweite, Schnelligkeit und Kosteneffizienz) auf die Risikokommunikation auswirken und für diese nutzbar gemacht werden können. Darüber hinaus werden Möglichkeiten aufgezeigt, wie Prinzipien einer effektiven Risikokommunikation durch das Internet umgesetzt und bereichert werden können. Anschließend werden Herausforderungen und deren mögliche Lösungen diskutiert.
Risk communication, an essential function of public health, involves the effective and accurate exchange of information about health risks and hazards - often during an emergency - that advances risk awareness and understanding and promotes health-protective behaviors among individuals, communities, and institutions. Although forged through decades of applied experience in response to infectious disease outbreaks, industrial accidents, and natural disasters, contemporary public health risk communication principles and practices build upon a foundation of behavioral, health, and social sciences theory and research. Increasingly, risk communication concepts are proving instrumental to pursuits in noncrisis contexts such as health care and health promotion.
Studies examining message framing effects on persuasion have produced mixed results. Some studies show positively framed messages, which specify attributes or benefits gained by using a product, to be more persuasive than negatively framed messages, which specify attributes or benefits lost by not using a product. Reverse outcomes have been obtained in other studies. The authors explore a theoretical explanation for such findings by investigating whether differences in the degree to which people engage in detailed message processing account for the mixed results. The findings support the view that positively framed messages may be more persuasive when there is little emphasis on detailed processing, but negatively framed messages may be more persuasive when detailed processing is emphasized.
The increasing diversity of American communities raises an important question about the efficiency, appropriateness, and feasibility of tailoring messages and intervention strategies to target groups identified by race and ethnicity. To explore this issue, This article distinguishes race and ethnicity from culture and then discusses four questions: (1) What is the meaning of culture in health promotion? (2) What is the role of culture in understanding health behavior? (3) What is the role of culture in the design of interventions? and (4) What do the relationships of culture to behavior and to intervention mean for cultural tailoring? Based on this analysis, the authors suggest that effective health promotion will tailor interventions by culture as necessary but reach across cultures when possible and appropriate. A framework is presented to assess the need for cultural tailoring, and a new generation of health promotion research is proposed to facilitate cross-cultural comparisons.
We discuss the cognitive and the psy- chophysical determinants of choice in risky and risk- less contexts. The psychophysics of value induce risk aversion in the domain of gains and risk seeking in the domain of losses. The psychophysics of chance induce overweighting of sure things and of improbable events, relative to events of moderate probability. De- cision problems can be described or framed in multiple ways that give rise to different preferences, contrary to the invariance criterion of rational choice. The pro- cess of mental accounting, in which people organize the outcomes of transactions, explains some anomalies of consumer behavior. In particular, the acceptability of an option can depend on whether a negative outcome is evaluated as a cost or as an uncompensated loss. The relation between decision values and experience values is discussed. Making decisions is like speaking prose—people do it all the time, knowingly or unknowingly. It is hardly surprising, then, that the topic of decision making is shared by many disciplines, from mathematics and statistics, through economics and political science, to sociology and psychology. The study of decisions ad- dresses both normative and descriptive questions. The normative analysis is concerned with the nature of rationality and the logic of decision making. The de- scriptive analysis, in contrast, is concerned with peo- ple's beliefs and preferences as they are, not as they should be. The tension between normative and de- scriptive considerations characterizes much of the study of judgment and choice. Analyses of decision making commonly distin- guish risky and riskless choices. The paradigmatic example of decision under risk is the acceptability of a gamble that yields monetary outcomes with specified probabilities. A typical riskless decision concerns the acceptability of a transaction in which a good or a service is exchanged for money or labor. In the first part of this article we present an analysis of the cog- nitive and psychophysical factors that determine the value of risky prospects. In the second part we extend this analysis to transactions and trades. Risky Choice Risky choices, such as whether or not to take an umbrella and whether or not to go to war, are made without advance knowledge of their consequences. Because the consequences of such actions depend on uncertain events such as the weather or the opponent's resolve, the choice of an act may be construed as the acceptance of a gamble that can yield various out- comes with different probabilities. It is therefore nat- ural that the study of decision making under risk has focused on choices between simple gambles with monetary outcomes and specified probabilities, in the hope that these simple problems will reveal basic at- titudes toward risk and value. We shall sketch an approach to risky choice that
This experiment compared the effectiveness of gain- versus loss-framed messages to persuade women to obtain mammography screening. One hundred and thirty-three women 40 years and older and not adhering to current guidelines for obtaining mammography screening were assigned randomly to view either gain-framed (emphasizing the benefits of obtaining mammography) or loss-framed (emphasizing the risks of not obtaining mammography) persuasive videos that were factually equivalent. Attitudes and beliefs were measured before and immediately following the intervention. Mammography utilization was assessed 6 and 12 months later. Consistent with predictions based on prospect theory, women who viewed the loss-framed message were more likely to have obtained a mammogram within 12 months of the intervention. These findings suggest that loss-framed messages may have an advantage in the promotion of detection behaviors such as mammography.
This article describes the development and pilot evaluation of a tailored multimedia program to improve dietary behavior among 378 lowincome women enrolled in the Food Stamp program in Durham, North Carolina. After randomization to intervention or control groups, participants completed a baseline survey and were resurveyed 1‐3 months post-intervention. Measures included dietary fat intake assessed using a brief food-frequency questionnaire, stage of change, knowledge of low-fat foods, self-efficacy and eating behavior questions. The computer-based intervention consisted of a tailored soap opera and interactive ‘info-mercials’ that provided individualized feedback about dietary fat intake, knowledge and strategies for lowering fat based on stage of change. At followup, intervention group participants had improved significantly in knowledge (P < 0.001), stage of change (P < 0.05) and certain eating behaviors (P < 0.05) compared to the control group. Both study groups had lowered their reported fat intake markedly at follow-up (P < 0.001), but did not differ significantly from each other. A majority of participants rated the program as very helpful and were interested in using a similar program in the future. The findings of this pilot study suggest that com
The impact of two computer-tailored nutrition education interventions was assessed and compared in a randomized trial among 315 subjects with a pre-test‐post-test comparison group design. Respondents in both the experimental and the comparison group received feedback tailored to their consumption of fat, fruit and vegetables. Respondents in the experimental group received additional psychosocial feedback tailored to their attitudes, perceived social support and self-efficacy expectations towards reducing their fat consumption and increasing their consumption of fruit and vegetables. A significant reduction in fat consumption and increase in the consumption of fruit and vegetables were found in both the experimental and the comparison group between pre-test and post-test. Respondents in the experimental group more often indicated that the feedback they received was interesting and easy to understand. Respondents in the comparison group more often reported having reduced their fat consumption because of the feedback they received. No significant differences in consumption of fat, fruit and vegetables were found at post-test between the experimental group and