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Applying Persuasion Strategies to Alter HIV-Relevant Thoughts and Behavior

September 2002
Review of General Psychology 6(3):287-304

DOI:10.1037/1089-2680.6.3.287

Authors:

Ashford 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 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)

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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 06520–8205. E-mail:

lorainedc@yahoo.com or peter.salovey@yale.edu

2002, Vol. 6, No. 3, 287–304 1089-2680/02/$5.00 DOI: 10.1037//1089-2680.6.3.287

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

Effective?

Threat appeals had been used in persuasive

communication long before the ﬁght 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 ﬁrst 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

behaviors.

Other researchers have tried to deﬁne 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 Leventhal’s (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

efﬁcacy 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

288 DEVOS-COMBY AND SALOVEY

consequences represent a danger for them (vul-

nerability to the threat), (c) they can avoid the

negative outcome by following the recommen-

dation (response efﬁcacy), and (d) they have the

ability to engage in the recommended behavior

(self-efﬁcacy). 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

Prevention

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 heart”printed 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 didn’t use a condom”is 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 “shake”or 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 ﬁrst advertisement, sponsored by the Aus-

tralian Ministry of Health, was known as the

“grim reaper”advertisement, 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 difﬁcult 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 reaper”adver-

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 others’risk (Sny-

289PERSUASION STRATEGIES AND HIV PREVENTION

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 one’s 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 ﬁlm 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 ﬁlm 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-efﬁcacy in regard to such behaviors.

However, many mass media campaigns relying

on fear appeals do not contain components en-

hancing self-efﬁcacy in the behaviors promoted

(Kenny, 1990). For instance, the “America Re-

sponds to AIDS”campaign presented a hetero-

sexual couple walking with a child and a voice

and written message stating the slogan

“AIDS—Protect yourself and your family—Get

the facts.”The message did not offer any con-

crete way to prevent the disease from destroying

one’s 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 speciﬁcally recom-

mended condom use to prevent AIDS.

What is the empirical evidence that efﬁcacy

components added to HIV prevention messages

increase their effectiveness? We could ﬁnd 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

efﬁcacy component more systematically. In

written messages presented to college students,

she either described condoms as highly efﬁcient

in preventing HIV (high efﬁcacy) or empha-

sized that condoms fail sometimes and high-

lighted the problems involved with their use

(low efﬁcacy). 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 efﬁcacy 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-efﬁcacy in persuasive HIV-relevant

messages. Insisting on the participants’ability

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-

290 DEVOS-COMBY AND SALOVEY

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-efﬁcacy 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-

tions—in particular, fear—elicited 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. Speciﬁcally, 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-efﬁcacy 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 ﬁghting 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

signiﬁcant 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-

291PERSUASION STRATEGIES AND HIV PREVENTION

ing the beneﬁts 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 don’t use condoms you are at greater

risk of sexually transmitted diseases”(attaining

an undesirable outcome, a loss frame) or “If you

don’t 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-

ﬁts 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

differences.

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 beneﬁts 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 speciﬁc

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 one’s 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 beneﬁts 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.

292 DEVOS-COMBY AND SALOVEY

Messages that are framed in unexpected ways

(Smith & Petty, 1996) or that do not match

participants’experiences 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-

eﬁts 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 people’s 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

one’s involvement in it has an impact on fram-

ing effects. Several ﬁndings 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

ﬁndings 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 beneﬁts. 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

don’t get tested for HIV, you may feel more

anxious because you may wonder if you’re 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

principles.

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 inﬂuence individ-

uals’intentions 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 one’s 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 ﬁnding

that one has HIV. For some individuals, re-

peated HIV tests may have a prevention func-

293PERSUASION STRATEGIES AND HIV PREVENTION

tion to the extent that they conﬁrm 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 beneﬁts 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 ﬁndings support the notion

that individuals’risk 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 inﬂuenced 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 speciﬁc 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 reﬂect individuals’appraisals

of risk or uncertainty. The subjective perception

of risk is often at odds with the objective ben-

eﬁts 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

them.

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-

ciﬁc behaviors would probably gain in persua-

siveness if they were matched to individuals’

perceptions of risks associated with the

behaviors.

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 inﬂu-

ence framing effects in the context of HIV?

How does the personal relevance of the infor-

mation presented inﬂuence the effectiveness of

messages stressing the beneﬁts or the costs of

HIV-relevant behaviors? Finally, one could ex-

amine to what extent HIV-related information

produces different affective reactions (such as

294 DEVOS-COMBY AND SALOVEY

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 deﬁned as any

combination of information or change strategies

intended to reach one speciﬁc 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

person’s data and generate customized feedback

to meet the individual’s speciﬁc 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 deﬁned population subgroup that

takes into account characteristics shared by the

subgroup’s 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 inﬂuences on different subgroups

(Paalman & Sandfort, 1990). At the same time,

there is an assumption that sufﬁcient 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, D’Onofrio, & Otero-Sabogal,

1996).

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-

ual’s 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 beneﬁts 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 ﬁve 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-

295PERSUASION STRATEGIES AND HIV PREVENTION

ceive more reasons for than impediments to

making the change. Thus, information is tai-

lored to individuals’perceptions of risks, barri-

ers, and beneﬁts.

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

efﬁcacy 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-efﬁcacy 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

Communications

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 “unthreatened”group in-

cluded people who were not at risk for HIV and

who perceived themselves as such. Therefore,

they would not necessitate particular attention.

“Panicked”individuals 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,”signiﬁcantly 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, “gamblers”were individuals

who recognized their risks but felt inefﬁcacious

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-efﬁcacy 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

296 DEVOS-COMBY AND SALOVEY

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

reﬂects how cultural, social, psychological, en-

vironmental, and historical factors inﬂuence

health behaviors differently across ethnic

groups. This involves understanding how

members of the target population perceive the

cause of illnesses and determinants of health

behaviors.

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 participants’characteristics. 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

conditions.

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-

pants’HIV-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 difﬁcult 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 difﬁcult to disentangle the spe-

ciﬁc 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 speciﬁc message with a

multicultural message. In a ﬁrst condition, the

videotape targeted a speciﬁc culture: Partici-

pants’ethnic identity and community identiﬁ-

cation were made salient by manipulating the

communicator’s 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

speciﬁc 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

participants’worries 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 inﬂuenced by the

videotapes.

297PERSUASION STRATEGIES AND HIV PREVENTION

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 speciﬁc 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

factor.

Furthermore, the beneﬁts 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 signiﬁcant 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

speciﬁc 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 reﬁne 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 beneﬁts (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, efﬁcacy, 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-

298 DEVOS-COMBY AND SALOVEY

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 receiver’s actual behavior affects

motivation to comply with the advocacy (Petty

& Wegener, 1998). The greater the discrepancy,

the more difﬁcult 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-

ciﬁc 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 AIDS”campaign

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 messages”as compared with

unilateral messages. Mixed messages can be

deﬁned 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

issues.

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

deﬁned 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. Source–receiver 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 celebrity’s HIV-positive status and

emotional involvement with the star. Mere

knowledge of Magic Johnson’s HIV status was

not enough to account for increased concern or

intentions to reduce risk taking. Rather, emo-

299PERSUASION STRATEGIES AND HIV PREVENTION

tional involvement with the celebrity was the

key factor. It was signiﬁcantly 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 identiﬁcation: 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 inﬂuential. 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 inﬂuence 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

analysis.

Our goal was to provide conceptual frame-

works that could be used to design effective

HIV communications and to stress the beneﬁts

of using theory-driven approaches. “Without re-

search, prevention policies will only succeed by

accident”(Paalman & Sandfort, 1990, p. 208).

To inﬂuence behavior, one needs to rely on

scientiﬁc knowledge about persuasion strate-

gies, the nature of the behaviors targeted, and

receivers’psychosocial and cultural charac-

teristics. We hope that this article will con-

vince policymakers, mass media campaign de-

signers, researchers, and other readers interested

in HIV communications of the necessity of bor-

300 DEVOS-COMBY AND SALOVEY

rowing frameworks from the broader literature

on persuasion.

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Cent States Speech J

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

Using Message Framing in Health‐Related Persuasion

Chapter

Dec 2012

Xiaoli Nan

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.

Risikokommunikation im Internet

Chapter

Sep 2016

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

Article

Dec 2008

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.

Fear-Arousing Persuasive Messages

Article

Full-text available

Jan 1984

Persuading People To Have Safer Sex: Applications of Social Science To the Aids Crisis

Book

Nov 2000

Richard M. Perloff

The Influence of Message Framing and Issue Involvement

Article

Aug 1990

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.

Choosing audience segmentation strategies and methods for health communication

Article

Jan 1995

Michael D Slater

Article

Dec 1996

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.

Choices, values, frames

Article

Jan 1984

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

The effects of message framing on mammography utilization

Article

Mar 1995

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.

A tailored multimedia nutrition education pilot program for low-income women receiving food assistance

Article

Apr 1999

M. K. Campbell

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

Computer-tailored nutrition education: differences between two interventions

Article

Apr 1999
HEALTH EDUC RES

Johannes Brug

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

Communication and Persuasion: Psychological Studies of Opinion Change

Article

Jun 1954

Applying Persuasion Strategies to Alter HIV-Relevant Thoughts and Behavior

Abstract

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