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AIDS preventive sexual behavior in college students: An empirical test of the health belief model

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AIDS preventive sexual behavior in college students: An empirical test of the health belief model

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Content AIDS PREVENTIVE SEXUAL BEHAVIOR IN COLLEGE
STUDENTS: AN EMPIRICAL TEST OF THE HEALTH BELIEF MODEL
by
Gustavo Angel Yep
A Dissertation Presented to the
FACULTY OF THE GRADUATE SCHOOL
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
DOCTOR OF PHILOSOPHY
(Communication Arts and Sciences)
December 1990
Copyright 1990 Gustavo Angel Yep
UMI Number: DP22463
All rights reserved
INFORMATION TO ALL USERS
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a note will indicate the deletion.
Dissertation Publishing
UMI DP22463
Published by ProQuest LLC (2014). Copyright in the Dissertation held by the Author.
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789 East Eisenhower Parkway
P.O. Box 1346
Ann Arbor, Ml 48106 - 1346
UNIVERSITY OF SOUTHERN CALIFORNIA
TH E GRADUATE SCHOOL
UNIVERSITY PARK
LOS ANGELES, CA LIFO R NIA 90089-4015
This dissertation, written by
Gustavo Angel Yep
under the direction of hf.*.... Dissertation
Committee, and approved by all its members,
has been presented to and accepted by The
Graduate School, in partial fulfillm ent of re
quirements fo r the degree of
P h.D.
CM
' 9 0
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3 o
D O C T O R O F P H ILO S O P H Y
D ean o f G raduate Studies
Date ...?..
DISSERTATION COMMITTEE
.............. Cha,
..........
C hairperson
ii
DEDICATION
To my parents, Cheng P. Yep and Aurora Whu, who provided me
with constant encouragement, support, and love in my
educational endeavors and mental pursuits. Everything that
I am today I owe to you. This dissertation, which
represents the culmination of years of training and hard
work, is dedicated to both of you.
i
iii
PREFACE
"If she is really hot, forget about discussing AIDS, "
an undergraduate declared in one of my classes. "Why ruin
an exciting prospect of a great time with unpleasant
conversation?," he added.
Why indeed. AIDS is a deadly disease. AIDS can be
transmitted in one single unprotected sexual encounter.
Once infected with HIV, AIDS carriers start up a chain of
infection of their own through exchange of body fluids with
future partners. And the alarming exponential spread of j
t
AIDS continues. Why worry about AIDS indeed? |
"Even for many of those who worry about AIDS, the \
I
I
prospect of an orgasm in ten minutes eclipses any thought of
the next twenty years of their lives," a popular essayist '
I
wrote.1 j
I
Why are seemingly logical and intelligent people so
willing to risk their lives? Why can't these people discuss
sexuality with each other? Why aren't people engaging in
|
what appears to be simple and straightforward safer sexual !
j
i
practices? 1
I became interested in AIDS prevention for two reasons, j
First, AIDS prevention is clearly a complex phenomenon which I
1 K. Leishman (1987). Heterosexual and AIDS. The Atlantic Monthly. ,
259, p. 57. |
IV
social scientists can readily assist. Describing,
explaining, and predicting social behavior and the
subsequent application of such understanding to social
causes such as halting the spread of AIDS are major goals of
the social scientific enterprise. Second, AIDS prevention
is clearly a communication issue. Disseminating information
about AIDS, educating people about the disease, and teaching
individuals how to utilize interpersonal and persuasion
tactics to motivate their partners to engage in safer sexual
practices are all based on communication principles and
practices.
I spent the last three years familiarizing myself with
the AIDS literature in general and AIDS prevention in
particular. Although the body of knowledge on AIDS risk
reduction is growing rapidly, one feature was notoriously j
missing: The lack of theory-based research. Although |
j
several well-established theories of preventive health
behavior exist, the application of such theories in the
context of understanding the complex process of AIDS
prevention has been virtually nonexistent.
The present study attempts to integrate relevant AIDS
risk reduction literature into the framework of the Health
Belief Model (HBM). The research focuses on the college
population, a "high-risk group for AIDS."
V
The present study is reported in five chapters.
Chapter 1 presents an overview of the nature of the AIDS
epidemic in relationship to the college population, a brief
explication of the Health Belief Model (HBM), the reason and
[benefits of the present research, and the main objectives of
the present investigation. Chapter 2 is a review of
relevant literature in terms of: (a) general studies related
to the HBM and preventive health behavior; (b) specific
empirical research using the HBM in the context of AIDS
prevention, and (c) atheoretical research associated with
college students and AIDS. The chapter concludes with 1
several proposed research questions and hypotheses. Chapter
3 is an overview of the research methodology utilized in the
present investigation including sample, procedures,
variables, and instrumentation. Chapter 4 reports research
I
findings in terms of: (a) research questions, (b) j
t
hypotheses, (c) predictor variables, and (d) criterion I
I
measures. Finally, Chapter 5 presents a summary of findings j
and their relationship to the proposed research questions, I
hypotheses, and the HBM. Implications for AIDS J
communication and education campaigns are also addressed in \
i
l
this chapter. It is my wish that the present investigation |
i
offer answers in some way to the formidable challenge that \
social scientists face in the era of AIDS: the understanding ,
vi
and application of AIDS risk reduction concepts to actual
HIV prevention efforts.
I am indebted to the many people who helped me
formulate ideas, collect information, prepare data for
statistical analysis, and translate my thoughts onto paper.
I give my exalted thanks to my committee members, Dr.
Everett M. Rogers and Dr. Patricia Riley whose guidance,
enthusiasm, constructive criticism, and helpful comments
I
'were appreciated. A grand acknowledgment goes to Dr. !
Kenneth Sereno, my chairperson, academic advisor, and
mentor, for his continuous encouragement, leadership, and
propelling support. Dr. Sereno has been the major catalyst
in my intellectual development during my years as an
undergraduate and graduate student. Dr. Walter Fisher, Dr.
Michael Cody, and Dr. Carl Broderick have also stimulated my ;
I
thoughts during my years in graduate school, and they have j
i
i
been valuable members of my guidance committee. ,
i
This dissertation would not be a reality without the i
I
help and overall encouragement of two very special people.
I give my eternal thanks to Michael Brill and Emma Negron.
They offered me their friendship, love, and perpetual
support in addition to their valuable assistance in library
I
research and preparation of data for statistical analysis. ■
i
I am forever indebted to you both. ■
Many other people helped make this dissertation
possible. I thank my longtime friends, Amy Taira, Helmut
Uhe, and Mariko Ochi, for their continuing support. I give
my special thanks to Dr. Lesley Di Mare for her faith in my
work as well as her positive and encouraging presence. I
t
thank my two favorite classmates during my graduate school
years, Joan Cashion and Melinda Welch, who kept me inspired
in our graduate seminars. I offer my gratitude to David
Illions for his tremendous assistance in personal matters
during the hectic period of dissertation writing. I give my
appreciation to my research assistant, Theresa Koppie, who
helped me with library work as well as data collection. And
special thanks to my little friends who kept me good company
during my graduate school years, Fenwick, Barney, and Mikey
Gee •
To all of you, I give my eternal thanks.
Gust A. Yep
Los Angeles, August 1990
viii
Table of Contents
Dedication................................................. ii
Preface................................................... iii
Chapter Page
I. Statement of the Problem.............................1
Significance of the Problem......................... 1
Reason for the Present Study........................ 7
Theoretical Foundations for the Present Study......14
The Health Belief Model......................... 17
Benefits of the Present Study...................... 19
Purpose of Study............... 23
II. Review of the Literature............................26
The Health Belief Model and Preventive Health
Behavior..........................................27
The Health Belief Model and AIDS-preventive
Behavior..........................................37
Atheoretical Research on AIDS Preventive
Behavior in College Students..................... 45
Summary, Research Questions, and Hypotheses........76
III. Method.............................................. 83 j
I
Sample.......................................... * ... 83 j
I
i
Procedures.......................... 84 !
Research Variables..................................86
ix
Instrumentation.....................................88
IV. Results.............................................94
Research Questions..................................94
Research Hypotheses.......................... 96
I
Perceived susceptibility, severity, benefits, and
barriers.........................................107
Indices of sexual behavior change.................. 108
V. Summary and Discussion.............................Ill
Summary............................................ Ill
The Health Belief Model and AIDS Preventive
Behavior in College Students..................... 116
Implications for AIDS Communication Campaigns 126
Limitations of the Present Study................... 139
Future Directions..................................140
Conclusions........................................143
i
References................................................ 145 J
Appendices................................................ 168 J
!
Figures................................................... 177 i
I
Tables.......................... ......................... 182 1
t
i
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I
X
List of Figures
Figure Page
1. The Health Belief Model.........................178
2. The Health Belief Model and AIDS-Preventive
Behavior......................................179
3. The Health Belief Model in the context of AIDS:
Research Questions and Hypotheses............ 180
4. Phases in AIDS Educational Campaigns........... 181
xi
List of Tables
Table Page
1. Results of Health Belief Model Studies and
Preventive Health Behavior.................... 183
2. Results of Health Belief Model Studies and
AIDS-preventive Behavior...................... 185
3. Atheoretical Studies on AIDS-preventive
Behavior in College Students.................. 186
4. Demographic Characteristics of the Sample....... 190
5. Ratings for Mediated Communication Sources j
of AIDS Information Acquisition 192 j
6. Ratings for Interpersonal Communication Sources ;
I
of AIDS Information Acquisition...............193
7. One Factor ANOVA for Repeated Measures:
Comparison of Mediated Communication Sources
vs. Interpersonal Communication Sources of
AIDS Information Acquisition.................. 194
8. Stepwise Multiple Regression Analysis of
Perceived Susceptibility and Barriers on
Avoidance of Sex as a means of AIDS
Prevention.................................
9. Stepwise Multiple Regression Analysis of
Perceived Susceptibility on Condom Use as a
means of AIDS Prevention...................
I
195 i
I
i
i
i
i
197
xii
10. Stepwise Multiple Regression Analysis of
Perceived Susceptibility and Barriers on
Becoming Monogamous as a means of AIDS
Prevention.....................................198
11. Stepwise Multiple Regression Analysis of
Perceived Barriers on Becoming More Careful in
Sexual Situations............................. 200
12. Stepwise Multiple Regression Analysis of
Perceived Barriers on Making Sure that Partner
Does Not Have AIDS............................ 201
13. Descriptive Statistics for Predictor Variables:
Perceived susceptibility, severity, benefits,
and barriers.............................. 202
14. Descriptive Statistics for Criterion Variable:
Indices of Sexual Behavior Change.............203
15. Some Persuasion Approaches for AIDS
Communication Campaigns....................... 204
1
Chapter 1
STATEMENT OF THE PROBLEM
Since early medical reports in 1981 (Astor, 1983),
acquired immunodeficiency syndrome (AIDS) "has become a
worldwide phenomenon" (Feldman and Johnson, 1986, p.2).
Though the first reported cases of this disease were among
gay men, AIDS was soon discovered in intravenous drug users,
Haitians, hemophiliacs, and the heterosexual community at
large by 1982 (Altman, 1986). Currently, there are
approximately 100 new cases of AIDS per day reported to the
Centers for Disease Control in Atlanta and "that rate will
continue to accelerate" (Osborn, 1989, p. 2 4).
Furthermore, in her risk assessment of the AIDS epidemic,
Osborn (1989) pointed out that "in only the last two
decades, after a presumed interval of relative
endemicity..., it [AIDS] began its horrific pandemic march,
spreading with surprising efficiency in just a few years to
virtually every country on the face of the earth" (p. 23).
Significance of the Problem
Dr. Halfdan Mahler, former director-general of the
World Health Organization (WHO), in his first coordinated
global effort to combat the acquired immunodeficiency
syndrome (AIDS), announced, "We stand nakedly in front of a
very serious pandemic as mortal as any pandemic there ever
2
has been . . . I don’t know of any greater killer than AIDS,
not to speak of its psychological, social, and economic
maiming" (Altman, 1986, p. 1). Concurring with Mahler's
assessment of the AIDS epidemic as the worst health problem
of the century, Mann noted, "The acquired immunodeficiency
syndrome and the entire spectrum of disease associated with
human immunodeficiency virus (HIV) infection has recently
become a problem of intense international interest and
concern" ( 1986, p. 12). By the end of June, 1988, 138 out
of 176 countries and territories reporting to WHO had
officially documented cases of AIDS (Panos Institute, 1989).
The total number of cases recorded by WHO doubled between
1987 and 1988. Furthermore, the Panos Institute, in their
dossier on AIDS and the Third World, cautioned that the
disease may be grossly underreported, "there are a variety
of logistical, economic and political reasons for supposing
that official figures . . . significantly underestimate the
real position. WHO estimates that, worlwide to the end of
1987, only about half of all AIDS cases had been reported to
it" (1989, p. 30). Recognizing the enormity of the AIDS
epidemic, Mann (1986) added, "Public health control of HIV
cannot wait for the possible development of effective
antivirals and vaccines. The solution to pandemic health
problems calls urgently for international cooperation and
global coordination" (p. 15).
3
In the United States, former Surgeon General C. Everett
Koop (1988), in a brochure distributed by the U.S.
Government to every American household, declared, "AIDS is
one of the most serious health problems that has ever faced
the American public" (p. 2). According to the Centers for
Disease Control (CDC), a total of 139,760 AIDS cases had
been reported to CDC by the end of June 1990. Furthermore,
85,430 people from the reported total had already died
(Stewart, 1990). Public health officials estimate a
fivefold increase in the number of AIDS cases over the next
five years (Morgan and Curran, 1986). Though Koop (1987)
estimated that 1.5 million people are already infected by
the AIDS virus, others (e.g. Curran, 1985; Osborn, 1989)
argue that such figure is a very conservative estimate.
Curran (1985), for example, estimates that there may be 100
individuals infected by the HIV virus for every case of AIDS
reported to the CDC. If Curran's submissions are correct,
one may conclude that there are approximately thirteen
million people in the United States alone, who are carriers
of the AIDS virus. Osborn (1989) further added, "the most
striking fact is that the United States is at the epicenter
of this explosion and, with the exception of parts of Africa
and perhaps Brazil, is likely to remain so for years to
come" (p. 27).
4
Public health officials (e.g., Curran, 1988; Koop,
1987) cautioned that virtually everyone is at risk for AIDS.
However, with the exception of gay men and intravenous drug
users, "There has been a lot of denial regarding AIDS"
(Curran, 1988, p. 10). Stipp and Kerr (1989) suggested the
possibility that anti-gay attitudes constrain the ability of
the mass media to effectively disseminate information
regarding risk factors, transmission, and AIDS prevention to
the general public. Conversely, Hamilton (1988), in a
series of three studies, concluded that the media may be
promoting "the idea that AIDS is a 'gay disease,' thus
possibly increasing anti-homosexual backlash and
heterosexuals' underestimation of their own risk" (p. 1222).
Analyzing a sample of eighty articles about AIDS appearing
in various magazines, Albert (1986) concurred with
Hamilton's observations. Specifically, Albert (1986) found
that the media: (1) emphasized the lifestyle of gay men who
contracted the disease; (2) implied that social deviance has
a high price; (3) de-emphasized the medical and scientific
aspects of AIDS transmission and prevention, and (4) created
a distance between the general public and people with AIDS.
Thus, it is not surprising that other segments of the
population continued to underestimate their risk of
contracting the disease.
5
It was not until several years into the AIDS crisis
that other populations, namely heterosexuals, started to
recognize the nature and severity of the health threat
(Leishman, 1987). Curran, AIDS Program Director, Center
for Infectious Diseases of the CDC, proclaimed, "Maybe the
greatest disservice, in a sense, has been the denial of
heterosexual transmission" (1988, p. 10). He further
added, "among the cases in heterosexual men and women, the
greatest percentage increase from 1985 to 1986, over 130
percent, was in cases attributed to heterosexual contact
without any other known risk factor" (Curran, 1988, p. 10).
The AIDS epidemic has affected all racial and age
groups (CDC, 1986, 1987). Approximately forty percent of
all reported AIDS cases come from minority groups. To be
more specific, CDC (1986) reported that 25 percent of AIDS
cases were Black, 14 percent were Hispanic, and 1 percent
were Asian/Pacific Islander. While most people with AIDS
are adults in their twenties, thirties, and forties,
pediatric and adolescent cases are increasing in
numbers(CDC, 1987).
In addition, the nature and complexity of the AIDS
threat is undeniably serious for a number of reasons.
First, the mortality rate is very high--survival beyond
three years after diagnosis is unlikely. Second, the
disease can cause physical disfigurement, disability, and
6
dementia. Third, the AIDS threat extends to a person's
most intimate relationships with children and significant
others. Finally, AIDS is a costly disease. Hardy (1988)
calculated the estimated national cost for health care for
people with AIDS, including direct costs of hospitalization,
outpatient costs, and insurance administration, to be
between $3.5 and $9.5 billion by 1991. Osborn (1986) was
even more pessimistic in her assessment of the economic
impact of the epidemic, "No tropical storm has the
economically devastating potential of the new cases of AIDS
expected in the next few years" (p.' 780). She further
commented, "It is useful, in order to appreciate the
economic trouble to come, to think of every single case of
AIDS as costing the same as a heart transplantation" (1986,
p. 780).
In addition, AIDS remains an incurable disease in spite
of tremendous progress in biomedical research in the last
few years. The prospect of discovery of a vaccine to
protect individuals against HIV infection appears equally
bleak. In her address before the Institute of Medicine of
the National Academy of Sciences, Osborn (1986) stated,
There is room for much skepticism about the
advent of a vaccine any time soon. Even if a
vaccine were at hand,the logistics of testing it
would be hard to imagine. In order to establish
protective efficacy, one would need a group of
7
willing, thoroughly informed research subjects at
high risk but as yet unexposed. The slowness of
the viral infection would make assessment of both
efficacy and safety a tremendous challenge, and
the liability problems would be vast (p. 781).
Since neither a cure nor a vaccine for AIDS have yet been
identified, attention must therefore concentrate on the one
and only available measure: The alteration of those
behaviors which cause transmission of the AIDS virus (see,
for example, Albee, 1989; Batchelor, 1988; Becker and
Joseph, 1988; Koop, 1987). Albee (1989) further
elaborated, "AIDS is the first epidemic in human history in
which we have learned so quickly that the identified noxious
agent can be kept from spreading by specific behavioral
changes" (p. 17).
Reason for the Present Study
The magnitude and severity of the AIDS epidemic have
necessitated cooperation between the medical and the social
scientific communities. Batchelor (1984a, 1984b) asserts
the value of social scientific research in biomedical
investigations by recognizing the complex, yet direct,
relationship between behavioral/psychological and
health/disease factors. Such a relationship between
biological and psychosocial variables has been
substantiated in research (see, for example, Cataldo,
1983) and constitutes the basis for psychoneuroimmunology in
|
AIDS research (Coates, Temoshok, and Mandel, 1984; Coates, ]
8
Stall, Mandel, Bocellari, Sorensen, Morales, Morin, Wiley,
and McKusick, 1987), an emerging field of investigation
addressing the relationship between psychological,
behavioral, and environmental stress factors and the
development and progression of AIDS. Furthermore, Morin
(1988) addressed the need for social scientific involvement
by observing that the AIDS epidemic is three-fold consisting
of the medical epidemic (both AIDS and AIDS-related-complex
or ARC), the political and economic reactions, and the
behavioral, social, and cultural consequences. The latter,
Morin notes, is of special relevance to behavioral
scientists since social scientific research has been
effective in influencing health-related behaviors in the
past (e.g., smoking, cardiovascularly beneficial diets, and
seat belts).
Since the spread of AIDS can be greatly reduced by
adopting and altering certain behavioral patterns, the
research focus has been on prevention. Primary prevention
involves "proactive steps to reduce or eliminate the
undesirable condition [AIDS] in unaffected
populations...[it] nearly always involves the reduction of
risk to populations or to large groups at high risk" (Albee,
1989, p. 18). C. Everett Koop (1987) asserts that "every
person can reduce the risk of exposure to the AIDS virus
through preventive measures that are simple,
9
straightforward, and effective" (p. 1). However, Koop
adds, "educating people about AIDS has never been easy"
(1987, p. 1). But this difficult task of AIDS education
remains the only viable alternative to risk behavior
reduction leading to the prevention of HIV transmission
(Albee, 1989; Becker and Joseph, 1988; Mason, Noble,
Lindsey, Kolbe, Van Ness, Bowen, Drotman, and Rosenberg,
1988; Osborn, 1986, 1989; Voberding, 1988). The former
Surgeon General further emphasizes that "many people--
especially our youth— are not receiving information that is
vital to their future, health and well-being" (Koop, 1987,
p. 1), and this educational process is primarily based on
communication (Alcalay and Taplin, 1989; Reardon, 1988,
1989a, 1989b).
Communication scholars, psychologists, social workers,
and other behavioral scientists have recognized the
importance of the crucial role of communication in the AIDS
prevention process. AIDS is a disease surrounded by social
stigma (Herek and Glunt, 1988), extreme uncertainty (Weitz,
1989), isolation, and emotional turmoil (Morin, Charles, and
Malyon, 1984; Moynihan and Christ, 1987; Newmark and Taylor,
1987), and "communication and persuasion are the two
primary means of deterring (its) spread" (Reardon, 1988, p.
282). However, the field of communication is still in the
i
process of identifying, locating, and developing sound
10
communication programs and strategies to effectively
contribute to the control of this epidemic. Reardon (1988)
succinctly summarizes the work which is urgently required.
She writes that "research is needed to identify both
interpersonal and mass media strategies for motivating
people at risk for AIDS to use greater caution" (p. 283).
In terms of education and prevention, Alcalay and Taplin
(1989) describe the role of communication: "Health educators
with a solid background in communication can serve as
community leaders and resources in the planning,
implementation, and dissemination of health communication
campaigns" (p. 105).
The Centers for Disease Control stated that primary
prevention of AIDS through communication campaigns designed
to inform, educate, and persuade uninfected target
populations to engage in preventive behaviors appears to be
an effective public health solution (Mason et al., 1988).
Albee (1989) concurred with this position, "The strategy of
prevention of HIV transmission through education and the
j
modification of behaviors is clearly the most hopeful J
approach to the prevention of AIDS" (p. 19) since
communication campaigns constitute a powerful tool for
influencing public knowledge, attitudes, and behaviors
(Paisley, 1989). Albee (1989) further observed that
effective AIDS primary prevention refers to "educating
11
persons with information that leads to changed behaviors
that reduce or eliminate high-risk, unprotected sexual
encounters" (p. 19).
Communication campaigns aimed at social change have a
rich history of achievement in this country (Paisley, 1989).
In relation to AIDS, a number of communication programs
targetting the gay communities in San Francisco, Los
Angeles, and New York have resulted in dramatic reductions
in rates of HIV spread (see, for example, Stall, Coates, and
Hoff, 1988). Osborn (1989) highlighted the effectiveness
of AIDS communication campaigns, "The remarkable fact that
no new seroconversions occurred in a large study group in
San Francisco last year is a welcome antidote to the chronic
pessimism that usually pervades discussion of the efficacy
of health educational interventions" (p. 30). Therefore,
one may conclude that communication research in AIDS
education and prevention campaigns is the key in the fight
against the spread of HIV.
In terms of communication research, Reardon (1989a)
identifies three stages which are important in our fight
against AIDS. The first stage is the identification of
environmental pressures and idiosyncracies of the target
population, e.g., college students, adolescents, gay youth,
IV drug users, prostitutes, that predispose them to risk.
The second stage is the assessment of the level of
12
interpersonal and media dependency of the target group with
regard to AIDS information and the credibility they assign
to each source. Finally, the last stage consists of the
selection of persuasive strategies suited to the channel and
target group.
The population of sexually active young people,
including adolescents and college students, has been
identified as a specially important target group in terms of
AIDS educational efforts and prevention campaigns (Brooks-
Gunn, Boyer, and Hein, 1988; Carroll, 1988; Caruso and Haig,
1987; DiClemente, Zorn, and Temoshok,1986, 1987; Flora and
Thoresen, 1988; McDermott, Hawkins, Moore, and Cittadino,
1987; Price, Desmond, Hallinan, and Griffin, 1988; Reardon,
1989a; Shayne and Kaplan, 1988; Simkins and Eberhage, 1984;
Simkins and Kushner, 1986; Strunin and Hingson, 1987).
Since sexual behavior has been established as the primary
mode of HIV transmission, such preventive efforts have,
naturally, been concerned with this group. In her
discussion of sexuality in the college population, Renshaw
(1989) noted that "these young people have already placed
themselves in a high-risk group as carriers and active hosts
for all STDs, including AIDS. In time, they will also be
transmitters of these diseases" (p. 154). Widely reported
sexual activity and potential for multiple sexual partners
have been documented with this group (DeLamater and
13
MacCorquodale, 1979; Shafer, Irwin, and Millstein, 1988;
Shayne and Kaplan, 1988). In one study, Earle and
Perricone (1986) found a significant rise in the number of
sexual partners in a sample of undergraduates from North
Carolina between 1970 and 1981. Specifically, the results
demonstrated a 12.1 percent increase in men and a 29.4
percent increase in women. Increase in the number of
sexual partners is one of the documented vehicles for the
magnification of the probability of HIV exposure (U.S.
Surgeon General, 1988).
It is, therefore, without doubt that this population of
young adults has been considered "high-risk for AIDS."
Chilman (1983) notes that college students are vulnerable to
HIV exposure for a number of reasons. First, college
students have a tendency to believe that AIDS cannot happen
to them. Second, they are susceptible to the influence of
peer pressure with regard to sexual behavior. Third, they
are open to sexual experimentation. Finally, they are more
likely to have multiple sexual partners. However, few
empirical studies have dealt with the perceptions and
behaviors of the young, sexually active college population.
While most empirical research on AIDS risk reduction
and lifestyle change has focused on the gay male population
(e.g., Emmons, Joseph, Kessler, Wortman, Montgomery, and
Ostrow, 1986; Joseph, Montgomery, Emmons, Kessler, Ostrow,
14
Wortman, O'Brien, Eller, and Eshleman, 1987; Montgomery and
Joseph, 1988), the few studies examining the population of
college students and adolescents have been exploratory in
nature. With few notable exceptions (Manning, Barenberg,
Gallese, and Rice, 1989; Manning, Balson, Barenberg, and
Moore, 1989; Prewitt, 1989), such exploratory investigations
do not appear to use the widely accepted and integrated body
of explanatory models of preventive health behavior. Based
on a well established body of empirical research from
various fields including psychology (see, for example,
Becker and Maiman, 1974), public health (see, for example,
Gochman, 1988), and communication (see, for example, Seibold
and Roper, 1979), the Health Belief Model (HBM) "Is
recognized as among the most important theoretical
formulations to explain health behavior available in the
health education literature" (Simon and Das, 1984, p. 403).
This cognitive, social psychological model explicates the
relationship between individual perceptions associated with
a disease, i.e., perceived susceptibility, severity,
benefits, and barriers, and likelihood of engaging in
preventive health actions.
Theoretical Foundations for the Present Study
Originally derived from the decision-making models of
Lewin, Tolman, Rotter, Edwards, Atkinson and others (Maiman
and Becker, 1974), the "value-expectancy" approaches, and
15
the theories about "decision-making under conditions of
uncertainty", the Health Belief Model has been applied to a
diversity of illnesses and preventive health behaviors. In
particular, it has been applied to participation in
screening for tuberculosis (Hochbaum, 1958), preventive
dental checkups (Kegeles, 1963), smoking behavior (Croog and
Richards, 1977; Swinehart and Kirscht, 1966; Weinberger,
Greene, Mamlin, and Jerin, 1981; Velicer, DiClemente,
Prochaska, and Brandenburg, 1985), flu immunization (Carter,
Beach, Inui, Kirscht, and Prodzinski, 1986; Cummings, Jette,
Brock, and Haefner, 1979; Oliver and Berger, 1979),
preventive medical visits (Rundall and Wheeler, 1979a),
driving under the influence (Beck, 1981), dieting for
obesity (Becker, Maiman, Kirscht, Haefner, and Drachman,
1977), and hepatitis B vaccination (Bodenheimer, Fulton, and
Kramer, 1986; Palmer and King, 1983).
In addition to its heuristic value (see, for example,
Leventhal, Zimmerman, and Gutmann, 1984), the Health Belief
Model has received considerable empirical support. In
their review, "The Health Belief Model: A Decade Later,"
Janz and Becker (1984) wrote,
Overall, these investigations provide very
substantial empirical evidence supporting HBM
dimensions as important contributors to the
explanation and prediction of individuals '
health-related behaviors... This support is
16
particularly remarkable given the wide diversity
of populations and settings studied, health
conditions and health-related actions examined,
and the multiplicity of different approaches and
tools used to assess health beliefs and
behavioral outcomes (p. 41).
Kirscht, in his review of research and issues in preventive
health behavior, further elaborated, "Where the actions are
voluntary and there is an occasion for action, the health
belief model has demonstrated success in accounting for
preventive behavior" (1983, p. 286).
The relevance of this model to the process of
behavioral risk reduction associated with the AIDS epidemic
has recently been addressed. Investigating another high
risk group for AIDS, the population of gay males, Kotarba
and Lang (1986) argued that the model can illuminate this
process of AIDS behavioral risk reduction in three ways.
First, the HBM is designed to explain preventive health care
behaviors. Second, the HBM incorporates a wide range of
social, psychological, and communication variables which
influence the decision to modify at-risk behavior associated
i
with AIDS. Finally, the HBM demonstrates how this complex
myriad of variables interrelate to influence behavior
modification and change. In particular, they noted that
the absence of one variable may serve as an obstacle for the
adoption of preventive health behaviors, a phenomenon
i
specially relevant to AIDS communication campaigns. For
17
instance, an AIDS education campaign would not be effective
if it only takes into account isolated variables (e.g., fear
of AIDS) without considering their relationship with other
relevant factors (e.g., personal perception of
susceptibility, severity, and efficacy of adopting safe-sex
behaviors). Thus, the Health Belief Model is not only
applicable to AIDS behavioral risk reduction but it points
out, clarifies, and establishes the relationship between
relevant psychological, social, and communication factors
related to this complex process of AIDS prevention. In
their discussion of the necessity of the use of an
integrative model of preventive health behavior in relation
to AIDS, Kirscht and Joseph (1989) wrote, "In searching for
application of the health belief model to the problem of
behavior related to HIV infection, we find rather little in
the literature" (p. 117). The present study attempts to
partially fill this gap.
The Health Belief Model
This model was originally designed to explain
preventive health behaviors (Rosenstock, 1974). Kasl and
Cobb (1966) defined preventive behavior as "any activity
undertaken by a person believing himself to be healthy, for
the purpose of preventing disease or detecting it in an
asymptomatic state" (p. 246). This model assumes that
preventive health behavior is contingent upon two main
18
variables: (1) the individual's desire to avoid illness
(e.g., not wanting to get AIDS), and (2) the individual's
belief that a specific health action (e.g., engaging in
safe-sex activities) will prevent illness.
The HBM consists of several interrelated dimensions
(see Figure 1) . They are: Perceived susceptibility,
perceived severity, perceived benefits, perceived barriers,
and cues to action. Perceived susceptibility is the
individual's subjective perception of the risk of
contracting a specific illness (e.g., AIDS). Perceived
severity is the individual's subjective perception of the
seriousness of a specific illness in terms of clinical
(e.g., death, disfigurement) as well as social (e.g., social
stigmatization) consequences. Perceived benefits are the
individual's subjective perceptions of the degree of
effectiveness of the recommended course of action to be
taken in order to reduce a disease threat (e.g., the
perceived effectiveness of safe sex behaviors). Perceived
barriers are the individual's subjective perceptions of the
cost associated with taking the recommended course of action
(e.g., the perceived inconvenience and unpleasantness of
safe sex practices). Finally, cues to action are
communication messages (e.g., AIDS prevention messages from
health care practitioners, television programs) which
trigger the individual to take the recommended course of
19
preventive action. This communication dimension of the
model has been neglected by researchers, as Janz and Becker
(1984) noted, "few HBM studies have attempted to assess the
contribution of 'cues' to predicting health actions" (p.3).
The present study attempts to explore the importance of this
communication dimension.
Benefits of the Present Study
Public health officials (e.g., Curran, 1988; Koop,
1987; Mann, 1986; Mason et al., 1988) agree that AIDS will
be with us for a long time. Medical history taught us that
disease prevention is usually less costly and more effective
than disease cure and treatment. In the case of AIDS, there
is no cure nor a vaccine in the near future, therefore,
further necessitating prevention. Fortunately, HIV
infection can be prevented through behavioral change.
Behavioral risk reduction constitutes primary prevention.
This prevention process is primarily based on communication.
Specifically, AIDS information and education efforts are
essentially public communication campaigns designed to
create and promote social change in terms of behavioral risk
reduction.
The process of behavioral change is a complex area of
social scientific inquiry. Furthermore, the investigation
of behavior modification in AIDS prevention is a new area of
behavioral research. In Confronting AIDS; Directions for
20
Public Healthr Health Care, and Researchf a report by the
Institute of Medicine of the National Academy of Sciences,
the Committee on a National Strategy for AIDS observed that
"there has been little social science research specifically
focusing on HIV infection and AIDS" ( 1986, p. 27). The
report further noted that "a major research need is for
studies that will improve understanding of all aspects of
sexual behavior and drug abuse and the factors that
influence them" (1986, p. 27). The present study is aimed
at improving such understanding of sexual behavior among
college students.
Although there is reported success of certain
behavioral risk reduction programs among gay and bisexual
men (see, for example, Stall, Coates, and Hoff, 1988), the
overall success of behavioral intervention to increase self-
promoting behaviors has been limited if not disappointing
(Baum and Nesselhof, 1988). On the surface, AIDS risk
reduction appears simple and straightforward. The causal
agent (HIV) is known. Modes of transmission (e.g.,
exchange of body fluids) are also well established. So if
uninfected people stop unprotected and high-risk sexual
activity or intravenous drug users discontinue the sharing
of needles, the epidemic might be restricted. However,
this has not been the case; AIDS continues to spread to
other high-risk populations such as adolescents and college j
21
students. Although the majority of college students appear
to be knowledgeable about AIDS, they do not manifest this
knowledge in terms of actual behavioral change (Edgar,
Freimuth, and Hammond, 1988). The media is partially
responsible for creating a barrier between people with AIDS
and the general population, thus promoting the "it-won't
happen-to-me" attitude in uninfected individuals (Albert,
1986). In addition, the media, through the use of
masculine generic terms in their coverage of the epidemic,
may also be perpetuating the misconception that AIDS is a
"gay disease," thus creating a misperception of lower AIDS
risk in the general population (Hamilton, 1988).
Edgar, Freimuth, and Hammond (1988) offered three
additional explanations for the problem of motivating change
in college subjects. First, college students may lack
skills to perform safe sex practices. In particular, they
may lack the necessary interpersonal skills to negotiate
safe sex with a potential partner (e.g., difficulty in
discussing sexual behavior) or may lack the actual
performance skills (e.g., how to wear a condom properly).
Second, college students may experience fear of homosexual
association. Kantrowitz (1987) noted that homophobic
attitudes may inhibit AIDS information seeking as well as
performance of safe sex behaviors. Finally, college
students may experience lack of personalization of risk.
22
College subjects may have an intellectual understanding of
the problem but do not view themselves as personally
susceptible to the disease. National survey data support
this observation (Washington Post. 1987) and it may be the
greatest barrier to AIDS risk reduction behaviors.
As previously noted, few studies address the problem of
motivating change in college students with respect to the
AIDS risk. Additionally, most research on this topic does
not utilize the well integrated body of behavioral research
in health preventive behaviors which were proven successful
in the past. One such exemplar of preventive health
behavior is the Health Belief Model. The present study
utilizes the assumptions and tenets of the HBM to increase
understanding of this process of communicating and
motivating change among college subjects.
Informing and motivating the target audience to change
their behavior can be accomplished through communication
campaigns. McGuire (1989) presented a communication and
persuasion matrix for the analysis of public communication
campaigns. This matrix consists of two sets of variables:
(1) input (communication) variables, and (2) output
variables. Input variables are the components for
constructing the persuasive communication. In other words,
it formulates the communication process in terms of who says
what, to whom, through what medium, and directed at what
23
kind of target audience. Specifically, it focuses on
source (e.g., credibility, attractiveness), message (e.g.,
type of appeal, type of information), channel (e.g.,
modality, directness), receiver (e.g., lifestyle and skills
of target audience), and destination factors (e.g.,
immediate/long term change, prevention/cessation of
behavior). Output variables refer to the various outcomes
of the persuasive process. They range from exposure to the
message to comprehension, acceptance, behavioral change, and
subsequent behavioral reinforcement and maintenance. The
present study attempts to delineate the implications of the
research findings in terms of the design of AIDS
communication campaigns aimed at college students.
Purpose of Study
Using a communication approach, the present study
attempts to generate a greater understanding for the complex
process of behavioral risk reduction and AIDS prevention
with the college population by addressing the three stages
outlined by Reardon ( 1989a): (1) the identification of
characteristics of the college population that predispose
them to AIDS risk, e.g., personal perceptions of
susceptibility to the disease; (2) the assessment of the
level of interpersonal and media dependency with respect to
AIDS information dissemination, e.g., sources of AIDS
information acquisition, and (3) the selection of persuasive
24
message strategies suited to the channel and target group,
e.g., type of message appeals to promote health-enhancing
behaviors in the era of AIDS.
The general purpose of the present study is twofold:
(1) To test empirically a popular model of preventive
health behavior, the Health Belief Model (HBM), in the
context of AIDS prevention. Specifically, it examines the
relationship between college students' perception of
susceptibility, perceived severity, efficacy, and barriers
and sexual behavior change. Furthermore, it investigates
the role of mediated and interpersonal channels as cues to
action in this complex process of AIDS information
acquisition.
(2) To address the implications of the Health Belief
Model on the design, implementation, and evaluation of AIDS
communication campaigns. Specifically, it utilizes the
research findings, namely, preferred communication channels
with respect to AIDS information (e.g., television,
newspapers), perception of susceptibility (e.g., assessment
of personal risk to the exposure of AIDS), perceived
severity (e.g., personal beliefs of the seriousness of the
AIDS epidemic), efficacy (e.g., personal beliefs associated
with the effectiveness of safe sex practices), and barriers
(e.g., personal beliefs of the degree of cost such as sexual
impulse control involved with the adoption of safe sex
25
behaviors), in the context of health campaign messages for
college students. Finally, various approaches to health
communication campaigns are presented as alternatives to
AIDS information efforts.
26
Chapter 2
REVIEW OF THE LITERATURE
As mentioned in the previous chapter, the Health Belief
'Model has been extensively tested with a variety of
populations and health-related behaviors, as Kirscht
observed, "[the HBM] is the most widely applied approach to
the explanation of medically based preventive actions"
(1983, p. 285). In a comprehensive examination of the
literature (from late 1950’s to June, 1990) which included
several computer searches of major social science,
humanities, and general indexes, several dozens empirical
studies were evaluated. The following indexes were
scrutinized: Communication Abstracts, Psychological
Abstracts. Education Index. Social Science Index, and the
Humanities Index. For inclusion in the present review, the
empirical studies had to meet the following criteria: (1) j
they must focus on the HBM and preventive health behavior or
AIDS preventive behavior in college students, and (2) they
must be fairly current (late 1970’s to June, 1990). Three
categories of empirical investigations emerged from the
literature search, therefore, creating three sections for
the current analysis. Specifically, the present review of
empirical research is divided into three sections: (1)
empirical studies using the HBM to investigate preventive
27
health behaviors in general, (2) empirical studies using
the HBM to investigate preventive health behaviors
associated with AIDS in particular, and (3) relevant
empirical studies, which are not based on the HBM, yet
examine attitudes, perceptions, and beliefs of college
students associated with AIDS.
The Health Belief Model and Preventive Health Behavior
The first section addresses a number of studies which
utilizes the model to explain preventive health behaviors in
general (see table 1). Such behaviors include taking a
chest X-ray for the detection of tuberculosis (Hochbaum,
1958), vaccinating for swine influenza (Aho, 1979; Cummings
et al., 197 9? Rundall and Wheeler, 197 9a), reducing driving
under the influence of alcohol (Beck, 1981), changing
smoking patterns (Croog and Richards, 1977; Weinberger et
al., 1981), adopting preventive behaviors to reduce heart
disease (Aho, 1977), accepting hepatitis B vaccination j
(Bodenheimer et al., 1986; Palmer and King, 1983), seeking !
I
sexuality and contraceptive knowledge (Eisen and Zellman,
1986; Simon and Das, 1984) and adopting a wide variety of
preventive health behaviors such as exercise and dental
checkups (Langlie, 1 9 7 7). Both retrospective and
prospective research were included.
Hochbaum (1958) conducted the first empirical study
t
t
using this theoretical formulation. In his retrospective j
28
research, a sample of 1,200 adults was interviewed to
identify the various factors underlying their decision to
obtain a chest X-ray for the detection of tuberculosis.
Both perceptions of susceptibility and benefits were found
to be related to the particular health action, i.e., getting
a chest X-ray. However, the Hochbaum study did not clearly
identify the role of perceived severity in the decision
making process.
More recent empirical investigations on the HBM and
preventive health behavior addressed other conditions beyond
getting a chest X-ray for the early detection of
tuberculosis. The present review focuses on such current
research.
In a prospective study investigating predisposing
factors leading to swine influenza vaccination, Cummings and
his associates (1979) tested a sample of 286 adults in
Michigan. Research findings indicated that several
predictor variables played an important role. They
included behavioral intention, cues to action provided by
the physician, socioeconomic status, cues to action provided
by mediated sources, past experience with flu shots,
perceived barriers to obtain vaccination, perceived efficacy j
of vaccination, perceived severity of swine influenza, and
perceived susceptibility to swine influenza. In addition
to behavioral intention, that is, the individual's intention
i
29
to get a swine flu shot, HBM variables were influential in
the process of explanation and prediction of inoculation
behavior. To be more specific, there was a direct
relationship between cues to action — both interpersonal and
mediated--, perception of efficacy, severity, and
susceptibility and immunization behavior. On the other
hand, there was an inverse relationship between perceived
barriers and inoculation behaviors.
Rundall and Wheeler (1979a) tested the HBM in the
context of a swine influenza vaccination program for senior
citizens. A sample of 232 senior citizens were tested in
New York through the use of a mail survey. Results
indicated that several HBM accounted for the utilization of
preventive health services in the sample. They included
perceived susceptibility and severity of disease, perceived
efficacy and barriers associated with receiving swine flu
immunization, and general health motivations. The
researchers concluded that the most important predictors of
utilization of the swine flu vaccination program were
perception of susceptibility to the flu and perceived danger
(barrier) associated with receiving the flu shot.
Specifically, the greater the perception of susceptibility,
the greater the likelihood of receiving a flu vaccination
and the greater the perception of danger associated with the
30
vaccine, the lesser the likelihood of utilizing the services
of the program.
Investigating a random group of primarily black and
Portuguese-American senior citizens, Aho (1979) tested the
HBM variables and their relationship to swine influenza
inoculation status. Using a retrospective design, the
sample of 12 2 subjects was interviewed to assess the degree
of importance of HBM variables such as perceived
susceptibility, severity, benefits, and barriers. Findings
indicated a significant positive relationship between the
predictor variables, namely, perception of susceptibility,
benefits, and barriers, and the outcome variable, the
decision to receive the swine flu inoculation shot.
In a prospective research, Beck (1981) tested HBM |
variables associated with drinking and driving behavior in a
college population. Using a nonprobability sample of 272
undergraduate college students, Beck investigated activities
related to alcohol consumption and driving under the
influence by asking them to complete anonymous
questionnaires. Three HBM variables were measured. The
first was perceived seriousness/severity, i.e., getting
caught by the police and causing an accident while driving
under the influence of alcohol. The second was perceived
susceptibility, i.e., the individual's estimate of the
.likelihood of getting caught by the police and causing an
31
accident while driving under the influence of alcohol. The
third was perceived effectiveness/efficacy, i.e., the
individual's estimate of his/her effectiveness in avoiding
being caught by the police and avoiding a traffic accident
iwhile driving under the influence of alcohol. Data
analysis produced mixed findings giving only partial
i
empirical support to the model. The strongest predictor
w a s t h e individual's belief in his/her
effectiveness/efficacy at being able to avoid getting caught
by the police and cause a traffic accident. Furthermore,
Beck noted that the best predictor of actual drinking-
driving behavior was the individual's intention.
In a longitudinal study, Croog and Richards (1977)
investigated the relationship between some factors of the
I
HBM and smoking patterns over a period of eight years in
patients who had a myocardial infarction. A sample of 205
male patients was selected from the Massachusetts area to
assess their smoking patterns and their relationship to
conceptions of susceptibility, threat, and belief in the
efficacy of prevention. Though a massive and persistent
reduction in smoking was found among the subjects, specific
l
beliefs concerning perceptions of severity, susceptibility,
and power of prevention were not found to be associated
with such a drastic and stable change in smoking behavior.
The authors concluded that, "when motivation is sufficiently
32
strong, as in the case of a man recovering from a heart
attack, the other components of the model might be of lesser
importance." (p. 928)
In another study dealing with smoking behavior,
Weinberger and his associates (1981) tested a sample of 120
former and current smokers in Indiana. Three HBM variables
were addressed in the research. They were perception of
susceptibility, severity, and cues to action. Research
findings indicated that there was a significant difference
in the perception of susceptibility to the adverse effects
of smoking between lighter and past smokers and moderate
smokers. On the other hand, both ex-smokers and moderate
smokers reported perceptions of smoking as a serious health
threat. The authors suggested that several factors of the i
HBM must be operating simultaneously in order for preventive
behavior to take place, specifically, both perceptions of
severity and personal susceptibility must be present before
smoking cessation can occur.
Investigating the relationship between wives'
preventive health orientation to their beliefs about heart
disease in husbands, Aho (1977) interviewed a sample of 199
wives in Pennsylvania. Wives' preventive health
orientation was defined as the degree to which the women
perceive themselves to play a significant role in helping
their husbands from getting heart disease. Several HBM
L l _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
33
variables were assessed. They were perception of severity
of the disease, perception of susceptibility, perception of
efficacy, and cues to action. Research findings were
supportive of the predictions of the HBM. Specifically,
there was a significant positive relationship between
perceptions of severity, susceptibility, and efficacy and
(preventive health orientation. In terms of cues to action,
[mediated sources (i.e., magazines, television, and
newspapers) played a significantly greater role than their
interpersonal counterparts (i.e., immediate family, friends,
neighbors) in the dissemination and acquisition of
information about heart disease.
Addressing a different population and health condition,
Palmer and King (1983) analyzed attitudes toward hepatitis
vaccination among high-risk hospital workers. In order to
do this, a sample of 123 subjects was surveyed. Though not
all HBM variables were included in the research, the authors
found that most of their subjects considered their
occupation (e.g., registered nurses, laboratory technicians)
to be at medium to high risk for acquiring hepatitis and
reported corresponding perceptions of seriousness of the
disease. On the other hand, individuals who had chosen not
to receive the vaccination reported higher levels of
perceived barrier, that is, the belief that the hepatitis B
vaccine was risky and dangerous.
34
In a more comprehensive study, Bodenheimer, Fulton, and
jKramer (1986) investigated the relationship between health
beliefs, sociodemographic status, knowledge of hepatitis B,
experience with prior vaccinations, health locus of control,
and desire to receive hepatitis B vaccine. A sample of
1,500 hospital employees was tested in Rhode Island. Data
analysis indicated that perception of efficacy and safety of
vaccine was the important predictor of acceptance of
hepatitis B inoculation. Similarly, perceived
susceptibility and severity, defined as the belief
concerning the likelihood of contracting hepatitis B and the
probability of becoming seriously ill respectively, also had
considerable effects on the determination of vaccine
acceptance. Finally, the researchers suggested that the |
other factors in the study such as knowledge and experience
with vaccinations were more important as determinants of
health beliefs rather than predictors of hepatitis B vaccine
acceptance.
Interviewing a sample of 20 3 teenagers from the Texas j
area, Eisen and Zellman (1986) evaluated a 15-hour HBM-based
sex education program. In particular, they investigated
sexual and contraceptive knowledge, attitudes toward
pregnancy and contraception, and prior sex education and
sexual experience. Research findings demonstrated that
perceived seriousness of teen pregnancy was a significant
35
predictor of sexual and contraceptive knowledge.
Additionally, subjects who perceived fewer barriers to
contraception were more knowledgeable about contraceptive
■methods. The authors concluded that the HBM "was highly
successful in accounting for a substantial portion of the
variance in total knowledge scores" (p. 9). Finally,
implications for sex education programs were presented.
Specifically, it was recommended that such programs must
include a persuasive, attitude-changing, and motivation-
building component to encourage sexual and contraceptive
knowledge seeking in teenagers.
Using the VD Health Belief Scale, Simon and Das (1984)
tested the HBM with a sample of 416 undergraduates in New
York City. The four traditional HBM variables,
susceptibility, seriousness, barrier, and benefit, were used
as predictors. The criterion variable was likelihood of
action, which was operationalized as frequency of
asymptomatic VD check-ups. Though perceived seriousness of
VD did not correlate to likelihood of action, other findings
I
I
demonstrated a significant relationship between perceived
susceptibility, barriers, and benefits, and likelihood of
going to get a medical examination for venereal disease.
The implications of the HBM on VD education programs were
discussed. Specifically, the authors emphasized the use of
perceived susceptibility, e.g., a person can get VD even if I
36
s/he is clean, perceived barriers, e.g., fear of pain and
embarrassment of VD check-ups, and perceived benefits, e.g.,
iproper use of condoms in casual sexual encounters, to create
educational messages which promote periodic asymptomatic
check-ups for VD.
In an attempt to examine the degree of consistency
among a person's vast array of preventive health behaviors
(e.g., seat belt use, nutrition, driving, personal hygiene),
Langlie (1977) tested the ability of the HBM to explain
variations in such behaviors by examining a sample of 383
adults in Illinois. Preventive health behaviors were
further categorized into two separate groups: direct risk
preventive health behavior and indirect risk preventive
health behavior. Direct risk behavior refers to those
i
actions which put the individual in more immediate danger, !
i.e., driving, pedestrian and smoking behavior; personal
hygiene. Indirect risk behavior refers to those actions
which are not hazardous in and of themselves, i.e., seat
belt use, exercise, nutrition, medical and dental checkups,
immunizations, and other medical examinations. The
respondents were also reclassified into "behaviorally
consistent," that is, those individuals who scored either \
i
above or below the mean for his/her gender, or "behaviorally
inconsistent," that is, those individuals who scored around
[
the mean of his/her gender. Three components of the HBM
37
were measured in this retrospective study: perceived
susceptibility, benefits, and barriers. Research findings
indicated that for "behaviorally consistent" subjects, there
was a significant relationship between perceived
susceptibility, benefits, and barriers, and both direct and
indirect risk preventive behaviors. For "behaviorally
inconsistent" subjects, the only significant relationship
jwas between perceived benefits and both direct and indirect
preventive health behaviors.
Irhe Health Belief Model and AIDS-preventive Behavior
The second section addresses a number of studies which
utilizes the model to explain preventive health behaviors
associated with AIDS (see table 2). The application of the
HBM to the explanation and prediction of behavioral risk !
reduction associated with AIDS is a relatively new area of
empirical research. Most of this research has focused on
another high risk group, namely, the population of gay males
(Emmons, Joseph, Kessler, Wortman, Montgomery, and Ostrow,
1986; Joseph, Montgomery, Emmons, Kirscht, Kessler, Ostrow,
Wortman, O'Brien, Eller, and Eshleman, 1987; Kirscht and
Joseph, 1989; Kotarba and Lang, 1986; Montgomery and Joseph,
1988). Only three empirical investigations addressing the
population of college students has been found using the HBM .
(Manning, Barenberg, Gallese, and Rice, 1989; Manning,
Balson, Barenberg, and Moore, 1989; Prewitt, 1989).
38
Investigating the relationship between several
variables of the HBM and sexual behavior modification in gay
men at risk for AIDS, Emmons and her associates (1986)
tested a cohort of 909 men in Chicago. Three HBM variables
were utilized in the research: perceived
susceptibility/risk, perceived benefits/efficacy, and
iperceived barriers. Such variables were tested in
relationship to sexual behavior modification which was
defined in terms of five outcome measures: (1) any change in
behavior; (2) limiting the number of sexual partners; (3)
avoiding anonymous sexual partners; (4) avoiding receptive
anal activity, and (5) changes in receptive anal intercourse
in ways which may reduce exposure to the AIDS virus, e.g.,
use of condoms. Results indicated that perceived
susceptibility to AIDS and perceived efficacy of behavioral
change were related to multiple outcome measures, i.e.,
limiting the number of sexual partners, avoiding anonymous
sexual encounters, or any change in sexual behavior.
Perceived barriers, operationalized as difficulties with
sexual impulse control, belief in biomedical technology to
prevent/cure AIDS, and perceived social norms, were related
to some outcome measures, i.e., number or type of sexual
partner. A negative interaction between perceived
susceptibility and perceived efficacy of behavioral change
was also noted. Finally, knowledge, a variable which is
39
not a component of the HBM, was found to be positively
related to all outcome measures.
i
In a concurrent supplemental psychosocial study,
jMontgomery and Joseph (1988) tested the same group of gay
men participating in the Chicago-based Multicenter AIDS
Cohort Study (MACS) reported by Emmons and her associates
(1986). The aim of the study was to test the explanatory
ipower of the HBM in relationship to change in sexual
I
behavior among gay males. Research findings supported the
predictions of the HBM. To be more specific, the data
revealed that there was a consistent reduction in high-risk
behaviors, e.g., contact with multiple partners, and an
overall increase in AIDS preventive behaviors, e.g., use of
condoms during sexual activity. Though such an extensive
aggregate risk reduction occurred in the subjects,
approximately one fourth of the sample reported inconsistent
patterns of enactment of safe sex practices. The authors
noted that certain sociodemographic factors such as age and
relationship status of the participants as well as personal
predispositions such as personal coping styles may have a
significant impact in this complex process of change and
maintenance of AIDS risk reduction behaviors.
In a longitudinal study of a sample of 637 gay men from !
the Chicago area, Joseph, Montgomery, Emmons, Kirscht,
Kessler, Ostrow, Wortman, O'Brien, Eller, and Eshleman
40
(1987) explored the relationship between perception of
susceptibility/risk of AIDS and various behavioral and
ipsychosocial consequences. Behavioral consequences were
assessed in terms of change in sexual behavior.
Psychosocial consequences were defined in terms of perceived
efficacy of behavior in reducing the risk for AIDS,
perceived barrier to behavioral change, knowledge of the
disease, and social network characteristics including gay
network affiliation and peer norm support of AIDS behavioral
risk reduction. In addition, psychological distress, i.e.,
anxiety, depression, somatization, was also assessed under
the rubric of psychosocial consequences. Data analysis
demonstrated a relationship between perception of
susceptibility/risk of AIDS and subsequent behavioral risk
reduction. However, after adjustment for sociodemographic
variables and initial behavior, such a relationship was no
longer true. Joseph and her associates (1987) concluded
that "taken together, these results suggest that there is
little or no observable benefit to an increased sense of
risk, but that such a sense subsequently leads to distress
and dysfunction in a variety of realms" (p. 231).
Interviewing a sample of 48 gay males, Kotarba and
Lang ( 1986 ) examined the impact of the AIDS phenomenon on
gay lifestyle using the health belief model and locus of j
control as their theoretical foundations. The following
41
information was extracted from their interview schedule: (1)
socioeconomic/demographic characteristics; (2) health status
and behavior before and after the onset of the epidemic; (3)
sexual attitudes and behavior before and after the onset of
AIDS; (4) experiences of homophobia since the onset of the
epidemic; (5) sources of information about the disease; (6)
the nature of the respondent's political involvement related
to the gay community's collective response to the AIDS
phenomenon, and (7) the respondent's initial reactions to
AIDS. Based on the data, the dependent variable, lifestyle
change, was then coded into four basic categories. The
first, public-public, refers to respondents who have not
altered their lifestyles since the onset of the AIDS
phenomenon by remaining in the participation of high-risk
behaviors. The second, public-private, refers to those
respondents who have altered their lifestyles since the
f
onset of the AIDS phenomenon by moving from high-risk to
low-risk behaviors. The third, private-private, refers to
those respondents who have not altered their lifestyles
since the onset of the epidemic by remaining low-risk in
their behavior. The fourth, private-public, refers to those
respondents who have altered their lifestyles since the
onset of the epidemic by moving from low-risk to high-risk
behaviors. Though the HBM appears "to be (a) useful tool
i
in the analysis of gay lifestyle change as preventive health
42
care" (p. 141), the researchers concluded that behavioral
responses to AIDS are much more varied and complex than
jpreviously recognized.
Examining the relationship between knowledge and health
beliefs about AIDS, Manning, Barenberg, Gallese, and Rice
(1989) administered a questionnaire to 139 college students
in the New Orleans area. Data analysis indicated that
level of knowledge about AIDS was related to risk reduction
behaviors, e.g., perceived likelihood of practicing safer
sex. Specifically, higher levels of knowledge were
associated with greater perceived likelihood of engaging in
AIDS preventive actions. In addition, level of knowledge
affected perception of barriers to practicing safe sex. In
particular, greater perceived barriers were reported among
subjects with low-knowledge about AIDS when compared to j
their high-knowledge counterparts. The authors recommended
that communication campaigns targeting the low-knowledge
student should focus on overcoming perceptions of high
barriers with regard to the practice of safer sex.
In another study, using the nominal group technique,
Manning, Balson, Barenberg, and Moore (1989) presented an
in-depth examination of college students' perceived j
i
susceptibility to AIDS and barriers to prevention. Results
from the sample of 122 college freshmen provided answers to
the following research questions: (1) why college students
43
do not believe that they are susceptible to the AIDS-causing
virus?; (2) what health education measures can be used to
help college students recognize that they are susceptible to
the AIDS-causing virus?; (3) what are the barriers to
following "safer sex" practices in college students?, and
(4) what health education measures can be used to remove the
barriers college students see in practicing safer sex?.
Responses to the first question indicated that college
students retain many stereotypes about who can and cannot
contract AIDS (e.g., "Only homosexuals get AIDS," "only IV
users get AIDS," "no Haitians on campus") as well as
i
paintain and perpetuate an illusion of invulnerability
(e.g., "students here come from good backgrounds, so they
won't get AIDS," "faith in their partners," "invulnerability
complex"). Responses to the second question revealed that
college students view AIDS-information campaigns as
effective health education measures (e.g., "promote
informational meetings with alcohol or other incentives,"
"use scare tactics and actual cases," "posters and
pamphlets," "health center doctors should say something
about AIDS to each patient"). Responses to the third
question indicated that safe sex practices were perceived as
unattractive ("awkwardness in confronting partner about
condom use," "sex is not enjoyable with condoms," "condoms
are a 'hassle' in the heat of the moment," "too shy to get
44
condoms"). Finally, responses to the fourth question
revealed that safe sex practices can be made attractive
through education ("sex education at an early age," "teach
availability and proper use of condoms and various
contraceptives," "show AIDS as a health danger rather than
showing sex as bad," "sex counselors to answer safe sex
questions") and increased exposure to condoms ("pamphlets
and complimentary condoms in welcome box," "ready supply of
free condoms by mail order," "dispensers in bathrooms").
The researchers concluded that AIDS prevention campaigns
should take into account the perspective of the target as
well as correcting misinformation about the disease.
In a content analysis of educational pamphlets from
state-approved agencies from six states— New York,
California, Florida, Texas, New Jersey, and Illinois--
Prewitt (1989) selected the HBM variables, locus of control,
and self-efficacy to examine their relationship to barriers
to acceptance of public health behavior recommendations.
Locus of control refers to the degree to which individuals
believe that they control their own health outcomes (Rotter,
1966). Self-efficacy can be defined as the degree to which
individuals believe that they are capable of enacting
preventive health behavior recommendations (Bandura, 1989).
Using the HBM, locus of control, self efficacy, and a sample
of AIDS educational pamphlets, nine thematic categories were
45
analyzed. They are: (1) transmission of AIDS; (2) effects
of drugs and alcohol on sexual behavior; (3) HIV antibody
testing; (4) the existence of asymptomatic, yet HIV
infected, individuals; (5) severity of AIDS; (6) reassurance
and personal responsibility; (7) suggestions to overcoming
jbarriers to recommended preventive health behavior; (8)
methods in which HIV is not transmitted; (9) a simple
jdefinition of AIDS. Analysis of results indicated that
most pamphlets emphasized susceptibility, de-emphasized
information regarding sexual behavior, and failed to mention
barriers to recommended actions. The author concluded that
while AIDS information is widely disseminated to various
target groups, such information is neither clear nor
complete. Therefore, the execution of AIDS preventive
health behavior as a result of educational pamphlets may be
limited.
Atheoretical Research on AIDS Preventive Behavior in College
Students
In addition to theoretically based research on AIDS
I
preventive behaviors, this third section of the review
presents a number of studies which illuminate the
I
perceptions and sexual behavior of college students in
response to the AIDS epidemic (see table 3). Some examined
perceptions, attitudes and behaviors (Edgar, Freimuth, and
Hammond, 1988; Mangan, 1988; Chervin and Martinez, 1987;
I
j
46
Simkins and Eberhage, 1984; Simkins and Kushner, 1986;
jRoyse, Dhooper, and Hatch, 1987; Hughey, 1987; Price,
Desmond, Hallinan, and Griffin, 1988; Carroll, 1988;
Kegeles, Adler, and Irwin, 1988; Catania, Dolcini, Coates,
jKegeles, Greenblatt, Puckett, Corman, and Miller, 1989;
Baldwin and Baldwin, 1988), others measured AIDS knowledge
and awareness (Atkinson, Ktsanes, and Hassig, 1987;
Gottlieb, Vacalis, Palmer, and Conlon, 1988; DiClemente,
Zorn, and Temoshok, 1986; Goodwin and Roscoe, 1988; Thurman
and Franklin, 1990; Katzman, Mulholland, and Sutherland,
1988; DiClemente, Zorn, and Temoshok, 1987; Strunin and
Hingson, 1987; DiClemente, Boyer, and Morales, 1988; Thomas,
Gilliam, and Iwrey, 1989; Gilliam and Seltzer, 1989; Fan and
Shaffer, 1990; Freimuth, Edgar, and Hammond, 1987), while
others addressed AIDS information seeking and sources of
I
information acquisition (Price-Greathouse and Trice, 1986;
Trice and Price-Greathouse, 1987; Gerrard and Reis, 1989;
McDermott, Hawkins, Moore, and Cittadino, 1987; Yep and
Negron, 1989).
In their assessment of several empirical studies
regarding AIDS risk among American university students,
Edgar, Freimuth, and Hammond (1988) argued that there is |
limited information about the use of persuasive strategies j
for AIDS education campaigns. Their review revealed that I
the majority of university students are fairly knowledgeable
47
about the modes of HIV transmission as well as the proper
preventive measures. However, they observed that AIDS
transmission and preventive knowledge did not necessarily
produce appropriate behavioral modification. They
emphasized this problem of motivating change,
"unfortunately, only a minority (of students) are
translating their knowledge into behavioral change" (p. 59).
Since communicating the AIDS risk to college students is a
complex process, the researchers concluded that AIDS
information disseminators should be more careful about their
use of strategies in their campaigns to ensure that such
persuasive tactics are firmly grounded in communication
theory and research.
Mangan (1988) concurred with the conclusions drawn by
Edgar, Freimuth, and Hammond (1988). College students are
fairly knowledgeable about AIDS but they do not perceive
themselves as personally vulnerable to the disease nor are I
they taking precautions against the virus. In a sample of
640 students surveyed at the University of Texas at Austin,
94 percent did not consider themselves personally
susceptible to contracting AIDS. Additionally, 55 percent
I
of the sexually active respondents did not report using
condoms during their sexual encounters. This latter
finding appears to be consistent with studies around other
American college campuses. For instance, over 60 percent
48
of the respondents at Oregon State University stated that
they engaged in sexual intercourse over the past year
without a condom as a protective measure against AIDS. In
sum, college students appear to know how the HIV virus is
transmitted and consequently, how AIDS can be prevented but
most of them, unfortunately, are not perceiving themselves
as personally vulnerable to contracting the deadly virus.
In a study conducted at Stanford University, Chervin
and Martinez (1987) investigated the sexual behavior of
students on campus. Specifically, the researchers
attempted to find: (1) the level of discussion of sexual
health prior to sexual activity, and (2) the frequency of
utilization of safe sex methods. Results indicated that 74
percent of the respondents did not discuss sexual health
before a sexual encounter. In addition, less than 30
percent (27 percent for undergraduates and 24 percent for
graduates) of the subjects claimed that they engage in safe
sex practices. Some of the subjects— both undergraduates
and graduates, males and females— did not have any knowledge
i
about safe sex practices. The researchers concluded that
the vast majority of sexually active students have not
altered their sexual behavior in response to the threat of
AIDS.
Using a questionnaire, Simkins and Eberhage (1984)
j j
investigated a sample of 232 college subjects to assess |
49
their attitudes about AIDS, herpes, and Toxic Shock
Syndrome. Their subjects were mostly undergraduates from
the University of Missouri. The authors found that the
-majority of subjects expressed very little concern about any
of these diseases. Most respondents reported very low
concern about contracting AIDS from their present sexual
partner, "with close to 75 percent of respondents rating one
on the seven-point scale (from no concern to very high
concern)" (p. 782). Subjects also reported low concern
about contracting AIDS from a future sexual partner, "still
close to 60 percent of respondents recorded a scale value of
one" (p. 782). While female respondents showed
significantly more concern for Toxic Shock Syndrome than
herpes or AIDS, most subjects expressed very little concern
for the above conditions. Reflecting such a minimal -
concern for contracting either herpes or AIDS, the majority
of the subjects did not report any changes in levels of
sexual activity. Only 24.1 percent of the sample indicated
that their concern for herpes and AIDS affected their sexual
behavior. The investigators concluded that media reports
regarding profound sexual behavior changes as a response to j
the AIDS epidemic should be interpreted with caution
since their sample data appear to indicate contradictory
findings.
50
In a follow-up study, two years later, Simkins and
Kushner (1986) assessed the changes in attitudes and
behaviors with respect to the same diseases, namely, AIDS,
herpes, and Toxic Shock Syndrome. For this investigation,
they used a sample of 212 undergraduates from the same
university. Results indicated very minimal modification in
either attitudes or sexual behaviors. They elaborated,
"despite the increasing incidence of AIDS and its spread to
the heterosexual population..., the results of this survey
indicate there has been little change in expressed attitudes
during the last two years" (p. 889) when they presented
percentages such as 7 0.8 percent and 65.1 percent of the
subjects displaying no concern for AIDS or herpes,
respectively. Since the AIDS epidemic may exacerbate
homophobic attitudes, Simkins and Kushner analyzed the
nature of the relationship between attitudes toward AIDS and
homophobic sentiment. They found a low (r= .18, p< .005),
though significant, correlation between homophobic attitudes
and concern about AIDS and herpes. Finally, the
researchers noted that women were much more concerned about
Toxic Shock Syndrome than either AIDS or herpes.
In a study designed to explore how fear of AIDS may be
associated with knowledge about the disease and empathy
toward people with AIDS (PWA), Royse, Dhooper, and Hatch
(1987) examined the attitudes of 219 subjects at the
51
University of Kentucky. Three research instruments were
used in the study. These scales were designed to assess
the three main variables in the study, namely, knowledge
about AIDS, fear of AIDS, and empathy toward people with
AIDS. Their research findings indicated that class status
(undergraduate/graduate) was not a good predictor of empathy
toward people with AIDS, fear of AIDS, or knowledge of AIDS.
Furthermore, knowledge about the disease was a better
predictor of fear of AIDS than demographic characteristics
such as age, race, or sex. Finally, higher level of
knowledge about AIDS was associated with greater empathy
toward people with the disease. The researchers concluded
that the fear of AIDS is pervasive and suggested that
i
educating people about the condition can reduce fear of AIDS
and produce greater empathic reactions toward those who
already have the disease.
In a study undertaken to explore how college students
are willing to help people with AIDS, Hughey (1987)
administered his research instrument to a sample of 12 6
speech communication undergraduates in Oklahoma. The
independent variable in the study was type of disease. It i
consisted of three levels: AIDS, Toxic Shock Syndrome, and
Legionnaire's disease. The dependent measures were:
knowledge, image, and behavioral intent. Five research
questions were proposed: (1) how do perceived knowledge
52
about AIDS, Toxic Shock Syndrome, and Legionnaire's disease
compare?; (2) how knowledgeable are the subjects about the
three diseases?; (3) how does the image of AIDS, that is,
the social perception of the disease, compare with the image
of Toxic Shock Syndrome?; (4) how does the behavioral intent
to assist people with AIDS compare with the intention to
assist people with Toxic Shock Syndrome?, and (5) how do
factual knowledge, image dimensions of stigma, and subject's
gender relate to the willingness to assist people with AIDS
and Toxic Shock Syndrome? In response to the first
question, Hughey found that awareness of AIDS and Toxic
Shock Syndrome appeared to be higher than awareness for
Legionnaire's disease. However, results for the second
research question indicated that less than 50 percent of the
respondents were able to answer correctly half of the items
on the AIDS knowledge test. Examining the third research
question, findings indicated that AIDS is engulfed by social
stigma as demonstrated by a large and significant difference
(38 percent vs. 76 percent) in expressed sympathy for people
with AIDS and Toxic Shock Syndrome. This difference in
image of the two diseases was manifested in the response to
I
the fourth question, specifically, only 37 percent of the
respondents were willing to help people with AIDS while 7 8
percent agreed to help people with Toxic Shock. Results
i
addressing the fifth question were explored through i
53
discrimant and correlational analysis which revealed that
the sample may be divided into three groups: (1) the helpers
group (n=42) which consisted of subjects willing to assist
both people with AIDS and Toxic Shock Syndrome; (2) the TSS
helpers-AIDS nonhelpers group (n=56) which consisted of
subjects who agreed to help people with Toxic Shock Syndrome
but expressed neutrality or refusal to assist people with
AIDS, and (3) the nonhelpers group (n=24) which consisted of
respondents who were either neutral or unwilling to help
people with either disease. The remaining four subjects
expressed willingness to assist people with AIDS while
expressing neutral or unwillingness to help people with
Toxic Shock Syndrome. The relationship between knowledge
and image of AIDS, and behavioral intent and factual
knowledge of the diseases were found to be nonsignificant.
Finally, gender appeared to play a significant role in terms
of image and behavior for Toxic Shock Syndrome but a
nonsignificant role for either AIDS-related constructs
(image and behavior) or factual knowledge.
Using a sample of 535 subjects from three Midwestern
universities, Price, Desmond, Hallinan, and Griffin (1988)
investigated college students’ perceived risk and
seriousness of AIDS. Specifically, they compared subjects'
perceptions of AIDS in relation to five of the ten leading
i
causes of death among young adults, namely, heart disease,
54
cancer, cerebrovascular accident, diabetes mellitus, and
serious car accidents. Research findings indicated that
"the health problem males and females believed they were
least susceptible was AIDS; 3 percent of the females and 4
percent of the males believed it was likely they would get
AIDS sometime in their life" (p. 17). The researchers
concluded that such extremely low perceptions of
susceptibility may be explained in terms of group
membership. That is, most college students are not
members of a high risk group for AIDS, e.g., gay or IV drug
user. The results from the study appear to concur with the
findings of others conducted with the college population,
that is, most university respondents do not view themselves
as personally vulnerable to contracting AIDS.
Using a sample of 447 undergraduate students from the
University of Rhode Island, Carroll (1988) attempted to
establish the effects of concern over AIDS on self reported
frequencies of sexual activity. Specifically, the study !
was designed to: (1) determine the degree and distribution
j
of concern about AIDS among college subjects, and (2) assess i
the relationship between reported behavioral changes and
independent indices of the behavior. Results indicated
i
that 4 0 percent of the sample reported that concern over
AIDS had an impact in their sexual behavior. Thirty
percent of the sexually active subjects expressed greater
55
selectivity in their choice of sexual partners with no
change in coital frequency while 2 0 percent of the same
group indicated greater selectivity combined with some
decrease in frequency. Furthermore, subjects reporting
that AIDS has affected their sexual behavior are less likely
than others to be involved in some kind of relationship.
However, the author noted that findings are somewhat
inconclusive, "Contrary to popular accounts, the students in
this sample express widespread concern about AIDS...
However, there is no relationship, net of other factors,
between the changes reported by sexually active students and
independent measures of their behavior" (p. 410).
Examining a sample of sexually active adolescents in !
San Francisco, Kegeles, Adler, and Irwin (1988) tested
changes in knowledge, attitudes, and use of condom over a
one-year period. In particular, the study assessed six
variables: (1) knowledge that condoms can prevent sexually
transmitted diseases (STDs); (2) perception of the value of
fusing a contraceptive which prevents STDs; (3) perception of
!
the importance of using a contraceptive which prevents STDs;
(4) perceptions of the partner's wishes with respect to
condom use; (5) behavioral intentions to ever use condoms,
and (6) behavioral intentions to use condoms most of the
time. Research findings were disconcerting as the authors
discovered that sexually active subjects placed "high value
56
and importance on using a contraceptive that protects
against STDs and know that condoms prevent STDs, yet the
females continued not to intend to have their partners use
condoms and the males' intentions to use condoms decreased"
(p. 461) over the period of their assessment. It was
concluded that knowledge is not a sufficient factor to
increase condom use if the target subjects do not perceive
personal vulnerability to contracting STDs including AIDS.
In a study examining psychosocial correlates of condom
use and sex with multiple partners among sexually active
adolescent women, Catania, Dolcini, Coates, Kegeles,
Greenblatt, Puckett, Corman, and Miller (1989) tested a
!
sample of 114 women attending a family planning clinic in
California. The sample appeared to engage in higher levels
I
of sexual activity when compared to the national average.
Such activities included both vaginal as well as anal
f
intercourse. Forty seven percent of the sample reported
some use of condoms with their primary sexual partner;
however, only an average of 27 percent of the coital
contacts with a primary partner involved condom use.
Twenty eight percent reported sexual encounters with
secondary partners. Results indicated that perceptions of
susceptibility, self-efficacy, AIDS-anxiety, condom norms,
health beliefs associated with condoms, egocentrism, and
t
general sexual communication were not significantly related ;
57
to condom use. However, perceptions of greater enjoyment
of condoms and greater willingness to request partners to
use condoms were significant predictors of condom use.
Finally, the researchers discovered a direct relationship
between number of sexual partners and increased perceptions
of susceptibility, decreased quality of sexual communication
with sexual partners, and greater peer acceptance for being
sexually active.
Analyzing factors affecting AIDS-related sexual risk-
taking behavior among college students, Baldwin and Baldwin
(1988) tested a final sample of 513 subjects in the Southern
California area. Nine independent variables were examined
in this study: (1) age, (2) family background, (3) religious
commitment, (4) ethnic background, (5) gender, (6) sexual
conservativeness, (7) sex education, (8) patterns of
seatbelt use, and (9) cognitive-emotional factors including
knowledge, perceived susceptibility, and concern about the
possibility of contracting AIDS. Three dependent measures
were utilized to assess sexual risk-taking behavior
associated with AIDS. They were: (1) frequency of condom
use during vaginal intercourse, (2) number of sexual
partners in the previous three months, and (3) frequency of
casual sexual activities in the last three months. Results
revealed that the most consistent predictors of cautious
i
sexual behavior were age at first sexual encounter, average
58
number of sexual partners per year, gender of the subject
(female), and use of seatbelts while driving. On the other
hand, sex education and religiosity were not significant
predictors of safer sexual practices. Furthermore, the
regression analysis suggested that knowledge and worry about
AIDS appear to be better predictors of cautious sexual
behavior than personal perception of susceptibility.
However, it is worth noting that AIDS worry and perceived
susceptibility may have overlapping operational meaning.
i
This may be demonstrated by the operationalization of the
two constructs, "How much do you think you are at risk for
I
being exposed to the AIDS virus?" (AIDS risk/susceptibility)
and "As a result of your sexual activity, how much do you
worry about the possibility of contracting AIDS?" (AIDS
worry). In this case, it appears that AIDS worry is
associated with perceptions of personal susceptibility to
the disease.
In a study assessing knowledge, information sources and ;
behavior, Atkinson, Ktsanes, and Hassig (1987) administered
I
their research instrument to college freshmen in Louisiana. !
Their findings were consistent with other research examining
the population of university students (see, for example,
McDermott, Hawkins, Moore, and Cittadino, 1987; Yep and
Negron, 1989; Baldwin and Baldwin, 1988; Gottlieb, Vacalis,
Palmer, and Conlon, 1988). Specifically, the researchers j
found that the subjects were fairly knowledgeable about AIDS
and inodes of HIV transmission. Additionally, they
discovered that television was the major source of AIDS
information acquisition. In terms of changes in sexual
behavior, the authors noted that 5 9 percent of the subjects
indicated some change in their choice and number of sexual
partners as a result of knowledge and information about
AIDS. However, the strength and magnitude of such changes
were not reported.
Exploring the relationship between knowledge, belief,
and practices of college students with regard to the AIDS
crisis, Gottlieb, Vacalis, Palmer, and Conlon (1988) mailed
a survey to a group of randomly selected students from the
various campuses of the University of Texas. Most of the
subjects were undergraduates. Based on a final sample of
670 respondents, the authors attempted to establish a
relationship between students' knowledge, attitudes and
beliefs with respect to AIDS, their level of sexual
activity, changes in sexual parctices, willingness to engage
in prosocial actions, and preferred channels of AIDS
information acquisition in the future. Though inaccurate
knowledge was exhibited by many respondents (e.g., 42
percent of the sample believed that mosquito bites were a
somewhat or very likely mode of HIV transmission), students
were generally knowledgeable about documented modes of
60
transmission for AIDS, HIV testing and interpretation of
test results. Similarly, subjects expressed the belief
that condoms can reduce the risk of HIV infection. Further
examination of results revealed that 94 percent of the
respondents did not perceive themselves as personally
susceptible to AIDS. In terms of preferred communication
channels for the acquisition of AIDS information, mediated
sources such as magazine, pamphlets, or a television program
were ranked higher than interpersonal sources such as
communication with their personal physician. Finally,
students indicated that they were at least somewhat likely
to engage in some AIDS-related prosocial actions including
reading more about AIDS (88 percent), informing others about
AIDS resources (56 percent), and donating money to the local
AIDS organization (43 percent), among others. In sum, the t
present research findings appear to be consistent with past
research (see, for example, DiClemente, Zorn, and Temoshok,
1986; Price, Desmond, and Kukulka, 1985).
In a survey of knowledge, attitudes, and beliefs about
AIDS, DiClemente, Zorn, and Temoshok (1986) tested a sample
of 1,326 adolescents in the San Francisco Bay Area.
Research findings suggested that students possess some
knowledge about AIDS. The sample exhibited great !
variability in knowledge across informational items,
J
however. For instance, while 92 percent of the respondents '
61
correctly indicated that "sexual intercourse was one mode of
contracting AIDS," only 60 percent correctly responded that
"use of a condom during sexual intercourse may lower the
risk of getting the disease." Similarly, most respondents
were aware that receiving infected blood from a transfusion
(84 percent) or sharing intravenous drug needles (81
percent) were established routes of HIV transmission, while
considerably fewer respondents were aware that using the
personal belongings of a person with AIDS (66 percent) and
engaging in casual contact with an infected person (68
percent) were not identified modes of contracting AIDS.
Morever, only 41 percent of the students correctly
identified that kissing was not a transmission route for the
HIV virus. In terms of AIDS fear and concern, 78.7 percent
of the students reported "being afraid of getting AIDS,"
while 73.7 percent indicated being "worried about
contracting AIDS." Not surprisingly, the degree of social
stigma associated with AIDS appears to be high as 50.6
percent of the students indicated that they would rather
"get any other disease than AIDS." !
To determine college students' knowledge and attitudes
regarding AIDS and the relationships between acceptance of
homosexual behaviors, their knowledge, and fear of AIDS,
Goodwin and Roscoe (1988) examined a sample of 495
undergraduates at a midwestern university. It was
62
hypothesized that college subjects who expressed a negative
attitude toward homosexuality would be more likely to
display a greater fear of AIDS. Results indicated that
respondents who were highly accepting of homosexual behavior
appeared significantly less fearful of AIDS transmission
(e.g., not fighting to have a child with AIDS removed from
school, not worrying about children passing AIDS to one
another). Furthermore, college subjects appeared to have
moderate knowledge concerning AIDS, manifest some concern
about the transmission of AIDS, and display nonaccepting and
homophobic attitudes toward gay people. Morever, males
reported more negative attitudes toward homosexuality than
their female counterparts. The researchers suggested that
i
m addition to imparting accurate information about the
disease, AIDS educational efforts should also help target
subjects lessen their inappropriate fears and responses to
the epidemic as well as teach safer sex practices.
As an extension of the research conducted by Price,
Desmond, and Kukulka (1985), DiClemente, Zorn, and Temoshok
(1986), and Goodwin and Roscoe (1988), a study was designed
by Thurman and Franklin (1990) to examine knowledge, threat,
and AIDS prevention at a Northwestern university. To do
this, a sample of 294 undergraduates was interviewed by
telephone. Their findings indicated that students are
fairly informed and knowledgeable about AIDS. To be more
63
specific, more than 80 percent of the respondents correctly
identified the proper response for each knowledge item.
Additionally, these subjects were aware of the recommended
course of action for prevention of HIV infection. For
instance, most students (97 percent) appeared to believe
that condoms are either very effective or somewhat effective
in the prevention of AIDS. A substantial number of
subjects (60.6 percent) also reported to be at least
somewhat fearful of the spread of AIDS in the student
population. Finally, only a small segment of the sample
(18.3 percent) admitted to be at least somewhat personally
susceptible to the AIDS virus. In conjunction to the
perception of such lack of personal threat of HIV infection,
most college students have not changed their sexual behavior
in response to the AIDS epidemic.
Arguing for more comprehensive, continuous analysis of
student knowledge, attitudes, and sexual behavioral changes
related to AIDS, Katzman, Mulholland, and Sutherland (1988)
interviewed 166 undergraduates in Arizona. In terms of
i
knowledge, the data suggested that students are highly
knowledgeable about AIDS and its prevention.
Specifically, over 88 percent of the subjects responded \
correctly to items regarding routes of HIV infection and
98.5 percent expressed that condoms are at least somewhat
effective in the process of AIDS prevention. With regard
64
to attitudinal measures, some subjects (37.6 percent)
reported feeling that they have received enough information
about AIDS and possess a clear understanding of the issues
while others (41.2 percent) expressed that they have
received a lot of information about the disease yet still
feel very confused. Other measures included concern about
the spread of AIDS and sexual behavior changes. Though
■most subjects (95.2 percent) expressed at least some concern
over the spread of AIDS in the national student population,
only a segment of the research population (44.2 percent)
reported at least some change in sexual behavior as their
personal response to the AIDS crisis. Finally, respondents
were asked to ascertain their preferred sources of AIDS
information acquisition. Once again, mediated sources
(e.g., magazine and newspaper articles, television programs
or movies) ranked higher than interpersonal sources (e.g.,
health care practitioner, workshops or discussion groups).
In a large-scale survey designed to assess students'
knowledge, attitudes, and beliefs about AIDS, DiClemente,
Zorn, and Temoshok (1987) extended their previous study
(DiClemente, Zorn, and Temoshok, 1986). Data obtained from i
1,326 adolescents in San Francisco were used to determine
the association of gender, ethnicity, and length of
residence in the Bay Area to AIDS knowledge and attitudes.
There was considerable variability in terms of knowledge
65
about AIDS in the sample. While perceived severity and
fear of AIDS were fairly high, perceptions of personal
susceptibility to the disease was fairly low. In
particular, an optimistic bias can be inferred when 53
percent of the students reported that they are less likely
than most people to contract AIDS. In terms of gender,
negligible, though statistically significant, differences in
knowledge appeared between males and females. With regard
to ethnicity, Caucasians displayed higher levels of AIDS
knowledge than Blacks, Asians, and Hispanics. Furthermore,
Blacks scored higher than Asians in the knowledge variable.
With respect to length of residence in the San Francisco
I
area, findings revealed a statistically significant direct
correlation between length of residency and higher levels of
AIDS knowledge. Additionally, respondents expressing a
higher level of perceived susceptibility to AIDS were more
likely to have lower scores on the AIDS knowledge
instrument. Finally, respondents indicating higher levels
of perceived severity of the disease were more likely to
have higher AIDS knowledge scores. Therefore, it appears
that knowledge is significantly associated with perceived
susceptibility and severity, two important mediators of
health behavior. The authors recommended that AIDS health
education should incorporate medical information to increase
66
knowledge and correct misconceptions or gaps in information
about the disease.
Examining knowledge, beliefs, attitudes, and behaviors
in 860 adolescents in the Massachusetts area, Strunin and
Hingson (1987) conducted a random-digit telephone interview.
Results indicated that there was considerable misinformation
and confusion about AIDS and its transmission. For
instance, 60 percent of the sample believed that AIDS can be
transmitted through blood donation while 37 percent noted
that sharing eating and drinking utensils with a person with
AIDS is a viable method of contracting the disease.
Furthermore, 70 percent of the respondents indicated that
they were sexually active but only 15 percent of them
reported any change in sexual behavior as a response to the
AIDS crisis. In addition, only 20 percent of those
individuals who reported changes in sexual behavior used
effective methods of prevention (e.g., use of condoms,
prevention of transmission of bodily fluids). Lastly, the
majority of the respondents (54 percent) expressed no
t
concern (perceived susceptibility) about contracting AIDS.
Investigating minority students' knowledge, attitudes,
and misconceptions, DiClemente, Boyer, and Morales (1988)
administered the AIDS Information survey to 628 subjects
(261 White, 226 Black, and 141 Latino). The instrument was
comprised of three sub-scales measuring the following
67
research variables: (1) knowledge of AIDS, (2) perceived
susceptibility, and (3) misconceptions about casual
contagion of AIDS. In terms of knowledge of the cause,
transmission, and prevention of AIDS, ethnic differences
were identified. Specifically, White respondents were more
knowledgeable than their Black counterparts, and Black
students were more knowledgeable than their Latino peers.
With respect to the second variable, perceived
susceptibility, a relationship between ethnicity and
knowledge level emerged. In particular, Black and Latino
respondents were more likely to be found in the lower AIDS
knowledge group and lower level of knowledge was associated
with a higher level of perceived susceptibility to AIDS.
Simply put, results indicated that less knowledge about AIDS
was correlated with greater levels of perceived risk of
contracting the disease. Finally, Black and Latino
respondents were approximately twice as likely as White
subjects to have misconceptions about the casual
transmission of the AIDS virus, e.g., "you can get AIDS by
I
using someone's personal belongings," or "you can get AIDS
by shaking hands with someone who has the disease." Such
disparity in knowledge regarding the transmission and *
prevention of AIDS seems to indicate that the ethnic
background of the student should be taken into account in
research and health communication campaigns.
68
In a study of knowledge about AIDS and reported risk
behaviors among Black college students, Thomas, Gilliam, and
Iwrey (1989) surveyed 975 undergraduates attending a large
East Coast university. AIDS knowledge, in this
I
investigation, covered four broad domains: (1) the nature of
AIDS and HIV, (2) the routes of transmission of HIV, (3)
AIDS prevention and risk reduction, and (4) knowledge of
high-risk groups. Research findings indicated that overall
knowledge of basic AIDS-related facts was satisfactory. On
the 25-item knowledge assessment scale, raw scores ranged
from 7 to 25, with a mean of 20.5 (82 percent correct) and a
mode of 22 (88 percent correct). However, there was
significant confusion regarding modes of HIV transmission.
For instance, 29.4 percent of the respondents did not know
that AIDS cannot be transmitted by sitting on the same
toilet seat used by a person with AIDS. An even larger
segment of the sample (73.3 percent) did not know that AIDS
cannot be transmitted by insect bites. Though knowledge of
AIDS prevention and risk reduction appeared satisfactory,
knowledge of high-risk groups was not. For example, 32
percent of the subjects incorrectly believed that "most
blacks who get AIDS are homosexual," and 33.3 percent
incorrectly stated that "most babies who get AIDS are
white." In terms of reported risk behaviors, 16.3 percent
of the respondents had engaged in anal intercourse, 6.2
69
percent had used heroin, 31 percent had sexual activity with
multiple partners, and 15.3 percent had been treated for
sexually transmitted diseases. Further analysis revealed
that respondents engaging in high-risk behaviors had
statistically significant lower knowledge levels than those
who reported not engaging in those same high-risk behaviors.
In short, low knowledge scores were significantly correlated
with risk behaviors associated with HIV infection.
Testing the efficacy of educational movies on AIDS
knowledge and attitudes, Gilliam and Seltzer (1989) measured
the reactions of 27 8 students attending a large East Coast
university. Using a pretest-posttest design, the study
consisted of two conditions: (1) subjects viewing a movie on
AIDS (experimental group), and (2) subjects viewing a movie
on first aid (control group). The dependent measures in
the research included: (1) knowledge of AIDS, (2) attitudes
toward AIDS, and (3) attitudes toward gays. Findings
indicated that the effects of exposure to a film about AIDS
had some impact on knowledge about the disease. For
instance, subjects who were exposed to the movie on AIDS
were more likely to correctly identify that one cannot
contract AIDS from kissing and from drinking glasses when
compared to those who saw the movie on first aid.
Furthermore, educational movies on AIDS appear to have a
slight effect on social attitudes, namely, attitudes toward
70
AIDS and homosexuality. For example, subjects in the
experimental group were more likely than subjects in the
control group to strongly oppose policy aimed at stopping
homosexuality as a method of controlling the spread of AIDS.
Finally, subjects who saw the film on AIDS were marginally
more likely than those who saw the film on first aid to
report that they were taking certain precautions to prevent
HIV infection, e.g., having less sex or fewer sexual
partners, using condoms during sexual intercourse.
Using open-ended essays and computer content analytic
procedures, Fan and Shaffer (1990) surveyed 619 college
students' knowledge and attitudes about AIDS at a large
midwestern university. Results from this innovative method
of analysis revealed that the majority of subjects
accurately identified the most important methods of HIV
transmission. More specifically, the analysis covered five
AIDS-related topics: (1) education, (2) sexual behavior, (3)
transmission of HIV, (4) social policies for HIV carriers,
and (5) issues in HIV testing. In terms of education,
students indicated that they focused on six sources of
educational information, namely, schools, the media, health
care facilities, the home, other institutions such as church
and the workplace, and hotlines. Regarding sexual ;
behavior, most subjects stressed the importance of safer
sexual practices such as the use of condoms and spermicides.
71
With respect to methods of contracting AIDS, most
respondents accurately identified the four established modes
of transmission: intravenous drug use, exchange of blood,
sexual activity, and birth involving an infected mother.
Most respondents also indicated that AIDS cannot be
transmitted through casual contact. In their discussion of
policy toward HIV carriers, most respondents advocated
compassionate treatment and avoidance of discriminatory
practices. Finally, in terms of HIV testing, a number of
respondents stated that AIDS testing should be used to check
partners before sex or marriage, insure safe blood, and
performed at periodic intervals like once a year. The
researchers concluded by discussing the advantages--
flexibility and efficiency — of this new computer
methodology.
Examining college students’ awareness and
interpretation of the AIDS risk, Freimuth, Edgar, and
Hammond (1987) surveyed subjects at the University of
Maryland. Consistent with other research findings, AIDS
knowledge was fairly high. Most respondents were aware
that HIV is transmitted through sharing contaminated
intravenous drug needles and unprotected sexual intercourse.
Approximately two thirds of the respondents were aware that
HIV cannot be transmitted through saliva, teardrops, or
insect bites. Additionally, upperclassmen scored higher on
72
the knowledge test. Finally, in terms of sources of AIDS
information acquisition, health care practitioners, AIDS
educational literature, the AIDS hotline, and the campus
health center were rated as the most credible sources of
information.
Investigating the relationship between health locus of
control and AIDS information seeking, Price-Greathouse and
Trice (1986) tested a sample of 66 sexually active subjects
who had more than one single sexual partner. Two levels of
the locus of control variable (internality and chance) were
used to predict attendance at AIDS education sessions.
Findings indicated that only the Chance subscale of the
Multidimensional Health Locus of Control (Form A) Scale
predicted subsequent behavior. The authors further
elaborated, "such findings suggest that a chance-health
orientation may identify a group initially less informed
who, given their health orientation, may acquire less
information, which places them at considerable risk, given
the life-threatening nature of AIDS" (p. 10). Additional
findings indicated that more internal subjects attended
informational meetings than external subjects (70 percent
versus 45 percent, respectively). Finally, more internal
respondents attended two or more sessions than their
external counterparts.
I
73
Continuing their research on personality variables
affecting individuals in their acquisition of information
about AIDS, Trice and Price-Greathouse (1987) investigated a
sample of 124 college women in a liberal arts college on the
East Coast. Three predictor measures were used: health
locus of control, academic locus of control, and previous
AIDS knowledge. The outcome variable was attendance at an
on-campus AIDS prevention symposium. Overall, research
findings suggested that Chance Health Locus of Control,
Academic Locus of Control, and previous information about
the disease predicted attendance at the AIDS symposium.
External subjects (30 percent) on the Academic Locus of
Control Scale had a lower attendance rate than internal
subjects (47 percent). Conversely, externals on the
Multidimensional Health Locus of Control Scale also had a
lower attendance rate (27 percent) than their internal, low
chance counterparts (51 percent). Finally, subjects who
attended the symposium were characterized by higher levels
of prior AIDS knowledge before the sessions than those
!
subjects who elected not to attend the on-campus symposium.
In a study attempting to clarify the relationship
between emotional orientation toward sex and ability to
acquire sexually relevant materials including contraceptive j
and AIDS information, Gerrard and Reis (1989) tested 180
college undergraduates at a large midwestern university.
74
Using a 2 (high/low sex-guilt) x 2(male/female) factorial
design, the researchers compared pre-test and post-test
knowledge of contraception and AIDS. High sex-guilt male
subjects were less knowledgeable about contraceptives and
AIDS in the pre-test phase of the experiment. However,
after exposure to the experimental stimulus— the
presentation of birth control and AIDS information
materials— no statistically significant differences in
knowledge were detected. Specifically, there were no
differences in knowledge between males and females or
erotophobics (high sex-guilt) and erotophilics (low sex-
guilt) at the end of the experimental training. Results
from the study indicated that erotophobics are capable of
acquiring sexual knowledge (e.g., information about AIDS
i
transmission and prevention) if they are properly exposed to
it. In terms of AIDS communication campaigns, this
research finding suggests that individuals with varying
degrees of sex-guilt are capable of retaining AIDS
information. However, the authors cautioned that retention
of AIDS knowledge may not necessarily lead to sexual
behavior change.
McDermott, Hawkins, Moore and Cittadino (1987)
investigated AIDS awareness and information sources among
157 college respondents at a large midwestern university.
In terms of overall AIDS awareness and knowledge, the
75
subjects exhibited high levels of understanding about the
key AIDS-related facts. Furthermore, there were no
significant differences in knowledge between males and
females. Similarly, no significant differences in
knowledge were detected between heterosexual and
homosexual/bisexual subjects. Additionally, the authors
found that the three leading sources of AIDS information
were mediated as opposed to interpersonal. To be more
specific, their respondents reported that the three major
sources of AIDS information were television, newspapers, and
magazines. The researchers also noted that interpersonal
sources, such as friends, teachers, or health care
practitioners were either seldom mentioned or not cited at
all. Finally, one of the limitations of the use of mediated
sources of communication in AIDS education is the nature of
the channel itself; specifically, mediated coverage of the
disease tends to be brief, simplistic, and sensationalistic.
It is worth noting, however, that McDermott and his
associates (1987) only reported the single primary source of
I
AIDS information as opposed to multiple sources from which
information may be acquired. This appears somewhat limited
in the light of the complex multichannel nature of
!
1
communication and information acquisition (Atkin, 1981;
Flay, 1981; Reardon, 1989a; Reardon and Rogers, 1988).
76
In their exploratory study, Yep and Negron (1989)
extended the research conducted by McDermott, Hawkins,
Moore, and Cittadino (1987). They investigated a sample of
200 college students from the Southern California area to
determine the sources of AIDS information acquisition.
Their research findings confirmed the multichannel nature of
the process of AIDS information acquisition, that is, the
receiver’s simultaneous use of multiple sources and channels
of communication to learn about AIDS. Furthermore, their
results indicated that mediated channels of communication,
i.e., newspapers, magazine, television, were more important
than interpersonal channels, i.e., health care practitioner,
family member, friend, in the process of AIDS information
acquisition among college subjects.
Summary. Research Questions, and Hypotheses
Although the findings reported were not completely
consistent, most studies appear to support the predictions
of the Health Belief Model (see Figure 2). Based on the
present review of empirical research on the model, several
research questions and hypotheses were generated with regard
to the relationship between the variables of the model,
cue s -1 o - ac t ion , perceived susceptibility, perceived
severity, perceived benefits, and perceived barriers, and;
preventive health actions, the adoption of AIDS risk
reduction behaviors. With regard to cues-to-action, past
77
research seems to indicate the prevalence of mediated
sources of AIDS information acquisition. Perceived
susceptibility, severity, and benefits appear to be directly
related to the adoption of safer sexual behaviors. On the
other hand, perceived barriers appear to be inversely
related to the adoption of the same sexual practices.
In particular, the foci of this investigation focused
on the following research questions and hypotheses (see
figure 3):
RQ1: Which mediated communication sources are most important
for the disssemination of information about AIDS?
RQ2: Which interpersonal communication sources are most
important for the dissemination of information about
AIDS?
HI: In terms of cues-to-action, mediated communication
sources are more important than interpersonal
communication sources for the acquisition of
information about AIDS.
H2: The greater the perceived susceptibility to AIDS, the
more likely individuals will adopt risk reduction
behaviors.
(a) The greater the perceived susceptibility to AIDS,
the more likely individuals will be more
selective about sexual partners;
H3:
78
(b) The greater the perceived susceptibility to AIDS,
the more likely individuals will be more careful;
(c) The greater the perceived susceptibility to AIDS,
the more likely individuals will avoid sexual
activity;
(d) The greater the perceived susceptibility to AIDS,
the more likely individuals will use condoms
during sexual activity;
(e) The greater the perceived susceptibility to AIDS,
the more likely individuals will be monogamous;
(f) The greater the perceived susceptibility to AIDS,
the more likely individuals will avoid
transmission of body fluids with a partner;
(g) The greater the perceived susceptibility to AIDS,
the more likely individuals will reduce certain
types of sexual practices;
(h) The greater the perceived susceptibility to AIDS,
the more likely individuals will attempt to make
sure that a partner does not have AIDS;
(i) The greater the perceived susceptibility to AIDS,
the more likely individuals will reduce the
number of sexual partners.
The greater the perceived severity of AIDS, the more
i
likely individuals will adopt risk reduction behaviors.
(a) The greater the perceived severity of AIDS, the
more likely individuals will be more selective
about sexual partners;
(b) The greater the perceived severity of AIDS, the
more likely individuals will be more careful;
(c) The greater the perceived severity of AIDS, the
more likely individuals will avoid sexual
activity;
(d) The greater the perceived severity of AIDS, the
more likely individuals will use condoms during
sexual activity;
(e) The greater the perceived severity of AIDS, the
more likely individuals will be monogamous;
(f) The greater the perceived severity of AIDS, the
more likely individuals will avoid transmission
of body fluids with a partner;
(g) The greater the perceived severity of AIDS, the
more likely individuals will reduce certain types
of sexual practices;
(h) The greater the perceived severity of AIDS, the
more likely individuals will attempt to make sure
that a partner does not have AIDS;
(i) The greater the perceived severity of AIDS, the
more likely individuals will reduce the number of
sexual partners.
H4:
80
The greater the perceived efficacy of AIDS risk
reduction behaviors, the more likely individuals will
adopt such behaviors.
(a) The greater the perceived efficacy of AIDS risk
reduction behaviors, the more likely individuals
will be more selective about sexual partners;
(b) The greater the perceived efficacy of AIDS risk
reduction behaviors, the more likely individuals
will be more careful;
(c) The greater the perceived efficacy of AIDS risk
reduction behaviors, the more likely individuals
will avoid sexual activity;
(d) The greater the perceived efficacy of AIDS risk
reduction behaviors, the more likely individuals
will use condoms during sexual activity;
(e) The greater the perceived efficacy of AIDS risk
reduction behaviors, the more likely individuals
will be monogamous;
(f) The greater the perceived efficacy of AIDS risk
reduction behaviors, the more likely individuals
will avoid transmission of body fluids with a
partner;
(g) The greater the perceived efficacy of AIDS risk
reduction behaviors, the more likely individuals
will reduce certain types of sexual practices;
H5 :
81
(h) The greater the perceived efficacy of AIDS risk
reduction behaviors, the more likely individuals
will attempt to make sure that a partner does not
have AIDS;
(i) The greater the perceived efficacy of AIDS risk
reduction behaviors, the more likely individuals
will reduce the number of sexual partners.
The greater the perceived barrier to AIDS risk
reduction behaviors, the less likely individuals will
adopt such behaviors.
(a) The greater the perceived barrier to AIDS risk
reduction behaviors, the less likely individuals
will be more selective about sexual partners;
(b) The greater the perceived barrier to AIDS risk
reduction behaviors, the less likely individuals
will be more careful;
(c) The greater the perceived barrier to AIDS risk
reduction behaviors, the less likely individuals
will avoid sexual activity;
(d) The greater the perceived barrier to AIDS risk
reduction behaviors, the less likely individuals
will use condoms during sexual activity;
(e) The greater the perceived barrier to AIDS risk
reduction behaviors, the less likely individuals
will be monogamous;
(f) The greater the perceived barrier to AIDS risk
reduction behaviors, the less likely individuals
will avoid transmission of body fluids with a
partner;
(g) The greater the perceived barrier to AIDS risk
reduction behaviors, the less likely individuals
will reduce certain types of sexual practices;
(h) The greater the perceived barrier to AIDS risk
reduction behaviors, the less likely individuals
will attempt to make sure that a partner does not
have AIDS;
(i) The greater the perceived barrier of AIDS risk
reduction behaviors, the less likely individuals
will reduce the number of sexual partners.
83
Chapter 3
METHOD
Sample
Students from ten communication classes, including both
lower and upper division, at three major universities in the
greater Southern California area served as respondents for
the present study. Three hundred and twenty-three research
packets were handed out and 266 protocols (82.35 percent
response rate) were returned. All returned and completed
instruments were usable for the final analysis. The final
sample consisted of 266 respondents (N = 266). The data
were collected from April to September, 1989.
In terms of demographic characteristics, the following |
variables were examined (see table 4): (1) age, (2)
ethnicity, (3) sex, (4) relationship status, and (5) sexual
activity. With one exception, all research subjects (n =
265) reported their age in this study. The respondents
ranged from 18 to 43 years of age with a mean of 22.96 (s.d.
= 4.32). Again, with the exception of one subject, all
respondents (n = 265) reported their ethnicity. The sample
distribution in terms of ethnicity was as follows: 61.51
percent were White (n = 163), 16.98 percent were
Asian/Pacific Islander (n = 45), 10.19 percent were Hispanic
(n =27), 8.68 percent were Black/African American (n = 23),
84
1.13 percent were Indian/Native American (n = 3), and 1.51
percent classified themselves as "Other" (n = 4). With the
exception of one subject not responding to the gender
question, all respondents (n = 265) reported on this
variable. More specifically, the sample distribution in
terms of gender was as follows: 63.02 percent were female (n
= 167) and 36.98 percent were male (N = 98). Subjects were
also assessed in terms of relationship status. Of the
total sample of 266 respondents, 60.90 percent (n = 162)
reported that they were involved in a romantic relationship
while 39.10 percent (n = 104) reported that they were not
involved in a romantic relationship at the time the research
was conducted. Finally, subjects were also examined in
terms of sexual activity/inactivity. With one subject not
reporting on sexual activity, 68.30 percent of the sample (n
= 181) were sexually active while 31.70 percent (n = 84)
were not sexually active.
Procedures
The research subjects were recruited from ten
communication courses including the basic introductory
course, interpersonal communication, theories of human
communication, persuasion, intercultural communication, and
sex roles in communication. The researcher, a research
associate, or a research assistant introduced the nature of
the project with a short, yet thorough, description of the
85
research and the research packet by asking for voluntary
participation. When the prospective respondents showed
interest in participating, they were invited to do so by
securing their informed consent. This was accomplished by
asking the potential respondents to participate in this
project as well as informing them more about the nature of
the research and their individual rights. They were also
reassured that confidentiality and anonymity will be
preserved and that they may choose to decline participation
at any point during the survey process. They were then
given specific instructions regarding the length of the
packet, nature of the items in the questionnaire, as well as
precise instructions for completing each section of the
instrument. The following verbal instructions were given
to all prospective respondents:
Thank you for volunteering to participate in this
project. The research packet which consists of
four pages will take approximately fifteen
minutes to complete. The questionnaire contains
a number of statements concerning your personal
perceptions about the Acquired Inmunodeficiency
Syndrome (AIDS). We are interested in your
personal beliefs and it is important that you
respond according to your actual beliefs and not
according to how you feel you should believe or
how you think we want you to believe. There are
no right or wrong answers to the statements in
the packet. Your responses to this
86
questionnaire are both confidential and
anonymous. Please do not identify yourself by
name in any portion of this instrument. There
are four sections to the research packet, each
containing specific directions which must be
followed. Please read the instructions for each
section carefully before attempting to respond to
the actual items. If there are any questions,
please ask. Please make sure that you have
answered every item — do not skip items!
Provide an answer to each item by following the
instructions for that section and do not go back
to the items once you have answered them. Thank
you in advance for your help.
Furthermore, research participants were encouraged to
contact the principal investigator to discuss any portion of
the project, including research findings and final results,
if they were interested. Instructions in how to contact
the principal investigator were then provided to such
participants. Finally, completed research packets were
collected, numbered, and placed in a file for preparation
for data analysis.
Research variables
In the present investigation, six factors from the
Health Belief Model were measured. In particular, these
variables were: (1) communication/cues to action, (2)
perceived susceptibility, (3) perceived severity, (4)
perceived efficacy/benefits, (5) perceived barriers, (6)
sexual behavior change. Assessment of the first variable,
87
communication/cues to action, was exploratory. This
variable has been a relatively unexplored component of the
HBM in terms of its contribution to the explanation and
understanding of preventive health actions (Janz and Becker,
1984). Specifically, the study assessed this component in
terms of AIDS information acquisition, e.g., mediated and
interpersonal channels from which the respondent learned
about the disease including general information about AIDS,
methods of transmission, preventive measures, HIV testing,
and high-risk groups. The other five variables were
measured to test the explanatory and predictive capacity of
the model in the AIDS context using the population of
college subjects. Specifically, four predictor measures
were utilized, perceived susceptibility, perceived severity,
perceived efficacy, and perceived barriers, to predict the
criterion measure, AIDS behavioral risk reduction. This
variable was further constitutively and operationally
defined in terms of nine indicators of AIDS behavioral risk
reduction behaviors: (1) becoming more selective about
sexual partners, (2) becoming more careful about sexual
encounters, (3) avoiding sexual activity, (4) using condoms
during sexual activity, (5) living a sexually monogamous
lifestyle, (6) avoiding the transmission of bodily fluids i
with a sexual partner, (7) reducing certain types of sexual
practices, (8) making sure that a sexual partner does not
88
have AIDS, and (9) reducing the number of sexual partners.
All of the above variables were then operationalized and
administered in the form of a questionnaire packet.
Instrumentation
The instrument for this research was a questionnaire
packet consisting of four distinct sections. They were:
(1) Demographic sheet, (2) AIDS Information Acquisition
Questionnaire, (3) Health Beliefs Measurement, and (4) AIDS
Behavioral Risk Reduction Assessment.
The first section of the research packet contained
general information about the project as well as items on
demographic characteristics of the respondent (see Appendix
A). Specifically, the demographic profile sheet contained
questions regarding the respondent's age, sex (male,
female), year in school (freshman, sophmore, junior, senior,
graduate), ethnic background (White, Black, Native American,
Hispanic, Asian/Pacific Islander, and Other), religious
affiliation, relationship status including the duration of
their romantic involvement if they were in a romantic
relationship at the time of the data collection.
The second section was the AIDS Information Acquisition
Questionnaire (see Appendix B). This instrument was
I
I
designed to assess the sources of AIDS information;
acquisition, thus, consisted of items related to the rating \
of sources of AIDS information. More specifically, fifteen
89
sources of information about AIDS (eight mediated and seven
interpersonal) were listed: newspaper article, acquaintance,
brochure/fIyer, family member (e.g., parent, brother,
sister, etc.), television program, girlfriend/boyfriend,
magazine article, spouse/"intimate other," television
commercial, date, print ad, health care practitioner (e.g.,
doctor, nurse, etc.), nonfiction book (e.g., a book about
AIDS), friend, and fiction book (e.g., a novel). In
addition, respondents were asked to include other sources of
information about AIDS not included in the list. The
sources of information from this section were taken and
expanded from previous research (McDermott, Hawkins, Moore,
and Cittadino, 1987; Freimuth, Edgar, and Hammond, 1987;
Atkinson, Ktsanes, and Hassig, 1987; Gottlieb, Vacalis,
Palmer, and Conlon, 1988; Katzman, Mulholland, and
Sutherland, 1988). Furthermore, this instrument wasl
successfully tested in a pilot study involving 2 00 college\
subjects (Yep and Negron, 1989).
The third section is the Health Beliefs Measurement
Questionnaire (see Appendix C). It consisted of six
statements assessing various health beliefs, the predictor
variables in the research, including items for four HBM
variables, namely, perception of susceptibility, perceived
severity, benefits, and barriers. This instrument was an
adapted version of the Health Belief Model research on AIDS
90
risk reduction behavior in the School of Public Health at
the University of Michigan (see, for example, Kirscht and
Joseph, 1989). More specifically, it was utilized in two
large-scale studies, both involving samples of approximately
1,000 subjects, the Multicenter AIDS Cohort Study (MACS) and
the Coping and Change Study (CCS). The Multicenter AIDS
Cohort Study is a collaborative biomedical study of the
natural history of AIDS and HIV funded by the National
Institute of Allergic and Infectious Diseases. This study
is an ongoing, longitudinal psychosocial assessment of a
cohort of about 1,000 subjects in the Chicago area. The
Coping and Change Study is an ongoing
behavioral/psychosocial investigation designed to measure
changes in sexual behavior in approximately 1,000 homosexual
men in Chicago. Needless to say, the research instrument
has been extensively and successfully tested in both of
these ongoing research projects (Emmons, Joseph, Kessler,
Wortman, Montgomery, and Ostrow, 1986; Joseph, Montgomery,
Emmons, Kessler, Ostrow, Wortman, O'Brien, Eller, and
Eshleman, 1987; Joseph, Montgomery, Emmons, Kirscht,
Kessler, Ostrow, Wortman, and O'Brien, 1987; Joseph, Ostrow,
Montgomery, Kessler, Phair, and Chmiel, 1987; Montgomery and
Joseph, 1988; Kirscht and Joseph, 1989). All statements
measuring health beliefs followed a five-point Likert scale.
Specifically, perception of susceptibility was
91
operationalized in terms of the respondents' perception of
personal vulnerability or likelihood of contracting AIDS and
a personal assessment of their level of risk as compared to
those of the "average person." These items were ratings on
a five-point scale from "not likely" to "very likely."
Perceived severity was operationalized in terms of the
respondents' beliefs associated with the degree of
seriousness of the AIDS threat with a five-point scale
rating ranging from "strongly agree" to "strongly disagree."
Perceived benefit was operationalized in terms of the
respondents' beliefs regarding the efficacy of recommended
AIDS preventive behaviors, e.g., safe sex practices endorsed
by the medical establishment, with a five-point scale
ranging from "very little" to "a great deal." Finally,
perceived barrier was operationalized in terms of the
respondents' perceptions regarding difficulties in
controlling sexual impulses and in modifying their sexual
behavior to reduce their probability of HIV infection.
Items measuring this construct followed a five-point scale
l
ranging from "strongly agree" to "strongly disagree."
The final section, AIDS Behavioral Risk Reduction
Assessment (see Appendix D), consisted of items measuring
AIDS preventive health actions, the dependent variable in
the study. This segment of the research protocol was also
I
adapted and expanded from the Behavioral Assessment Index of j
92
the longitudinal MultiCenter AIDS Cohort Study (MACS) and
the Coping and Change Study (CCS) at the University of
Michigan. Such instrument had been previously tested in
several Health Belief Model studies on AIDS preventive
behaviors (see, for example, Emmons, Joseph, Kessler,
Wortman, Montgomery, and Ostrow, 1986; Kirscht and Joseph,
1989; Montgomery and Joseph, 1988). The present protocol
expanded the original list of AIDS preventive behaviors from
the Behavioral Assessment Index (see, for example, Emmons et
al., 1986). The latter consisted of five items: (1) any
behavioral change since AIDS, (2) reduction of the number of
sexual partners, (3) avoidance of anonymous partners because
of AIDS, (4) avoidance of receptive anal intercourse because
of AIDS, and (5) modification of receptive anal sex such as
use of condoms. Adapting these risk reduction behaviors to
a mostly heterosexual, college population, the items were
modified by using the findings from other studies examining i
this population (Strunin and Hingson, 1987; Becker and
Joseph, 1988; Carroll, 1988; Kegeles, Adler, and Irwin,
1988; Catania, Dolcini, Coates, Kegeles, Greenblatt,
Puckett, Corman, and Miller, 1989; Thurman and Franklin,
1990; Katzman, Mulholland, and Sutherland, 1988; Thomas,
Gilliam, and Iwrey, 1989) as well as identified behavioral
risk factors from epidemiologic research (see, for example,
Hulley and Hearst, 1989). The final set of items measuring
93
AIDS preventive behaviors included being more selective
about sexual partners, being more careful, avoiding sexual
encounters, using condoms, being monogamous, avoiding
transmission of body fluids, reducing certain types of
sexual practices, making sure that a sexual partner does not
have AIDS, reducing the number of sexual partners, and
overall change in sexual•behavior. A second modification
of the items in the Behavioral Assessment Index was the
conversion of original nominal response items (subjects
reporting behavioral change versus subjects not reporting
behavioral change) to interval scale of measurement. To
accomplish this, each indicator of preventive behavior was
reframed in terms of a seven-point Likert scale ranging from
"completely true description of my behavior" to "completely
false description of my behavior," thus, increasing the
richness of the data and allowing the use of parametric data
analysis.
94
Chapter 4
RESULTS
The research findings from the present study are
reported here in four sections. The first section
discusses the findings from the study related to the
proposed research questions. The second section addresses
the results of the study in relationship to the research
hypotheses. The third section presents the findings in
terms of the four predictor variables of the Health Belief
Model, namely, perceptions of susceptibility, severity,
efficacy, and barriers as reported by the sample of college
respondents surveyed in the research. The last section
reports the findings in terms of the criterion variable of
the study, AIDS preventive sexual behavior.
Research Questions
Two research questions were examined in the present
study. The first, "Which mediated communication sources
are most important for the dissemination of information
about AIDS?," investigated mediated sources of communication
(see table 5). Research findings revealed that the most
important source of AIDS information acquisition was from
newspaper articles (mean = 3.35, s.d. = 2.17). The second
most important source of information was from a television
program (mean = 3.66, s.d. = 2.55). The third most
95
important source of information was from a magazine article
(mean = 3.70, s.d. = 2.17). The fourth most important
source of information was from a brochure or flyer about
AIDS (mean = 4.16, s.d. = 2.52). The fifth most important
source of information was from a television commercial about
AIDS (mean = 5.62, s.d. = 2.72). The sixth most important
source of information was from a print advertisement about
the disease (mean = 6.43, s.d. = 2.51). The seventh most
important source of information was from a nonfiction book
such as a book about AIDS (mean = 6.95, s.d. = 4.39). The
eighth most important source of AIDS information acquisition
was from a fiction book such as a novel containing a theme
about AIDS (mean = 11.90, s.d. = 3.07). Other mediated
sources which were mentioned by some of the respondents
included radio programs such as talk shows, news reports,
and commentaries from radio disk jockeys, and leaflets about
AIDS in popular music albums and compact discs.
i
The second research question, "Which interpersonal
communication sources are most important for the
dissemination of information about AIDS?," investigated the
nature of interpersonal sources of information about the 1
disease (see table 6). Research findings revealed that the
most important source of AIDS information acquisition was
from a health care practitioner such as a medical
practitioner, nurse, pharmacist, or medical assistant (mean
96
= 4.79, s.d. = 3.02). The second most important source of
information was from a family member such as a parent,
brother, or sister (mean = 5.95, s.d. = 3.29). The third
most important source of information was from a friend (mean
= 7.37, s.d. = 2.69). The fourth most important source of
information was from a spouse or "intimate other" (mean =
8.10, s.d. = 3.42). The fifth most important source of
information was from a girlfriend/boyfriend (mean = 8.18,
s.d. = 3.00). The sixth most important source of
information was from an acquaintance (mean = 8.75, s.d. =
3.27). The seventh most important interpersonal source of
AIDS information acquisition was from a date (mean = 11.04,
s.d. = 2.53). Other interpersonal sources reported by
respondents included university instructors, peer
counselors, and people with AIDS.
Research Hypotheses
Five research hypotheses were tested in the present
study. The first compared the degree of importance between
mediated and interpersonal sources of AIDS information
acquisition. The second, third, and fourth hypotheses,
established a direct, positive relationship between
1
perceived susceptibility, severity, and efficacy and AIDS j
preventive sexual behavior, respectively. The fifth and
final hypothesis proposed an inverse, negative relationship
between perceived barriers/costs to preventive action and
97
AIDS preventive sexual behavior. Data analysis revealed
mixed support for the various research hypotheses.
Hypothesis 1 stated: "In terms of cues-to-action,
mediated communication sources are more important than
interpersonal communication sources for the acquisition of
information about AIDS." The data support this hypothesis
(see table 7). More specifically, a one-way ANOVA using
repeated measures showed a statistically significant
difference between mediated and interpersonal communication
sources of AIDS information acquisition (F = 133.80, p <
.0001). Post-hoc analysis revealed that such difference
between mediated (mean = 4.46, s.d. = 2.00) and
interpersonal sources (mean = 6.19, s.d. = 2.82) is
statistically significant for both the Fisher (Fisher PLSD =
.29) and the Scheffe (Scheffe F-test = 133.80) comparison
tests . College students acquire more information about
AIDS, e.g., the basic facts about the disease, modes of
transmission, HIV testing, high-risk groups, and safe sex
behaviors, from the mass media than from personal contacts
and interpersonal communication. Furthermore, this
population clearly utilizes multiple sources, both mass
media and interpersonal, to learn about the disease,
therefore, confirming the multichannel nature of AIDS
information acquisition.
98
Hypothesis 2 stated: "The greater the perceived
susceptibility to AIDS, the more likely individuals will
adopt risk reduction behaviors." This hypothesis consisted
of nine subhypotheses.
Hypothesis 2a stated: "The greater the perceived
susceptibility to AIDS, the more likely individuals will be
more selective about sexual partners." Stepwise multiple
regression analysis does not support this hypothesis.
Hypothesis 2b stated: "The greater the perceived
Susceptibility to AIDS, the more likely individuals will be
more careful." Stepwise multiple regression analysis does
not support this hypothesis.
Hypothesis 2c stated: "The greater the perceived
susceptibility to AIDS, the more likely individuals will
avoid sexual activity." Stepwise multiple regression
analysis supports hypothesis 2c (R= .23, p < .05). See
table 8.
Hypothesis 2d stated: "The greater the perceived
susceptibility to AIDS, the more likely individuals will use
condoms during sexual activity." Stepwise multiple
regression analysis supports hypothesis 2d (R = .14, p <
.05). See table 9.
Hypothesis 2e stated: "The greater the perceived
susceptibility to AIDS, the more likely individuals will be
99
monogamous . " Stepwise multiple regression analysis
supports hypothesis 2e (R = .31, p < .05). See table 10.
Hypothesis 2f stated: "The greater the perceived
susceptibility to AIDS, the more likely individuals will
avoid transmission of body fluids with a partner."
Stepwise multiple regression analysis does not support this
hypothesis.
Hypothesis 2g stated: "The greater the perceived
susceptibility to AIDS, the more likely individuals will
reduce certain types of sexual practices." Stepwise
multiple regression analysis does not support this
hypothesis.
Hypothesis 2h stated: "The greater the perceived
susceptibility to AIDS, the more likely individuals will
attempt to make sure that a partner does not have AIDS."
Stepwise multiple regression analysis does not support this
hypothesis.
Hypothesis 2i stated: "The greater the perceived
susceptibility to AIDS, the more likely individuals will
reduce the number of sexual partners." Stepwise multiple
regression analysis does not support this hypothesis.
In sum, hypothesis 2 is partially supported. Stepwise
multiple regression analysis revealed that perceived
susceptibility is a statistically significant predictor of
avoiding sex as a means of prevention to HIV exposure, using
100
condoms during sexual activity, and becoming monogamous as a
means to avoid AIDS infection. As college students
perceive themselves to be personally at risk for AIDS, they
will have a greater tendency to adopt certain preventive
measures such as becoming celibate, using condoms as
protection, or establishing and maintaining monogamous
intimate relationships. Conversely, those students who do
not perceive themselves to be .personally at risk for the
disease are less likely to take precautionary measures to
protect themselves against HIV infection.
Hypothesis 3 stated: "The greater the perceived
severity of AIDS, the more likely individuals will adopt
risk reduction behaviors." Though respondents expressed
that AIDS in a very serious health threat as indicated by a
mean severity rating of 4.65 (s.d. = .84) on a Likert scale
of one (not serious at all) to five (extremely serious),
this hypothesis is not supported. More specifically,
stepwise multiple regression analysis showed that perceived
severity of AIDS is not significantly related to the
adoption of AIDS risk reduction behaviors among college
subjects.
Hypothesis 3a stated: "The greater the perceived
severity of AIDS, the more likely individuals will be more
selective about sexual partners." Stepwise multiple
regression analysis does not support this hypothesis.
101
Hypothesis 3b stated: "The greater the perceived
severity of AIDS, the more likely individuals will be more
careful." Stepwise multiple regression analysis does not
support this hypothesis.
Hypothesis 3c stated: "The greater the perceived
severity of AIDS, the more likely individuals will avoid
sexual activity." Stepwise multiple regression analysis
does not support this hypothesis.
Hypothesis 3d stated: "The greater the perceived
severity of AIDS, the more likely individuals will use
condoms sexual activity." Stepwise multiple regression
analysis does not support this hypothesis.
Hypothesis 3e stated: "The greater the perceived
severity of AIDS, the more likely individuals will be
monogamous." Stepwise multiple regression analysis does
not support this hypothesis.
Hypothesis 3f stated: "The greater the perceived
severity of AIDS, the more likely individuals will avoid
transmission of body fluids with a partner." Stepwise
multiple regression analysis does not support this
hypothesis.
Hypothesis 3g stated: "The greater the perceived
severity of AIDS, the more likely individuals will reduce
certain types of sexual practices." Stepwise multiple
regression analysis does not support this hypothesis.
102
Hypothesis 3h stated: "The greater the perceived
severity of AIDS, the more likely individuals will attempt
to make sure that a partner does not have AIDS." Stepwise
multiple regression analysis does not support this
hypothesis.
Hypothesis 3i stated: "The greater the perceived
severity of AIDS, the more likely individuals will reduce
the number of sexual partners." Stepwise multiple
regression analysis does not support this hypothesis.
In sum, hypothesis 3 is not supported by the data.
This research finding seems to point out that perceptions of
the seriousness of AIDS may not motivate students to engage
in preventive behaviors unless other motivators are present
such as viewing themselves as personally vulnerable to the
disease.
Hypothesis 4 stated: "The greater the perceived
efficacy of AIDS risk reduction behaviors, the more likely
individuals will adopt such behaviors." Once again, though
most respondents indicated that AIDS risk reduction
behaviors (e.g., safe sex practices) were perceived at
beneficial and effective in stopping the spread of HIV as
demonstrated by a mean benefits rating of 4.14 (s.d. = 1.31)
on a Likert scale of one (not effective at all) to five
(extremely effective), this hypothesis is not supported by
the data. More specifically, stepwise multiple regression
103
analysis indicates that perceptions of the effectiveness of
safe sex practices such as condom use and avoidance of the
transmission of bodily fluids are not significantly related
to the enactment of such risk reducing sexual behaviors.in
the college population.
Hypothesis 4a stated: "The greater the perceived
efficacy of AIDS risk reduction behaviors, the more likely
individuals will be more selective about sexual partners."
Stepwise multiple regression analysis does not support this
hypothesis.
Hypothesis 4b stated: "The greater the perceived
efficacy of AIDS risk reduction behaviors, the more likely
individuals will be more careful." Stepwise multiple
regression analysis does not support this hypothesis.
Hypothesis 4c stated: "The greater the perceived
efficacy of AIDS risk reduction behaviors, the more likely
individuals will avoid sexual activity." Stepwise multiple
regression analysis does not support this hypothesis.
Hypothesis 4d stated: "The greater the perceived
efficacy of AIDS risk reduction behaviors, the more likely
individuals will use condoms sexual activity." Stepwise
multiple regression analysis does not support this
hypothesis.
Hypothesis 4e stated: "The greater the perceived
efficacy of AIDS risk reduction behaviors, the more likely
104
individuals will be monogamous." Stepwise multiple
regression analysis does not support this hypothesis.
Hypothesis 4f stated: "The greater the perceived
efficacy of AIDS risk reduction behaviors, the more likely
individuals will avoid transmission of body fluids with a
partner." Stepwise multiple' regression analysis does not
support this hypothesis.
Hypothesis 4g stated: "The greater the perceived
efficacy of AIDS risk reduction behaviors, the more likely
individuals will reduce certain types of sexual practices."
Stepwise multiple regression analysis does not support this
hypothesis.
Hypothesis 4h stated: "The greater the perceived
efficacy of AIDS risk reduction behaviors, the more likely
individuals will attempt to make sure that a partner does
not have AIDS." Stepwise multiple regression analysis does
not support this hypothesis.
Hypothesis 4i stated: "The greater the perceived
efficacy of AIDS risk reduction behaviors, the more likely
I
individuals will reduce the number of sexual partners."
Stepwise multiple regression analysis does not support this
hypothesis.
In sum, hypothesis 4 is not supported by the data.
Once again, this research finding seems to point out that
increasing or decreasing perceptions of how well safe sex
105
methods work in AIDS prevention may not motivate students to
change their sexual practices in intimate relationships.
Hypothesis 5 stated: "The greater the perceived barrier
to AIDS risk reduction behaviors, the less likely
individuals will adopt such behaviors." This final
hypothesis also consisted of nine subhypotheses.
Hypothesis 5a stated: "The greater the perceived
barrier to AIDS risk reduction behaviors, the less likely
individuals will be more selective about sexual partners."
Stepwise multiple regression analysis does not support this
hypothesis.
Hypothesis 5b stated: "The greater the perceived
barrier to AIDS risk reduction behaviors, the less likely
individuals will be more careful." Stepwise multiple
regression analysis supports hypothesis 5b (R = .17, p <
.05). See table 11.
Hypothesis 5c stated: "The greater the perceived
barrier to AIDS risk reduction behaviors, the less likely
individuals will avoid sexual activity." Stepwise multiple
regression analysis supports hypothesis 5c (R = .18, p <
.05). See table 8.
Hypothesis 5d stated: "The greater the perceived
barrier to AIDS risk reduction behaviors, the less likely
individuals will use condoms sexual activity." Stepwise
106
multiple regression analysis does not support this
hypothesis.
Hypothesis 5e stated: "The greater the perceived
barrier to AIDS risk reduction behaviors, the less likely
individuals will be monogamous." Stepwise multiple
regression analysis supports hypothesis 5e (R = .26, p <
.05). See table 10.
Hypothesis 5f stated: "The greater the perceived
barrier to AIDS risk reduction behaviors, the less likely
individuals will avoid transmission of body fluids with a
partner." Stepwise multiple regression analysis does not
support this hypothesis.
Hypothesis 5g stated: "The greater the perceived
barrier to AIDS risk reduction behaviors, the less likely
individuals will reduce certain types of sexual practices."
Stepwise multiple regression analysis does not support this
hypothesis.
Hypothesis 5h stated: "The greater the perceived
barrier to AIDS risk reduction behaviors, the less likely
individuals will attempt to make sure that a partner does
not have AIDS." Stepwise multiple regression analysis
supports hypothesis 5h (R = .16, p < .05). See table 12.
Hypothesis 5i stated: "The greater the perceived
barrier to AIDS risk reduction behaviors, the less likely
individuals will reduce the number of sexual partners."
107
Stepwise multiple regression analysis does not support this
hypothesis.
In sum, hypothesis 5 is partially supported by the
data. The research findings support the inverse
relationship between perceptions of barrier/cost and the
enactment of certain AIDS preventive behaviors. As college
students encounter more difficulties in changing their
sexual behavior or controlling their sexual impulses, they
are less likely to be careful in sexual situations, be
celibate or monogamous, or verify that their sexual partner
is not an AIDS carrier. Conversely, as college subjects
encounter less difficulties in alteration of their own
sexual behavior or management of their sexual urges, they
have a greater tendency to be more careful about sexual
partners, become celibate or avoid sexual contacts, have
monogamous relationships, or discover methods of ensuring
that a potential sexual partner is not infected by the AIDS
virus, therefore, exercising more caution in their sexual
encounters.
Perceived susceptibility, severity, benefits, and barriers
Descriptive statistical analysis of the predictor
variables revealed that college students' perceptions of the
AIDS epidemic appear to be consistent with past research.
I
The results indicated that although college respondents
believe that AIDS is a very serious health threat, they do
108
not view themselves as particularly vulnerable to the
disease. Additionally, college subjects appear to believe
in the efficacy of safe sex practices to combat the spread
of AIDS, however, they perceive some difficulties in
engaging in such preventive behaviors.
In terms of the specific findings in relationship to
the four predictor variables of the research (see table 13),
the respondents indicated that they mostly perceived
themselves as "not susceptible at all" to "somewhat
susceptible" to AIDS (mean = 1.78, s.d. = .79). However,
most respondents viewed AIDS as a very severe health threat
(mean = 4.65, s.d. = .84). Most college students believed
that safe sex practices are beneficial and efficacious in
controlling the spread of HIV (mean = 4.14, s.d. = 1.31).
Finally, the respondents indicated that they perceived some
to moderate barriers in their practice of safe sex behaviors
to prevent infection with the AIDS virus (mean = 2.29, s.d.
= 1.13) .
Indices of sexual behavior change
Data-analysis indicated that college students are
displaying some changes in their sexual behavior to protect
themselves from HIV infection. However, it is alarming to
note that these changes were not completely consistent.
As previously indicated, changes in sexual behavior
were measured by nine indicators (see table 14). The
109
first, becoming more selective about sexual partners,
indicated that respondents exhibited moderate change in the
direction of greater selectivity (mean = 2.85, s.d. = 1.69).
The second, becoming more careful in sexual situations, also
indicated that college students displayed moderate change in
the direction of exhibiting greater caution (mean = 2.55,
s.d. = 1.58). The third, avoiding sex and becoming
celibate as a result of AIDS, indicated that the college
population exhibited minimal change, that is, most of the
respondent did not stop having sexual encounters as a means
for protecting themselves against exposure to HIV (mean =
5.73, s.d. = 1.76). The fourth, using condoms during
sexual activity, indicated mixed findings, specifically, it
appears that while some college subjects are using condoms
as a protective device during their sexual encounters,
others continue to engage in unprotected, risky sexual
behavior (mean = 4.07, s.d. = 2.05). The fifth, becoming
monogamous as a result of the epidemic, indicated that some
to moderate changes were detected (mean = 3.83, s.d. =
2.39). The sixth, avoiding the transmission of bodily
fluids, indicated that little to some changes were reported
among college students (mean = 5.24, s.d. = 1.96). The
seventh, reducing certain types of sexual practices which
may put the target subject at risk for HIV infection,
indicated that some change was observed (mean = 4.68, s.d. =
110
2.00). The eighth, making sure that a sexual partner does
not have AIDS, indicated that some to moderate changes were
reported among college subjects (mean = 3.47, s.d. = 2.14).
Finally, the ninth indicator, reducing the number of sexual
partners, indicated that some to moderate changes were
detected in the direction of minimizing multiple sexual
partnerships (mean = 3.21, s.d. = 1.92). In sum, the
research findings appear to indicate that little to moderate
changes in sexual behavior to prevent exposure to the AIDS
virus were identified in the college population. Though
these changes may not lead to effective AIDS prevention,
they appear to be a change in the desirable direction.
Ill
Chapter 5
SUMMARY AND DISCUSSION
Summary
In the last decade, the acquired immunodeficiency
syndrome (AIDS) has become a serious international health
threat. Without a cure in sight, the only available method
to reduce its spread is prevention. AIDS prevention is the
alteration of behaviors which may cause HIV transmission.
Behavioral risk reduction is primarily based on
communication. Besides the gay and IV drug user
populations, college students and adolescents have been
identified as "high-risk for AIDS." However, most risk
reduction research using this college population are not
based on social scientific theory. Specifically, it does
not utilize the widely recognized body of theory and
research from various social scientific disciplines (e.g.,
psychology, public health, and communication) which have a
long history of success in the description, explanation, and
prediction of preventive health actions. j
The present study had two main objectives: (1) to test
empirically a popular model of preventive health behavior,
the Health Belief Model (HBM), in the context of AIDS
prevention among college students, and (2) to address the
implications of the HBM on the design, implementation, and
evaluation of AIDS communication campaigns. As noted ]
112
earlier, the HBM proposes a relationship between individual
perceptions such as perceived susceptibility, severity,
benefits, barriers, and likelihood of behavioral enactment
of specific health preventive actions. In the context of
the AIDS epidemic, the model attempts to explain and predict
specific health preventive behaviors, e.g., likelihood of
engaging in certain safe sex practices, in terms of
individual perceptions about the disease.
Six research variables were investigated in the present
study: (1) communication sources related to AIDS information
acquisition, (2) perceived susceptibility to AIDS, (3)
perceived severity of the AIDS epidemic, (4) perceived
benefits of recommended AIDS preventive behaviors, (5)
perceived barriers associated with the engagement of AIDS
preventive actions, and (6) enactment of AIDS preventive
behaviors. These research variables were operationalized
by using a previously-tested AIDS Information Acquisition
Questionnaire (Yep and Negron, 1989), the Health Beliefs
Measurement and the AIDS Behavioral Risk Reduction
Assessment from the Multicenter AIDS Cohort Study (MACS) and
the Coping and Change Study (CCS) from the School of Public
Health at the University of Michigan (Emmons, Joseph,
Kessler, Wortman, Montgomery, and Ostrow, 1986; Joseph, l
Montgomery, Emmons, Kessler, Ostrow, Wortman, O'Brien,
Eller, and Eshleman, 1987; Joseph, Montgomery, Emmons,
113
Kirscht, Kessler, Ostrow, Wortman, and O'Brien, 1987;
Joseph, Ostrow, Montgomery, Kessler, Phair, and Chmiel,
1987; Montgomery and Joseph, 1988; Kirscht and Joseph,
1989). In particular, the present inquiry consisted of two
research questions and five hypotheses which investigated
the role of communication, perceived susceptibility,
severity, efficacy, and barriers on AIDS risk reduction
behaviors.
The two research questions examined the importance of
communication channels in the process of AIDS information
dissemination. More specifically, the first question
stated: "Which mediated communication sources are most
important for the dissemination of information about AIDS?."
Research findings revealed that college students utilize a
variety of sources from the mass media to learn about AIDS
including newspaper articles, television programs, magazine
articles, brochures, television and print advertisements,
and books about the disease, among others. These results
indicate that college students utilize multiple
communication sources from the mass media to learn about
AIDS. The second research question stated: "Which
interpersonal communication sources are most important for
the dissemination of information about AIDS?.” Research
findings indicated that college respondents also utilize a
variety of sources from interpersonal encounters to learn
114
about the disease including health care practitioners,
family members, friends, spouse/"intimate other,"
girlfriend/boyfriend, acquaintances, and dates, among
others. These results indicate that college students
utilize several interpersonal communication sources of
various degrees of intimacy to get information about the
AIDS. Finally, the findings from the study also confirmed
the complex multichannel nature of communication and AIDS
information acquisition, that is, college students use a
diversity and multiplicity of communication sources (both
mediated and interpersonal) to learn about the history,
modes of transmission, HIV testing, high-risk groups, and
AIDS prevention behaviors. This conclusion has important
implications for AIDS communication campaigns: multiple
communication sources must be utilized simultaneously in
AIDS education efforts.
Five research hypotheses were proposed. The first
stated: "In terms of cues-to-action, mediated communication
sources are more important than interpersonal communication
sources for the acquisition of information about AIDS."
The present findings supported Hi. Specifically, the data
indicated that at this stage of the AIDS epidemic, most
college students are relying and learning about the disease
from the mass media rather than from interpersonal
communication. The second, third, and fourth hypotheses
115
proposed a positive relationship between perceptions of
susceptibility, severity, and benefits, and AIDS behavioral
risk reduction, respectively. Analysis of the data
revealed mixed results.
The second hypothesis stated: "The greater the
perceived susceptibility to AIDS, the more likely
individuals will adopt risk reduction behaviors." The
present findings partially supported H2. More
specifically, the data revealed a direct, positive
relationship between perceived susceptibility and the
enactment of certain AIDS preventive behaviors such as using
condoms during sexual intercourse as a protective device
against HIV infection.
The third hypothesis stated: "The greater the perceived
I
severity of AIDS, the more likely individuals will adopt
risk reduction behaviors." The present findings did not
support H3. More specifically, the data did not support a
direct, positive relationship between perceived severity of
the disease and the enactment of AIDS preventive behaviors.
The fourth hypothesis stated: "The greater thej
perceived efficacy of AIDS risk reduction behaviors, the
more likely will individuals adopt such behaviors." The
present findings did not support H4. More specifically,
the data did not support a direct, positive relationship
116
between perceived benefits of AIDS preventive actions and
their subsequent enactment.
The fifth hypothesis stated: "The greater the perceived
barrier to AIDS risk reduction behaviors, the less likely
individuals will adopt such behaviors." The present
findings partially supported H5. More specifically,
perceived barrier/cost of AIDS preventive behaviors was
inversely related to certain preventive actions such as
becoming celibate to avoid HIV infection.
The Health Belief Model and AIDS Preventive Behavior in
College Students
As noted earlier, the HBM has been tested with a
variety of illnesses and populations. With respect to AIDS
and the college population, however, few studies using this
theoretical approach have been conducted. The present
study attempted to empirically test the utility of the model
in the context of AIDS and to examine the role of
communication/cues to action in this process, an often
ignored factor of the HBM. Several variables were
examined in the research. The first, communication/cues to
action was exploratory in nature. In particular, the study
investigated the importance of mediated and interpersonal
channels of communication in the complex process of AIDS
information acquisition. The examination of the other
research variables was explanatory in nature. In
117
particular, the present research attempted to specify the
nature and direction of the relationship between predictor
and criterion measures. The second, third, fourth, and
fifth factors in this study, perceived susceptibility,
severity, benefits, and barriers, were predictor variables.
The criterion measure was AIDS behavioral risk reduction
which was further defined in terms of nine indices of sexual
behavior change as a result of the AIDS epidemic.
In terms of the first variable, communication sources
associated with AIDS information acquisition, it appears
that the process of gathering information about AIDS is
complex. In particular, the research findings indicated
that several simultaneous sources and channels of
communication are utilized to learn about the basic facts
about AIDS and its prevention. Furthermore, the data
indicated that college students, at this stage of the
epidemic, tend to rely more on the mass media than on
interpersonal contacts to acquire information about AIDS.
This appears to be consistent with Rogers' (1983)
observations that "mass media channels are relatively more
important at the knowledge stage and interpersonal channels
are relatively more important at the persuasion stage in the
innovation-decision process" (p. 199). Finally, the
results from the present study, indicating the higher
importance of the mediated channel as compared to its
118
interpersonal counterpart in terms of sources of AIDS
information acquisition, concur with the findings from
previous research focusing on the college population
(Atkinson, Ktsanes, and Hassig, 1987; Gottlieb, Vacalis,
Palmer, and Conlon, 1988; McDermott, Hawkins, Moore, and
Cittadino, 1987; Price, Desmond, and Kukulka, 1985; Yep and
Negron, 1989).
The second variable, perceived susceptibility, was
predicted to be positively associated with AIDS behavioral
risk reduction behaviors. Research findings appeared to
partially support this prediction, specifically, as
perceived susceptibility increased, certain AIDS behavioral
risk reduction behaviors increased, conversely, as perceived
susceptibility to AIDS decreased, certain subsequent
behavioral risk reduction behaviors also decreased. These
changes in sexual behavior were not consistent across types
of AIDS preventive actions, however. More specifically,
perceived susceptibility was positively related to avoiding
sex, using condoms, and becoming monogamous as a method of
avoiding HIV infection. On the other hand, perceived
susceptibility was not significantly associated with any
other changes in sexual behavior.
Two possible explanations may account for these mixed
findings: Lack of personalization of the AIDS threat and the
"optimistic bias." Past research (Edgar, Freimuth, and
119
Hammond, 1988; Singer, Rogers, and Corcoran, 1987; Thurman
and Franklin, 1990) has documented that college students do
not feel personally susceptible to the deadly disease.
Thurman and Franklin (1990) elaborated, "a more likely
explanation that commonly accounts for ignoring warnings
against warranted health risks is that students do not pay
attention to public health officials unless such a risk is
personalized" (p. 182). There are several explanations for
this lack of personalization of the AIDS risk. First,
Jones (1982) argued that information about a certain illness
only becomes salient when reality reinforces such health-
related claims. This appears to be true with most college
students who do not personally know someone with AIDS or
have contact with organizations where exposure to the
devastating effects of the disease is likely. Second, Koop
(1986) observed that many young people do not perceive
themselves to be susceptible to disease in any form. This
appears to concur with college students' perceptions of
invincibility over illness documented by other researchers
(Manning, Barenberg, Gallese, and Rice, 1989; Smilgis,
1987 ) .
The second explanation accounting for mixed findings
related to the positive association between perceived
susceptibility and AIDS risk reduction behavior is the
notion of "optimistic bias" (Larwood, 1978; Svenson,
120
Fischhoff, and MacGregor, 1985; Perloff and Fetzer, 1986;
Kulik and Mahler, 1987; Weinstein, 1980, 1982, 1984, 1987,
1989). Weinstein (1989) defined optimistic bias as "a
consistent tendency to view one's own risk as less than the
risk faced by others" (pp. 149-150). This pattern of
underestimating the likelihood of harm from negative life
events such as susceptibility to a disease as deadly as AIDS
has been documented in the gay male (McKusick, Horstman, and
Coates, 1985; Bauman and Siegel, 1987; Joseph, Montgomery,
Emmons, Kirscht, Kessler, Ostrow, Wortman, O'Brien, Eller,
and Eshleman, 1987) and college populations (Chilman, 1983;
Simkins and Eberhage, 1984; Simkins and Kushner, 1986;
Strunin and Hinson, 1987; Manning, Balson, Barenberg, and
Moore, 1989; Manning, Barenberg, Gallese, and Rice, 1989).
Furthermore, Weinstein (1989) pessimistically noted that
"perceptions of relative invulnerability to AIDS and other
hazards are likely to be difficult to change" (p. 161).
The third variable, perceived severity, was predicted
to be positively associated with AIDS behavioral risk
i
reduction behaviors. Though most respondents expressed
that the AIDS threat is between very to extremely serious,
this perception was not significantly related to alteration
of sexual behaviors to prevent HIV exposure.
The above research finding appears to indicate that j
perceived severity of the disease does not lead to the
121
enactment of health preventive actions unless it is
accompanied by other factors such as perceived
susceptibility. In other words, if college students
believe that AIDS is a serious disease but do not believe
that they are particularly vulnerable to it, they may not be
motivated to change their sexual behaviors. Additionally,
perception of severity is a mental construct which may not
be readily visualized. If this cognitive variable is
accompanied by a visual representation such as an image of
physical deterioration as a result of AIDS, motivation for
behavioral change may increase dramatically. The direct
relationship between image of AIDS deterioration and sexual
behavior change was found to be true in a study of 655 gay
men in San Francisco (McKusick, Wiley, Coates, Stall, Saika,
Morin, Charles, Horstman, and Conant, 1985) and 1,200 gay
men in France (Pollack, Schiltz, and Lejeune, 1987). In
both studies, visual image of AIDS deterioration and
physical disfigurement was significantly related to
appropriate sexual behavior modification.
The fourth variable, perceived efficacy or benefits of
preventive behaviors, was predicted to be positively
associated with AIDS behavioral risk reduction behaviors.
Though most respondents expressed the belief that safe sex
practices are effective in the prevention of the spread of
HIV, they did not manifest it in sexual behavior change.
122
Thus, the direct relationship between perceived efficacy and
subsequent enactment of AIDS preventive behaviors was not
substantiated by the present study. It is also worth
noting that past research (Joseph, Montgomery, Emmons,
Kessler, Ostrow, Wortman, O'Brien, Eller, and Eshleman,
1987) using a sample of 637 gay/bisexual men did not detect
a statistically significant relationship between perceived
efficacy and behavioral change (e.g., decreasing the number
of sexual partners, using condoms during sexual intercourse,
becoming monogamous in a primary sexual relationship)
either.
Once again, it appears that perceived efficacy/benefits
may not lead to desirable changes in sexual behavior unless
accompanied by other factors such as perceptions of personal
I
vulnerability to the AIDS threat. For example, college
students may not be motivated to engage in safer sexual
behavior even though they believe that these actions reduce
their probability of AIDS exposure if they do not feel
personally threatened by the disease. Changes in sexual
behaviors only occur when AIDS is a real threat in the
everyday existence of a college student. Past research
indicated that AIDS is not an everyday concern in the
college population (Manning, Balson, Barenberg, and Moore,
1989; Simkins and Eberhage, 1984; Simkins and Kushner,
1986). In addition, perception of efficacy/benefits
123
related to safe sex activities may not be a sufficient
predictor of behavioral change if college students lack the
skills to perform such actions. This behavioral deficit
may be found in either one of two areas: (1) lack of
knowledge of how to enact safe sex practices, e.g., how to
use a condom properly (Biemiller, 1987), and (2) lack of
interpersonal communication skills necessary to discuss and
negotiate safe sex, e.g., how to talk about sexual behavior
(Hirschorn, 1987).
The fifth variable, perceived barriers to preventive
action, was predicted to be negatively associated with AIDS
behavioral risk reduction. In particular, the present
research stated that as perceived barrier/cost increases,
modification in sexual behavior decreases, conversely, as
perceived barrier/cost decreases, modification in sexual
behavior increases. This inverse relationship was
partially supported by the research data. More
specifically, perceived barrier/cost of preventive action
was significantly and inversely related to becoming more
careful about sexual encounters, avoiding sex, becomingi
t
monogamous, and making sure that a sexual partner does not I
have AIDS. However, perceived barrier/cost was not
significantly associated with becoming more selective about
sexual partners, using condoms during sexual activity,
avoiding transmission of bodily fluids, reducing certain
types of risky sexual practices, or reducing the number of
sexual partners. These findings seem to reflect the
inconsistent patterns of sexual behavior modification in the
college population.
As previously noted, the above construct was
operationalized in terms of difficulties in changing sexual
behavior as well as sexual impulse control. The findings
appear to indicate that there are a number of obstacles
associated with sexual behavior change including lack of
knowledge about safe sex practices, e.g., "I don't know what
safe sex is," lack of motivation, e.g., "I don't know anyone
who has AIDS," lack of interpersonal skills, e.g., "I'm too
embarrassed to discuss sex with my partner," lack of
behavioral enactment skills, e.g., "I don't know how to use
a condom properly," and homophobia, e.g., "I don't want
people to think that I'm gay or bisexual." These
observations have been confirmed by past research (see, for
example, Catania, Dolcini, Coates, Kegeles, Greenblatt,
Puckett, Corman, and Miller, 1989; Edgar, Freimuth, and
Hammond, 1988; Goodwin and Roscoe, 1988; Stipp and Kerr,
1989) .
Overall, college students exhibited some changes in
sexual behavior as a response to the threat of AIDS. Even
though such changes are in the desirable direction, they
were neither consistent nor complete. For instance, a
125
number of respondents expressed that they were being more
careful in sexual situations, becoming more selective about
their sexual partners, making sure that their sexual partner
are not carriers of the AIDS virus, while continuing to
engage in the transmission of bodily fluids during sexual
encounters and practicing certain types of risky sexual
behaviors including unprotected sexual intercourse. These
inconsistent changes continue to place the respondents in
danger of HIV infection. Furthermore, there is no clear
evidence that college subjects are changing their sexual
behavior on a permanent basis, that is, they engage in safe
sex practices every single time they have a sexual
encounter. A lack of consistencyin the practice of AIDS
I
preventive behaviors overtime, obviously, continues to put
the subjects at risk for exposure to the deadly disease.
Manning, Barenberg, Gallese, and Rice (1989) argued
that college students may possess some traits which affect
their sexual behavior in the direction of increased risk for t
i
i
AIDS. They are: identity versus role confusion, definition |
of sex roles, sexual experimentation, cognitive development, !
i
risk taking, and egocentrism. The first, identity versus j
i
role confusion, refers to the search of the self including
sexual discovery which may put them at risk for HIV
i
exposure. The second, definition of sex roles, refers to i
the establishment of a sexual identity including sexual
126
orientation and appropriate sexual behaviors associated with
those roles which may include high-risk sexual practices.
The third, sexual experimentation, refers to exploration of
sexual behavior including practices which are considered
unsafe by public health officials. The fourth, cognitive
development, refers to the attainment of certain mental
faculties which allow the individual to forsee short and
long term consequences of their sexual behaviors. The
fifth, risk taking, refers to the tendency to engage in
risky and dangerous behaviors including unsafe sexual
practices. Finally, egocentrism, refers to personal
perceptions of invulnerability which is especially hazardous
in terms of sexual behavior in the era of AIDS. In order
to decrease this tendency toward high-risk behaviors,
DiClemente, Zorn, and Temoshok (1987, p. 229) asserted:
The most potent weapon in our armamentarium to
combat the spread of AIDS is health education.
Such programs should be based on current and
accurate medical information, awareness of the
students' gaps in information, as well as an
understanding of their attitudes and beliefs
about AIDS.
Implications for AIDS Communication Campaigns
The importance of information and education has become
"the only effective way at present of halting the spread of
the current HIV epidemic" (Ross and Rosser, 1989, p. 273).
Communication scholars, biomedical researchers, public
127
health officials, psychologists, social workers, and other
behavioral and medical scientists concur with this position
since there is no cure nor a vaccine in sight (Alcalay and
Taplin, 1989; Barnes, 1987; Batchelor, 1988; Brooks-Gunn,
Boyer, and Hein, 1988; Koop, 1987; Lenaghan and Lenaghan, t
1987; Mason, Noble, Lindsey, Kolbe, Van Ness, Bowen,
Drotman, and Rosenberg, 1988; Reardon, 1988, 1989a; Shayne
and Kaplan, 1988; Voberding, 1988; Weisburd, 1987).
Communication campaigns are an organized group of
communication activities intended to create specific effects
in a relatively large audience within a predefined period of
time (Rogers and Storey, 1987). AIDS is a complex disease,
"It is associated with stigmatized groups, it is often
sexually transmitted, and it is a terminal disease that can
be physically disfiguring" (Albee, Mays, and Schneider,
1989, p. 11). Furthermore, "Sexuality is a social
construct" (Brown, Waszak, and Childers, 1989, p. 85) and
communication campaigns designed to affect sexual behavior
have a long history of application in many socities in the
i
world. |
AIDS communication campaigns are distinctively
different from other health related campaigns which are
dose-related, e.g., smoking, diet and exercise, coronary
heart disease risks. Ross and Rosser (1989) offered three
reasons why AIDS campaigns are qualitatively and
128
quantitatively unique. Firstly, sexual behavior change to
prevent AIDS must be immediate all-or-nothing efforts for
one contact (e.g., exchange of bodily fluids) can lead to
HIV infection. Secondly, since AIDS is a highly
stigmatized condition, attitudes (e.g., homophobia) and
perceptions (e.g., lack of exposure to people with AIDS) may
play a significant role in altering sexual behaviors.
Thirdly, behaviors associated with HIV infection are usually
sexual and drug-related, topics which Rogers (1973)
identified as taboo communication, which may necessitate
different communication strategies to promote attitudinal
and behavioral changes. These differences must be taken
into account in the development of AIDS communication
campaigns.
Another factor to consider in the creation and
development of communication campaigns is the distinction
between information from education. Green, Kreuter, Deeds,
and Partridge (1980) defined such differences:
Health education is a process which bridges the
gap between health information and health
practices. Health education motivates the person
to take the information and do something with it-
-to keep himself healthier by avoiding actions
that are harmful and by forming habits that are
beneficial, (p. 4)
This differentiation has important implications for AIDS
communication campaigns. Ross and Rosser (1989) observed
129
that AIDS information by itself has extremely limited impact
on sexual behavior change, "information on its own, without
modification of attitudes [fear of homosexual association]
or perception of the subject as a personal concern
[perceived personal susceptibility] that one can do
something about will have no effect on knowledge and
behavior" (p. 282). Furthermore, retention and knowledge
I
| do not necessarily produce behavioral changes (Fineberg,
i
1988). In sum, for AIDS communication campaigns to be
effective, they must move beyond information dissemination
to AIDS education.
AIDS education campaigns present some difficult
challenges. Rice and Atkin (1989) succintly summarized
such campaign issues:
The problem of AIDS brings to bear the most
difficult aspects of many problems that campaigns
hope to solve: Consequences, though devastating,
are uncoupled from behavior because they occur so j
long after exposure to AIDS risks; risky behavior
involves activities perceived as pleasurable by
the participants (sex and drugs); detection of
contagious individuals is socially and
technically complex; and moral, economic, and
legal issues are raised, (p. 199)
However, education campaigns remain the only viable tool in j
the fight against AIDS. I
130
In their review of the role of education and
information about AIDS, Ross and Rosser (1989) proposed
three distinct phases to AIDS educational campaigns (see
figure 4). The first phase, education to reduce AIDS risk,
should be directed at modifying attitudes (e.g., decrease
homophobia in the college population) and beliefs (e.g.,
increase perceptions of personalized risk) that underlie
behaviors which may lead to transmission of HIV. The
second phase, changing beliefs and attitudes, should be
designed to motivate target subjects to change their
behaviors (e.g., use interpersonal contacts such as sexual
partners to promote changes in sexual behavior). The third
stage, providing skills to alter risk, should be directed at
providing target subjects with the necessary interpersonal
(e.g., how to discuss safe sex with a potential sexual
partner) and behavioral (e.g., how to use spermicide
properly) skills to promote AIDS risk reducing actions.
Although there is considerable debate regarding the
most fundamental concepts in communication campaign design
and research (see Dervin, 1989; McGuire, 1989), various
approaches to public communication campaigns have been
identified which can be applied to the context of AIDS
education and behavioral risk reduction. In this section, i
i
the following approaches to communication campaigns are
addressed: Alcalay and Taplin's (1989) community health
131
campaigns, Solomon's (1989) social marketing approach to
communication campaigns, and Reardon's (1989a) application
of persuasion research to AIDS prevention.
Since successful community-based AIDS education
programs have been launched in the gay community in San
Francisco, it is of special interest to the communication
researcher and campaign planner to understand the
ingredients of such a program. Alcalay and Taplin (1989)
discussed this approach to health campaigns by defining a
community as a social system characterized by shared values,
a power structure, and an agenda of community health
problems and issues in need of solution. Specifically,
they addressed the advantages of a community-based health
campaign and present the various strategic components of
such a campaign.
Alcalay and Taplin (1989) stated that there are several
advantages of a community-based approach to health |
education. First, this approach allows for the
participation and support from key members of the community
power structure which include community leaders and local
media opinion leaders. Second, it decreases dependency on
limited external resources. Third, it allows for a more
accurate and complete assessment of community needs so that
interventions can be specifically tailored to deal with such
needs. Finally, it provides the opportunity to enhance!
132
active community participation in terms of health education
and promotion activities.
In terms of community health campaign design, Alcalay
and Taplin (1989) outlined three major components: Planning,
advertising and media placement, and public relations. The
planning process encompasses the following: analysis of the
health issue to be addressed in the campaign (e.g., AIDS
education and awareness), definition of campaign goals and
objectives (e.g., to reach 20 percent of the student
population), identification of the target audience (e.g., a
specific university population), selection of media strategy
(e.g., campus media, interpersonal discussions, and groups
such as student government organizations), design of
communication messages (e.g., develop a campaign slogan),
implementation and placement of media messages (e.g., j
flyers, campus radio), and evaluation of the campaign to
find out the effectiveness of various communication messages
and strategies. The advertising and media placement
component includes the use of commercial (e.g., an ad in the
i
campus newspaper) and social issues (e.g., a public
announcement on the campus radio) advertising and their
placement in specific cost-effective communication mediums.
The last component, public relations and public affairs,
encompasses the creation of an image for the campaign (e.g.,
"AIDS is an equal-opportunity killer"), use of media tools
I
I
J
133
(e.g., campus radio interview ), and implementation of
public affairs strategies (e.g., establishment of a speaker
bureau to provide free presentations to various campus
organizations).
A distinctively different approach to health
communication campaigns is the social marketing perspective.
This perspective uses the four main variables of social
marketing, namely, product, price, place, and promotion in
the creation and design of public communication campaigns.
Solomon (1989) presented eleven fundamental concepts of
social marketing which may be applied to the design and
implementation of AIDS education campaigns. They are: (1)
i
j
the marketing philosophy (e.g., the goal of a campus AIDS |
awareness and education task force is to meet the needs of
their target audience), (2) a profit, or "bottom line,"
orientation (e.g., accomplishment of the objectives of the
program in some measurable sense may be considered as
profit), (3) the four Ps of marketing--product, price,
place, and promotion (e.g., the product may be a book mark
i
with basic information about AIDS and safe sex; the price j
may be a student donation; the place may be an AIDS !
I
information booth on campus, and promotion may entail the j
use of various strategies to increase students' awareness of |
the existence of a campus AIDS information booth), (4) j
1
hierarchies of communication effects (e.g., knowledge of HIV
134
transmission may lead to sexual attitude and behavior change
in the direction of safer sexuality), (5) audience
segmentation (e.g., dividing our student population into
undergraduate and graduate, male and female), (6)
understanding all the relevant markets (e.g., AIDS awareness
may include students as well as faculty and staff), (7)
information and rapid feedback systems (e.g., is the
campaign working?), (8) interpersonal and mass communication
interaction (e.g., mediated messages may bring students to
the AIDS awareness booth while interpersonal contact may
disseminate accurate AIDS information), (9) utilization of
commercial resources (e.g., use of campus radio), (10)
understanding the competition (e.g., are there other
concurrent campus campaigns which may detract students'
attention to AIDS awareness?), and (11) expectations of
success (e.g., how many people does this campaign plan to
reach?).
Persuasion undoubtedly plays a key role in
communication campaigns. Edgar, Freimuth, and Hammond
(1988) cautioned that "persuasive messages, however, will be
effective only if they are grounded in valid assumptions"
(p. 60). Reardon (1989a) integrated years of communication
and persuasion research which can be applied to the fight j
i
against AIDS (see table 15). She identified five |
persuasion strategies--four from traditional persuasion
1_______________________________________________________________________________
135
theories and one novel persuasion approach. They are: (1)
self-efficacy, (2) involvement, (3) reasoning, (4) fear, and
(5) illusion. The first approach, self efficacy, consists
of instilling confidence and motivation in the target
audience, e.g., motivate subjects to engage in safe sex
behaviors. This may include development of credible role
models and strong health values, e.g., use of celebrities to
teach subjects how to practice safe sex.. The second,
involvement, requires the active participation of the
persuadee such as role playing interpersonal resistance
skills and sexual decision-making tactics, e.g., invite the
target subject to participate in AIDS discussion forums.
The third approach involves the use of reasoning to practice
resistance to behaviors which are not sound health practices
in the era of AIDS, e.g., get the target subject involved in
the process of safe sex negotiation through discussion or
role play. The fourth persuasion approach is the use of
(
fear. Fear arousing messages may be utilized to present
AIDS behavioral risk reduction strategies, e.g., use images
of physical deterioration as a result of AIDS to motivate
target subjects to modify their sexual behavior. Finally,
persuasive messages may use the power of illusion to educate
and prevent the spread of AIDS. It was noted that
adolescents and college students hold three primary I
I
illusions with respect to their behavior: (1)
136
unrealistically positive view of self, (2) illusions of
control, and (3) unrealistic optimism. This approach urges
the creation of persuasive communication which build on
these three primary illusions, e.g. challenge target
subjects to control their impulsive sexual behavior.
(Finally, Reardon (1989a) urged the use of both interpersonal
and mediated channels in the application of these persuasive
approaches.
Regardless of which approach to communication campaign
is utilized, other factors must be considered in the process
of development and design of such a campaign. It is
evident that the research findings supported the
■multichannel nature of AIDS information acquisition, i
People learn about AIDS from a multitude number of
communication sources including mass media messages and
interpersonal encounters. Alcalay and Taplin (1989)
described the importance of the recognition and application
of the multichannel approach in health communication
campaigns, "while health educators have traditionally relied
primarily on interpersonal and small group communication, it
is increasingly important that they also be trained to use I
mass communications resources to reach large audiences
effectively" (p. 105).
Though the research indicated that mass media messages
appear to play a major role in the process of disseminating j
137
information about AIDS, it is important to point out that
interpersonal messages also contribute significantly. The
artificial separation of mediated and interpersonal channels
should not be viewed as support for the "false dichotomy"
i
(Reardon and Rogers, 1988). In their address of the
conceptual separation between interpersonal and mass
communication messages, Reardon and Rogers (1988) noted that
"a focus on only one or the other type of communication
channel is unsufficient for understanding a communication
process" (p. 295). Such an unsufficient understanding of
the process of information dissemination, obviously, leads
to detrimental consequences in public awareness campaigns
and AIDS educational efforts. Therefore, it is
recommended that any public communication campaign aimed at
increasing public knowledge regarding AIDS, reducing the
risk of HIV transmission, and preventing the further spread
of the epidemic to utilize a combination of mass media and
interpersonal messages to reach its target audience.
AIDS communication campaigns must also take into
account attitudes and beliefs expressed by college students.
For instance, there is evidence (Goodwin and Roscoe, 1988;
Simkins and Kushner, 1986) of homophobic attitudes in the
college population which may become a barrier in the
education process. Stipp and Kerr (1989) suggested that |
"AIDS education programs and the public debate about AIDS
138
need to address anti-gay attitudes along with knowledge
about transmission" (p. 99) . Additionally, campaign
messages must personalize the AIDS risk for the target
audience. Research findings from the present study as well
as past investigations (e.g., Simkins and Eberhage, 1984;
Thurman and Franklin, 1990) seem to show that most college
students do not perceive themselves to be personally at risk
for HIV infection. Furthermore, communication campaigns
must provide the target population with the necessary skills
to overcome perceived barriers, e.g., the proper enactment
of safe sex behaviors. I
Finally, AIDS communication campaigns must include an
evaluation component (see, for example, Atkin and Freimuth,
1989; Fetro, 1988; Flay and Cook, 1989). Evaluation
provides valuable information regarding the attainment of
the specified objectives at each stage of the campaign.
Such systematic assessment becomes a feedback mechanism
which will allow the communication campaign team to make j
proper adjustments and changes in input variables including
source, message, channel, receiver, and destination. ,
Furthermore, such feedback permits the campaign team to
observe the effects of input factors on output variables
such as message exposure, message involvement, message j
comprehension, message recall, message acceptance/rejection,
decision-making processes with respect to the target
139
behavior, behavioral change, and consistency and permanence
of such behavioral modification in the future.
Limitations of the Present Study
The present study has several limitations. First, the
sample was limited to students in the greater Southern
California area. There is evidence that geographical
location affects perceptions of susceptibility to AIDS as
well as other health-related attitudes (see, for example,
DiClemente, Zorn, and Temoshok, 1987).
Second, the research instrument, though widely used in
behavioral research using the Health Belief Model, is not
standardized. This lack of standardized instrumentation
has been a recurrent criticism of the model and some efforts
have been reported to overcome this limitation (see, for
example, Champion, 1984). J
Third, the present research is a cross-sectional study
which does not allow for a systematic assessment of the
f
changes in beliefs, attitudes, and behaviors associated with
AIDS. Such changes may provide additional insight
regarding the role of cognitive, affective, and behavioral
factors in understanding the complexity of the process of
activating students to engage in AIDS prevention efforts.
Fourth, other modifying factors of the model have not
been addressed in the present investigation though there is
i
some evidence of their impact on AIDS behavioral risk j
140
reduction. They include knowledge, health locus of
control, social network characteristics, and cultural
influences, among others. Past research has provided some
evidence of the effects of knowledge on health beliefs
including perceived susceptibility, severity , barriers, and
enactment of safe sex behaviors (DiClemente, Boyer, and
Morales, 1988; DiClemente, Zorn, and Temoshok, 1987;
Manning, Barenberg, Gallese, and Rice, 1989; Thomas,
Gilliam, and Iwrey, 1989). There is also some evidence
substantiating the relationship between health locus of
control and AIDS information seeking (Price-Greathouse and
Trice, 1 9 8 6 ; Trice and Price-Greathouse, 1987 ).
Additionally, cultural factors are also relevant in terms of
perceptions about the disease (Aoki, Ngin, Mo, and Ja, 1989;
Jue, 1987; Marin and Marin, 1990; Mays, 1989; Tafoya, 1989)
and individuals' receptivity to AIDS educational messages
(DiClemente, Boyer, and Mills, 1987). Finally, social-
network characteristics also appear to have some effect on
sexual behavior change (Emmons, Joseph, Kessler, Wortman,
Montgomery, and Ostrow, 1986; Joseph, Montgomery, Emmons,
Kessler, Ostrow, Wortman, O'Brien, Eller, and Eshleman, ]
1987) .
Future Directions
\
It is apparent that AIDS behavioral risk reduction
research is still in its infancy, therefore, there are a
141
number of tasks which require immediate attention from
behavioral scientists including communication scholars,
ipublic health researchers, psychologists, and social
workers. First, future research must focus on college
populations from a number of geographical locations
including communities which remain relatively unaffected by
.the AIDS epidemic as well as communities situated at the
epicenter of the disease such as New York, Chicago, Los
Angeles, and San Francisco. Furthermore, research on
college students must include cultural and subcultural
factors such as ethnicity, subcultural network affiliation,
cultural attitudes toward AIDS, among others.
Second, researchers must pay increasing attention to
the standardization of instruments measuring health beliefs
and attitudes. Standardized health beliefs assessment
devices can improve reliability and validity in measurement
of the HBM constructs.
Third, longitudinal data assessing changes in
attitudes, perceptions, and sexual behavior among college
students are urgently needed. To date, research focusing
on this population has been cross-sectional in nature,
I
therefore, observations of changes over time are more
difficult to deduce.
Fourth, other modifying factors of the Health Belief j
Model must be included in future investigations using this
142
theoretical framework to increase its explanatory power in
relation to AIDS preventive behaviors. Such factors may
include the effects of knowledge, health locus of control,
and peer group norms on attitudes, perceptions, and health-
related behaviors associated with HIV prevention.
Fifth, more research on the effectiveness of
communication strategies and persuasion tactics are
required. For instance, research on the use of emotional
appeals in AIDS communication campaigns, utilization of
images of AIDS deterioration, and effective safe sex
negotiation tactics can be applied to AIDS educational
efforts.
Finally, more emphasis should be placed on the
assessment of the effectiveness of various types of AIDS
educational campaigns. McDermott, Hawkins, Moore, and
Cittadino (1987) observed that "little research has focused
on the penetration of educational messages about AIDS in
sexually active groups that are not bisexual or exclusively
homosexual" (p. 223). Baldwin and Baldwin (1988) further
commented that while educational messages seem to have been
effective in decreasing risky sexual behaviors among some
high-risk gay/bisexual groups, "it is not clear that it will
have the same effect among people who do not perceive
themselves to be at high risk for contracting the virus" (p.
181) .
' \
143
Conclusions
The utility of the Health Belief Model in relation to
AIDS preventive health actions has been partially supported
in the present investigation. In particular, it appears
that perceived susceptibility and barriers are important
predictors of changes in sexual behavior among college
students. In terms of its implications to AIDS
communication campaigns, the research findings appear to
indicate that increasing AIDS information dissemination on
college campuses has a limited impact— unless such messages
are accompanied by AIDS educational strategies (including
personalization of the AIDS risk; overcoming homophobic
attitudes, and providing the target population with specific
behavioral and communication skills to properly engage in
safe sex behaviors).
The fight against AIDS must involve both biomedical and
social scientific communities. Since there is no cure nor
a vaccine for AIDS in the near future, the primary focus
must be on prevention. Prevention efforts must address the
audience's gaps in knowledge about the disease, cultural
relevance and sensitivity of the message, appropriateness of |
i
language and style of communication, and motivational i
devices which will induce changes in sexual behavior. It
is, therefore, apparent that AIDS education and prevention
programs represent formidable challenges in which
144
communication undoubtedly will continue to play a critical
role.
i
J
145
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i
i
APPENDICES
169
APPENDIX A
Thank you for volunteering to participate in this
project. In this questionnaire you will read many
statements concerning your personal views on health-related
issues. The statements deal with your perceptions. We
are interested in your personal beliefs and it is important
that you respond according to your ACTUAL BELIEFS and not
according to how you feel you should believe or how you
think we want you to believe.
Your answers to this questionnaire are confidential and
anonymous. In other words, do not identify yourself by
name in any portion of this questionnaire.
Please make sure that you have answered every item —
DO NOT SKIP ITEMS! PROVIDE AN ANSWER TO EACH QUESTION BY
FOLLOWING THE INSTRUCTIONS FOR THAT SPECIFIC SECTION AND DO
NOT GO BACK TO THE ITEMS ONCE YOU HAVE ANSWERED THEM. Thank
you in advance for your help.
YOUR AGE:
SEX: (circle one) MALE
FEMALE
YEAR IN SCHOOL: (circle one) FRESHMAN
SOPHOMORE
JUNIOR
SENIOR
GRADUATE
170
ETHNIC BACKGROUND: (circle one) WHITE
BLACK/AFRICAN AMERICAN
NATIVE AMERICAN
HISPANIC
ASIAN/PACIFIC ISLANDER
OTHER (Please specify)
MY RELIGIOUS AFFILIATION IS:________________________________
ARE YOU CURRENTLY IN A ROMANTIC RELATIONSHIP? (circle one)
YES
NO
IF YES, HOW LONG HAVE YOU BEEN WITH THE PERSON?___________
MONTHS.
171
APPENDIX B
For this section, please think about the various
sources from which you have learned about AIDS (acquired
immunodeficiency syndrome), and follow these steps:
1. First go through all sources of information listed
below and write "N/A" to their left if you HAVE NOT
LEARNED ANY INFORMATION ABOUT AIDS from them.
2. Then think of any other important source of
information from which you have learned about AIDS but
it is NOT LISTED BELOW. Add this on in the lines below
under "other sources of information not listed."
3. Now, carefully go over all the remaining sources of
information from which you have learned about AIDS and
select the MOST IMPORTANT source. Please place a "1"
in the blank space to the left of that most important j
source of information.
4. Next, think about which of all remaining sources of
information is SECOND MOST IMPORTANT and place a "2" in
the blank to the left. Continue ranking the third, '
i
fourth, fifth, etc. most important until you have
ranked all sources from which you have learned about
AIDS.
i
i
i
YOUR RANK ORDER SOURCES OF INFORMATION ABOUT AIDS
_________ Newspaper article.
_________ Acquaintance.
_________ Brochure/fIyer.
_________ Family member (e.g., parent, brother,
sister, etc.) j
172
TV program.
Girlfriend/boyfriend.
Magazine article.
Spouse/"intimate other."
TV commercial.
Date.
Print ad.
Health care practitioner (e.g., doctor,
nurse, pharmacist, etc.).
Nonfiction book (e.g., a book about
AIDS).
Friend.
Fiction book (e.g., a novel)
(Other sources of information about
AIDS not listed)
173
APPENDIX C
Below you will find a list of ten statements about
yourself in relationship to the AIDS epidemic. Answer all
questions -DO NOT SKIP ANY ITEMS- by following the specific
scale associated with each item.
1. My likelihood of getting AIDS is: (check one)
NOT LIKELY AT ALL : : : : VERY LIKELY
2. My likelihood of getting AIDS as compared with those of
the average person is: (check one)
MUCH LESS LIKELY ___: _____: _____: ___ : _____MUCH MORE
LIKELY
3. If I did everything that has been recommended to reduce
the chances of getting AIDS, this would actually reduce my
risk : (check one)
VERY LITTLE : : : : A GREAT DEAL
4. In spite of the possibility of getting AIDS, I have a
great deal of difficulty changing my sexual behavior .
(check one)
STRONGLY AGREE : : : : STRONGLY DISAGREE
5. I have no difficulty controlling my sexual impulses.
(check one)
STRONGLY AGREE : : : : STRONGLY DISAGREE
6 . The AIDS epidemic is a serious international health
threat. (check one)
STRONGLY AGREE : : : : STRONGLY DISAGREE
174
I am currently sexually active, (circle one) YES
NO
175
APPENDIX D
Below is a list of statements about your sexual
behavior. Answer all questions -DO NOT SKIP ANY ITEMS- by
carefully reading them and placing the appropriate number to
the left of the statement by following this key:
1 = if the statement is a COMPLETELY TRUE description of
your behavior
2 = if the statement is a MOSTLY TRUE description of your
behavior
3 = if the statement is a SOMEWHAT TRUE description of your
behavior
4 = if the statement DOES NOT APPLY to your behavior
5 = if the statement is a SOMEWHAT FALSE description of your
behavior
6 = if the statement is a MOSTLY FALSE description of your
behavior
7 = if the statement is a COMPLETELY FALSE description of
your behavior
_____ 1. Since the AIDS epidemic began, I have been more
selective about my sexual partners.
_____ 2. Since the AIDS epidemic began, I have been more
careful.
_____ 3. Since the AIDS epidemic began, I avoid sex.
4. Since the AIDS epidemic began, condoms were used
during sexual activity.
_____ 5. Since the AIDS epidemic began, I have been
!
J
176
monogamous.
6. Since the AIDS epidemic began, I avoid transmission
of body fluids with my partner.
7. Since the AIDS epidemic began, I have reduced
certain types of sexual practices.
8. Since the AIDS epidemic began, I made sure that my
partner(s) does/do not have AIDS.
9. Since the AIDS epidemic began, I have reduced the
number of sexual partners.
10.Since the AIDS epidemic began, I have not altered
my sexual behavior in any way.
FIGURES
The Health Belief Model
(Adapted from Maiman and Becker, 1974)
INDIVIDUAL PERCEPTIONS MODIFYING FACTORS LIKELIHOOD OF ACTION
MINUS
Perceived susceptibility
to disease "X"
to preventive action
Perceived barriers
Perceived severity of
disease "X"
Perceived threat of disease "X
Communication/cues-to-action
Mediated and Interpersonal
of preventive action
Perceived benefits
Likelihood of taking
preventive health
action
Sociopsychological variables
Figure 2
The Health Belief Model and AIDS-preventive Behavior
INDIVIDUAL PERCEPTIONS MODIFYING FACTORS LIKELIHOOD OF ACTION
SociopsychologicaL variables Perceived benefits
[socral network characteristics; of preventive action
cultural perceptions; peer norms; [efficacy of safe
knowledge about AIDS] sex methods, e.g.,
using a condom]
1
1
1
i
i
!
1
MINUS
V
Perceived susceptibility
i
i Perceived barriers
to disease "X" ----------------------» ,
to preventive action
[personal threat of AIDS]
i
i
(difficulties in
V
modifying risky
1
Perceived threat of disease "X"
sexual behavior]
Perceived severity of
I
1
1
- - > 1
i
disease "X"
* 4,
(seriousness of AIDS]
1
Likelihood of taking
Communication/cues-to-act ion preventive health
Mediated and Interpersonal action
I TV, magazines, doctors] [adoption of safe
sex practices]
Figure 3
The Health Belief Model in the context of AIDS: Research Questions and Hypotheses
INDIVIDUAL PERCEPTIONS MODIFYING FACTORS LIKELIHOOD OF ACTION
Perceived benefits/
efficacy of safe sex
H4: Efficacy — ---->
sexual behavior change
Perceived susceptibility
to AIDS
H2: Susceptibility— >
sexual behavior change
Perceived severity of
AIDS
H3: Severity { -l— >
sexual behavior change
Perceived barriers
to preventive action
H5: Barriers ---->
sexual behavior change
->
Likelihood of taking
preventive health Communication/cues-to-aqtion
Hi: Mediated sources > action
Interpersonal sources [adoption of safe
RQ1:Mediated; RQ2:Interpersonal sex practices)
< c —
Figure 4
Phases in AIDS Educational Campaigns
(Adapted from Ross and Rosser, 1989)
e.g., how to wear a
condom properly;
interpersonal, e.g.,
safe sex discussion)
Acquisition of
skills (behavioral,
contacts to promote
safe sex practices
Motivation to change
sexual behavior
PHASE TWO
, use interpersonal
AIDS (e.g., decrease
personalized risk
homophobia, increase
Modification of attitudes
and beliefs associated with
PHASE ONE
TABLES
Table 1
Results of Health Belief Model Studies
Author(s)
Cummings
et al.
Rundall &
Wheeler
Aho
Beck
Croog &
Richards
Weinberger
et al.
Aho
Palmer &
King
Bodenheimer
et al.
Eisen &
Zellman
Sample
n = 286
n = 232
n = 122
n = 272
n = 205
n = 120
n = 199
n = 123
n = 1,500
n = 203
Hea1th
Behavior
swine flu
inoculation
swine flu
inoculation
swine flu
inoculation
driving &
driving
smoking
smoking
heart
disease
hepatitis
vaccine
hepatitis
vacc i ne
contracepti
on
Perceived
susceptib
+/sig.
+ /sig
+ /sig
-/n.s.
n. s.
+ /sig
+ /sig
+
+ /sig
and Preventive Health Behavior
Perceived
severity
+ /sig
+/n.s.
+ /n.s.
-/n.s.
n.s.
+ /s ig
+ /sig
+
+ /sig
+ /sig
Perceived
benef its
+ /sig
+/sig
+ /sig
-/n.s.
n.s.
+/sig
+ /sig
Perceived
barriers
+ /sig
+ /sig
+ /sig
-/n.s.
-/sig
-/sig
183
Simon & Das n = 416 VD checkup +/sig +/sig -/sig
Langlie n = 383 general, -/sig +/sig +/sig
e.g.,
nutrition,
smoking.
(+) = positive relationship; (-) = negative relationship; sig = statistically
significant; n.s. = nonsignificant relationship; [empty cells] = not reported by
researcher (s)
184
Table 2
Results of Health Belief Model Studies and AIDS-preventive Behavior
Author(s)
Emmons et al.
Sample Perceived
susceptib
+ /sig
Perceived
severity
n.r.
Montgomery &
Joseph
Joseph et al.
Kotarba &
Lang
Manning et
al.
Manning et
al.
Prewitt
+*
Perceived
benefits
+ /sig
+ /sig
+/n.s.
n.r.
+ *
+*
n.r.
Perceived
barriers
-/sig
-/s ig
-/n.s.
n.r.
n = 909
gay men
n = 909 +/sig +/sig
gay men
n = 637 +/sig before +/n.s.
gay men adjustment
n = 48 n.r. n.r.
gay men
n = 139 +*
college Ss
n = 122 +*
college Ss
educational +* n.r. n.r. n.r.
pamphlets
(+) = positive realtionship; (-) = negative relationship; sig = statistically
significant; n.s. = nonsignificant relationship; n.r. = not reported; +* = assumed
positive relationship though not reported, nonparametric data; -* = assumed negative
relationship though not reported, nonparametric data.
Table 3
Atheoretical Studies on AIDS-preventive Behavior in College Students
Author!s)
Mangan
Chervin &
Martinez
Simkins &
Eberhage
Simkins
Kushner
Royse et
al.
Hughey
Price et
al.
Carroll
Perceived
personal
susceptib
to AIDS
low
low
& low
low
somewhat
Knowledge
of AIDS
fairly high
fairly high
Information Other
acquisition attitudes
various
levels
fairly high
Other
measures
homophobia
reported
fear of
AIDS
Sexual
behavior
change
low
low
low
low
empathy
toward PWA
behavioral
intent to
assist PWA
some
186
Keqeles et
al.
Catania et somewhat
al.
Baldwin &
Baldwin
not a good somewhat
predictor better
of change
Atkinson et
al.
Gottlieb et low
al.
predictor
of change
fairly high TV as major
source
fairly high magazines,
TV as major
sources
DiClemente fairly high fairly high
et al.
low
some
demographic demographic
factors
were fair
predictors
of change
some
Goodwin &
Roscoe
Thurman &
Franklin
Katzman et
al.
low
moderate
fairly high
high
homophobia
was high
mediated
sources are
preferred
low
somewhat
DiClemente
et al.
Strunin &
Hingson
DiClemente
et al.
Thomas et
al.
Gilliam &
Seltzer
Fan &
Shaffer
Freimuth
et al.
fairly low moderate ethnicity &
other
demographic
factors
low moderate
inverse
relation
between
knowledge &
suscept.
moderate attitudes
toward
AIDS,and
homosexuali
ty
fairly high
fairly high both inter
personal &
mediated
sources .
mixed ethnicity
fairly high ethnicity
low
low
low
188
Price-
Greathouse
& Trice
Trice &
Price-
Greathouse
Gerrard S .
Reis
McDermott
et al.
Yep &
Negron
moderate
high mediated
sources
mediated
sources &
multi
channel
locus of
control i .
information
acquisition
locus of
control
sex-guilt &
retention
of AIDS
information
190
Table 4
Demographic Characteristics of the Sample
(N = 266)
Age
Ethnicity
Sex
Relationship Status
Mean = 22.96; s.d. = 4.32;
range = 18 - 43
White = 61.51 percent (n=163)
Asian/Pacific Islander =
16.98 percent (n=45)
Hispanic = 10.19 percent
(n=27)
Black/African American = 8.68
percent (n=23)
Indian/Native American = 1.13
percent (n=3)
Other = 1.51 percent (n=4)
Female = 63.02 percent
(n=167)
Male = 36.98 percent (n=98)
Involved in a romantic
relationship = 60.90 percent
(n=162)
Not involved in a romantic
relationship = 39.10 percent
(n=104)
191
Sexual Activity Sexually active = 68.30
percent (n=181)
Not sexually active = 31.70
percent (n=84)
Ratings for
Table 5
Mediated Communication Sources of
Information Acquisition*
192
AIDS
SOURCE MEAN RATING STANDARD DEVIATION
1. Newspaper 3.35 2.17
articles
2. Television 3.66 2.55
program
3. Magazine 3.70 2.17
articles
4. Brochure or 4.16 2.52
flyer
5. Televsion 5.62 2.72
commercial
6. Print 6.43 2.51
advertisement
7. Nonfiction 6.95 4.39
book
8. Fiction book 11.90 3.07
*Lower numerical ratings represent sources of higher
importance
193
Table 6
Ratings for Interpersonal Communication Sources of AIDS
Information Acquisition*
SOURCE MEAN RATING STANDARD DEVIATION
1. Health care 4.79 3.02
practitioner
2. Family member 5.95 3.29
3. Friend 7.37 2.69
4. Spouse/"intimate 8.10 3.42
other"
5. Girlfriend/ 8.18 3.00
boyfriend
6. Social 8.75 3.27
acquaintance
7. Date 11.04 2.53
*Lower numerical ratings represent sources of higher
importance
194
Table 7
One Factor ANOVA for Repeated Measures:
Comparison of Mediated Communication Sources vs.
Interpersonal Communication Sources of AIDS Information
Acquisition
SOURCE df
Between 265
subjects
Within 266
subjects
Type of 1
source
Residual 265
Total 531
Sum of Mean F-test P-value
Squares Squares
2380.40 8.98 2.02
1186.09 4.46
397.94 397.94 133.80 .0001
788.15 2.97
3566.48
Post-hoc Comparisons: Fisher PLSD = .294 (p < .05)
Scheffe F-test = 133.80 (p < .05)
i
195
Table 8
Stepwise Multiple Regression Analysis of Perceived
Susceptibility and Barriers on Avoidance of Sex as a means of
AIDS Prevention
S te p w is e R e g re s s io n Y i :4.3 * X variables
STEP NOl 1 VARIABLE ENTERED: X3 : B a r r ie r s
R: R -squared Adi R -souared: Std E rror
183 034 03 1 737
Analysis of Variance Table
Source OF Sum Squares Mean Square' F -te s t
REGRESSION 1 27 607 27 607 9 151
RESIDUAL 264 796 442 3 017
t o t a l 2 65 824 049
S TEP NO. 1 S te p w is e R e g re s s io n Y , :4.3 4 x v a ria b le s
P a ra m e te r:
Variables in Equation
Value. S id. Err Std. Value: c to Remove
INTERCEPT
5.081
B a rrie rs
285 094 183 9 : 5:
Vanabios Not m Equation
P a ra m e te r' Par C orr F 10 Enter
S u s c e p tib ility t 42 5 41
B enefits • 053 749
S e v e rity 072 1 373
19ft
S te p w is e R a g ra a a lo n Y i :4.3 4 X v a ria b le *
(Leaf Step) STEP NO. 2 VARIABLE ENTERED: X i : S u s c e p tib ility
R: R -squared: Adj. R -squared: Std. E rror:
23 053 046 1.7 23
Analysis of Variance Table
S ource OF: Sum Squares Mean Square: F -te s t:
REGRESSION 2 43 659 2 t 829 7 357
RESIDUAL 2 63 780 39 2 967
t o t a l 2 65 824 049
S TEP NO. 2 S tep w ise R egression Y i :4.3 4 X variables
Variables in Equation
SiQ P ara m ete r: Std Value. F to Remove: Value
4 637
32 1 38
B a rrie rs
23 5 727 096
Vanabies Not in Equation
Par C orr P ara m ete r- F to Enter
B enefits 1 285
S e v e rity
065
i
i
197
Table 9
Stepwise Multiple Regression Analysis of Perceived
Susceptibility on Condom Use as a means of AIDS Prevention
S te p w is e R e g re s s io n Y i :4.4 4 X vsriables
(Last Step) STEP NO. 1 VARIABLE ENTERED: X T : S u s c e p tib ility
R R -squared' Adj R-squared: Std. E rror:
136 019 015 2 033
Analysis of Variance Table
Source OF Sum Squares Mean Square: F -te s t
REGRESSION 1 20 416 20 416 4 942
RESIDUAL 262 t 082 357 4 131
TOTAL 263 ' 1 0 2 .7 7 3
STEP NO. 1 Stepw ise R eg ressio n Y i :4.4 4 X variab les
Variables > n Equation
P a ra m e te r. Stb. Value Value r to Remove
4 695
- 35 2 4 942
Vanaoles Not m Equation
f :o Enter
Benefits ■ 0 8 6 1 962
B a rrie rs 1 06
S e v e rity • 03 2 781
198
Table 10
Stepwise Multiple Regression Analysis of Perceived
Susceptibility and Barriers on Becoming Monogamous as a means
of AIDS Prevention
S te p w is e R e g re s s io n Y i :4.S 4 x v a ria b les
STEP NO. 1 VARIABLE ENTERED: X3
B a r r ie r s
R: R -squared:
Aqj. R-squared: Std. E rror:
258 067
.063 2 311
Analysis at Variance Table
Source DP: Sum Souares Mean Sduare: F -te s t:
REGRESSION 1 100 289
100 289 18 781
RESIDUAL 263 1 404 406 5 34
TOTAL 2 64 1 504 694
STEP NO.
S tepw ise R eg ressio n Y , :4.5
4 X va ria b les
Variables in Equation
Value:
Std Value:
INTERCEPT
2.591
543
125 258
Variables Not m Equation
Par C orr
F lo Enter:
69 7 72
B enefits
06 934
S e v e rity
072
1 368
t
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199
S te p w is e R e g re s s io n Y i :4.5 4 X variablee
(Last Step) STEP NO. 2 VARIABLE ENTERED: X i : S u s c e p tib ility
Rl _ _____________ R -squared: Adi R -»qusred: Std. E rror:
306 093 086 2 282
S ource OF:
Analysis of Variance Table
F -te s t:
REGRESSION 2 140 488 70 244 13 491
RESIDUAL 262 1 3 64.2 06 5 207
TOTAL 2 64 1 504 694
STEP NO. 2 S tep w ise R eg ressio n Y i :4.5 4 X variables
Variables in Equation
P ara m ete r:______V a lu e ____________ StO. E rr._________ Std. Value:_______F to Remove:
INTERCEPT
1 888
S u s ce p tib ility 507 182 168 7 72
B a rrie rs 457 128 .217 1 2.8 33
Variables Not in Equation
P a ra m e te r Par C orr: F to Enter
B enefits 042 458
S e v e rity 064 1 072
Table 11
Stepwise Multiple Regression Analysis of Perceived Barriers
on Becoming More Careful in Sexual Situations
S te p w is e R e g re s s io n Y i .4.2 4 X variab les
(Last Step) STEP NO. t VARIABLE ENTERED: X3 . B a r r ie r s
R: R-sou a re a _______Adi. R-sguareO: S id. E rro r_______
.172 03 026 1,562
Analysis of Variance Table
Source OF. Sum Squares: Mean Square: F -te s t
REGRESSION 1 19 629 19 629 8 045
RESIDUAL 2 64 644 1 34 2 44
t o t a l . 2 65 663 763
S TEP NO. 1 S tepw ise R egression Yt 4.2 4 X v a ria b le s
Variables m Equation
Sta Err P a ra m e te r Std. Value: V alue: F :o Remove
2 003
B a rrie rs 24 085 172 8 045
Variables Not m Equation
1 293
S e v e rn y 04 42
Table 12
Stepwise Multiple Regression Analysis of Perceived Barriers
on Making Sure that Partner Does Not Have AIDS
S te p w is e R e g re s s io n Y i :4.8 4 X va rla b laa
( L u t Step) STEP NO. 1 VARIABLE ENTERED: X3 : B
R:________________ R -squared:______ Adj. R-squared: S td. E rror:
.16 4 027 023 2 11
Analysis of Variance Table
Source DF- Sum Squares: Mean Square: F -te s t:
REGRESSION 1 32 612 32 612 7 324
RESIDUAL 2 6 4 1 1 7 5 .5 8 4 4 453
TOTAL 265 1208 195
S TE P NO. 1 S tep w ise R eg ressio n Y ] :4 .i 4 x v a ria b le s
Variables in Equation
S td. Err.: F to Remove Std. Value: P a ra m e te r: V alue:
2 758
7 3 2 * 164
Vanables Not in Equation
Par C orr P a ra m e te r
S u s c e p tib ility 032 273
B ene fits 039
■ 037 354
202
Table 13
Descriptive Statistics for Predictor Variables: Perceived
susceptibility, severity, benefits, and barriers*
MEAN
Perceived 1.78
susceptibility
Perceived 4.65
severity
Perceived 4.14
benefits
Perceived 2.29
barriers
STANDARD
DEVIATION
.79
.84
1.31
1.13
STANDARD ERROR
.05
05
08
.07
♦measured on a scale of 1 to 5— from lowest to greatest
t
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Descriptive Statistics
Sexual
Table 14
for Criterion Variable:
Behavior Change*
203
Indices of
MEAN STANDARD DEVIATION
1. Becoming more 2.85 1.69
selective about
sexual partners
2. Becoming more 2.55 1.58
careful
3. Avoiding sexual 5.73 1.76
encounters
4. Using condoms 4.07 2.05
5. Becoming 3.83 2.39
monogamous
6. Avoiding 5.24 1.96
transmission of
body fluids
7. Reducing certain 4.69 2.00
types of sex
8. Making sure that 3.47 2.14
partner does not
have AIDS
9. Reducing number 3.21 1.92
of sexual
partners
* measured on a scale of 1 to 7 — from total change of
behavior to no change of behavior
204
Table 15
Some Persuasion Approaches for AIDS Communication Campaigns
(Adapted from Reardon, 1989a)
1. Self-efficacy
2. Personal involvement
3. Use of reasoning
4. Use of fear appeals
5. Power of illusion
t
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Asset Metadata

Creator Yep, Gustavo Angel (author)

Core Title AIDS preventive sexual behavior in college students: An empirical test of the health belief model

Degree Doctor of Philosophy

Degree Program Communication Arts and Sciences

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag health sciences, public health,OAI-PMH Harvest

Language English

Contributor Digitized by ProQuest (provenance)

Advisor Sereno, Kenneth (committee chair), [illegible] (committee member), Riley, Patricia (committee member)

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c17-724097

Unique identifier UC11343537

Identifier DP22463.pdf (filename),usctheses-c17-724097 (legacy record id)

Legacy Identifier DP22463.pdf

Dmrecord 724097

Document Type Dissertation

Rights Yep, Gustavo Angel

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the au...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus, Los Angeles, California 90089, USA