Applications to HIV Prevention
Intervention and Campaign Efficacy in the Prevention of HIV
I am strongly committed to applying psychological theory to the benefit of society, and have concentrated my efforts in modifying behaviors that pose risks to health. For example, my collaborators and I have examined the effectiveness of HIV-prevention campaigns in regards to changing attitudes, behaviors, and related cognitions (Albarracín et al., 2003, 2005; Tannenbaum et al., 2013). Our findings revealed that the persuasive messages communicated in these campaigns successfully increase recipients’ knowledge about HIV. These messages are also effective in promoting more favorable attitudes and intentions toward future condom use. However, on average, these programs bring about no change in actual behavior. Only complex, active programs that strengthen behavioral skills successfully increase condom use (Albarracín et al., 2003, 2005).
Another important finding from this line of research is that the less power a population has (ethnic minority, women, impoverished groups), the more important skills and actual resource provision become (Albarracín et al., 2005). For example, African-American audiences need to be taught self-management skills (how to manage moods, drugs, planning) and also need help obtaining condoms. These things are not as important for a European-American population, which enjoys more power and resources.
Through another meta-analysis, we have recently investigated the types of communicators (message source, counselor) that are most effective for privileged and disenfranchised groups (Durantini et al., 2006). Contrary to the beliefs of US policy makers, who often argue that non-expert community members are better to reach relatively marginalized or powerless groups, we found that women and African-Americans actually increase condom use to a greater extent when experts rather than community members appeal to them. This does not mean, however, that any expert will do; the experts must be similar to the audience in whatever characteristic makes that group distinct. Women respond better to female experts, African Americans respond better to African American experts, and so forth. These findings should have a strong impact on health policy and should also illuminate decisions with respect to affirmative action in admissions to professional and graduate schools.
An ongoing meta-analysis of the efficacy of health promotion campaigns concerns examining effects and theoretical mechanisms associated with fear appeals (Tannenbaum et al., 2013). Fear tactics evoke a polarizing reaction and constitute a controversial research arena. Our meta-analysis of 132 papers yielded 250 independent samples, and demonstrated a positive, linear effect of fear on overall intentions and behavior, particularly when the message encourages self-efficacy. Furthermore, the effects of fear were more positive for one-time rather than repeated behaviors, and for populations with a cultural emphasis on prevention (women, Asians or Asian-Americans, and older groups). This work, however, needs to consider that other persuasive techniques such as behavioral skills training are more powerful for changing behavior, thus leading to relative inefficacy of fear appeals used in isolation (see Albarracin et al., 2005; Earl & Albarracin, 2007).
Selective Exposure to HIV-Prevention Interventions
Disease prevention programs are scientifically designed and tested under the most sterile possible conditions, in an understandable attempt to reduce attrition and self-selection biases (Cook & Campbell, 1979). Ironically, though, these rigorous conditions yield illusory estimates of the effectiveness of these programs in real-world situations. Thus, the true effectiveness of these methodologies when transferred to the real world is, to a large extent, a guess.
For about ten years, I have received NIH funding to explore the effects of selective exposure to HIV-prevention programs. Through laboratory, meta-analytic, and field work (this last at the Alachua, Duval, and Champaign County Health Departments), we measured the impact of the audience characteristics and the type of behavior-change program on actual enrollment and attrition. In one example of experiments from this research line, we tested programs introduced with either the promise of change or with the promise of freedom for the client. In the first randomized controlled trial, we measured acceptance of an HIV prevention counseling session as a function of how the invitation to the program was issued. We found that an empowering, freedom-emphasizing description of the intervention as opening doors for the client produced considerably higher rates of enrollment than promises that the intervention would produce change. In a second randomized controlled trial (now close to completion), we introduced video messages at the end of a first counseling session and measured retention in two subsequent counseling sessions. The videos systematically varied the empowering content as well as describing the intervention as potentially instrumental to the client’s life goals (jobs, housing, education). Preliminary analyses indicate that the instrumental video is more successful in stimulating return and completion of the counseling program.
Selective exposure has been a general interest of mine, as well as using selective exposure as a model to understand recruitment and retention in health promotion interventions. In a meta-analysis by Noguchi et al. (2007), we examined whether exposure to health promotion interventions followed self-validation or risk-reduction motives. The dependent measures included initially accepting to partake in a program and later staying in the program. The results indicated that samples with high knowledge, high motivation, or high condom use were less likely to stay in an intervention than those with low measures. Moreover, there was some selection of interventions based on particular deficiencies of the audience. That is, low-knowledge individuals stayed more than high-knowledge individuals when the intervention was informational. Similarly, low-motivation individuals stayed more than high-motivation individuals when the intervention was motivational. Nonetheless, past condom use exerted the opposite bias. That is, high condom users stayed more than low condom users when the intervention surrounded behavioral-skills training.
Efficacy of Multi-Behavior Health-Promotion Interventions and Underlying Social Cognitive Mechanisms
We are currently developing theory and research to understand how interventions promoting multiple behaviors exert their effects. A meta-analysis of 150 research reports (Wilson et al., 2013) summarized the results of multiple behavior interventions and examined theoretical predictions regarding the number of recommended behavioral and clinical changes in the domains of smoking, diet, and physical activity. The meta-analysis yielded two main conclusions. First, there is a curvilinear relation between the number of recommendations and the observed change, with a moderate number of recommendations producing the highest level of behavioral and clinical change. A moderate number of recommendations attracts attention and engages recipients, ensuring the motivation to implement the recommended changes without making the intervention excessively demanding. Second, this curve was more pronounced when intervention conditions increased the difficulty of the intervention, such as when interventions were resource-demanding (e.g., included behavioral skills training), used lay (vs. expert) facilitators, or involved group (vs. individual) delivery formats. These findings provide important insights that can help guide the design of effective multiple behavior change interventions.
Other analyses of the same dataset have indicated that the direction of the recommendations (an action, such as increasing exercise or vegetable and fruit intake, vs. an inaction, such as quitting smoking or reducing fat intake) is important in determining the efficacy of these programs. Our findings suggest that multi-behavior interventions are more efficacious when the recommendation direction is homogeneous. That is, programs that emphasize reducing fat intake and quitting smoking (two inactions) produce more favorable behavior and clinical changes than programs that recommend increasing vegetable and fruit intake and quitting smoking (an action and an inaction). We are currently also analyzing memory for recommendations in the laboratory, varying not only recommendation numbers but also the direction of potential behavioral combinations.