Control of Sexually Transmitted Diseases
Section I: Management of STD Programs
Edited by Gina Dallabetta, Marie Laga, Peter Lamptey

Authors: LaHoma Smith Romocki, Susan Gilbert,
Donna Flanagan

An approach to effective communication

Preview Chapter 4 Introduction This chapter addresses communication strategies aimed at altering behavior in order to prevent infection. Historical Perspective on STD Messages In the past, some campaigns have had limited impact because of their use of scapegoats and moral judgments to convince people to change their behavior. Using Media to Deliver STD Messages The strength of mass media lies in their ability to convey information to a large population that leads to knowledge and an understanding of a problem or issue; interpersonal channels, on the other hand, are effective in changing attitudes and behavior. Communication and Behavior Change Theory Communications programs that are creative and effective need to be based on behavior change theory, sound public health practice and well-designed audience research. Personal or untested methods of changing behavior are not adequate substitutes. Contemporary Marketing Principles Communications programs should draw upon contemporary marketing principles to create effective programs. The principles include: Audience Segmentation Audience Research Concept Development and Pre-testing Accessibility of product Strategies for Reaching People With Messages About STDs An effective communications plan includes the following action-based steps: Defining the Problem (situation analysis) Setting the Objectives Identifying the Target Audience(s) Developing Key Messages Selecting Channels of Communication Pre-testing Messages/Materials Producing and Disseminating Implementing the Program Evaluating the Results Receiving Feedback to Improve Communication Conclusion Research and proper planning form the foundation of an effective communication campaign. Knowing the needs of the population and the best means of reaching that audience are crucial in achieving the goal of raising awareness and, ultimately, changing attitudes and behaviors. Introduction The cornerstone of STD management and prevention programs is the clinical setting. These clinic-based programs are extremely important (see Chapter 10) in providing treatment and information to eliminate future infections. However, most STD prevention education and communication opportunities exist outside the clinical setting. Unfortunately, in the past these efforts have been extremely limited. This chapter provides a framework for expanding the role of communication to include preventing infections, and early detection and treatment of existing infections. It is designed to help STD clinic or program managers by providing a theoretical structure and process for developing effective behavior change communication. Since approaches to interpersonal communication are described in detail in the chapter on patient education (see Chapter 10), they will not be emphasized here. Instead, the chapter will emphasize the use of mass (for instance, radio) and small (for instance, pamphlets) media to reach people outside of the clinical setting. However, the effectiveness of most interventions will be significantly strengthened when they combine these with interpersonal communication, which is particularly effective in influencing changes in attitudes and behavior. The chapter begins with a historical overview of STD communication. Later, there is a review of behavior change theories and, subsequently, a practical process is offered for developing communication strategies to reach people with prevention messages. At the end of the chapter, there is a list of additional resources for more in-depth study of communication. For additional communication assistance and support, the program manager is encouraged to identify and contact local resources. These include advertising or public relations agencies, universities, professional writers and editors, and other communication experts in health departments or nongovernmental organizations (NGOs). Historical Perspective on STD Messages Most STD communication efforts have been based on the clinical treatment model. While a number of media-based programs have been implemented worldwide, their messages have had a limited effect. Often messages have been fear-based and have not provided relevant incentives for target audiences to change behavior. Some messages have stigmatized certain groups and given false confidence to others, who inferred that they were not at risk of contracting STDs. For example, during World War I the U.S. military implemented an extensive communication program to prevent and control venereal disease (VD). This "social hygiene" campaign used fear-based messages that targeted women as the cause of VD, such as: "Women who solicit soldiers for immoral purposes are usually disease spreaders and friends of the enemy."1 Despite the general lack of effectiveness of these messages, a World War II campaign against VD continued to focus on women as the source of disease with pamphlets and posters entitled "She Looked Clean But…." In campaign posters, VD was often depicted as a woman, and "loose" women were characterized as a threat to soldiers.1 These campaigns also spread a message of moral judgment against those who contracted VD. In an effort to escape detection, many individuals did not seek medical care, often turning to home remedies. The powerful stigma associated with VD was reinforced through mass media efforts, further limiting both the public's and medical profession's ability to effectively respond to the disease.1 Prevention Messages Messages for prevention of STDs include the following: Encourage individuals to use latex condoms consistently and correctly every time they have sex. Encourage individuals to practice other safer sex behaviors, e.g., forms of non-penetrative sex. Encourage individuals to abstain from or delay sexual intercourse. Encourage people to reduce their number of sexual partners. Early detection and treatment efforts can be strengthened by communications that accomplish the following: Increase awareness of types and prevalence of STDs. Help individuals recognize signs and symptoms. Encourage individuals to seek without delay medical care from a biomedical provider especially if signs or symptoms are present. These detection and treatment efforts can be further improved by messages that: Reinforce prevention behaviors among people already infected with STDs. Encourage people infected with a sexually acquired infection to notify their partners and refer them for treatment. Communication and Behavior Change Theory Developing communication programs is both an art and a science. To help ensure that communication efforts are effective, programs should be based upon behavior change theory, sound public health practice and well-designed audience research combined with creative communication strategies. Too often, program planners develop communication strategies based on personal or untested assumptions about what leads to behavior change, and not upon clearly articulated theories of behavior change and communication. Planners often assume that providing factual disease information alone will lead individuals to change behavior. Others discard this assumption, but replace it with an equally untested belief that communicating about potential health benefits will bring about behavior change. In most cases, messages based on either assumption will not result in the desired behavior change, although both approaches may be useful in increasing a target population's knowledge. Behavioral scientists often refer to the disparity between knowledge gained and behavior changed as the "knowledge-behavior gap." Several behavior change theories and communication hypotheses have been developed to explain and bridge the gap. Although consensus has not been reached on adopting a single approach, several theories have proved useful in explaining the factors that influence behavior. These determinants of behavior, including attitudes and beliefs, social norms, religious values and socioeconomic status, often vary from culture to culture. It is important to identify determinants of behavior based on the cultures of each country and the targeted communities within a country. An overview of a model for behavior change and a model for developing effective communication is presented in the next two sections. The Aids Risk Reduction Model The AIDS Risk Reduction Model, which was developed to provide a framework for changing behavior known to increase the risk of contracting HIV infection, is also directly applicable to risky behavior that can lead to STD transmission.2 This model is based on the premise that to avoid disease, individuals must perceive that their sexual behavior places them at risk for HIV infection (labeling); make a commitment to behavioral change (commitment); and take action to change (enactment). Labeling is influenced by perceived susceptibility, knowledge of HIV transmission and perceived norms regarding sexual behavior. Commitment is influenced by the perceived costs and benefits of high-risk versus low-risk behavior. Enactment is influenced by social support, skills in developing health behaviors and perceived norms. Stages of Change Model Prochaska suggests that sustained behavior change occurs after an individual has moved through the stages described in Box 1.3 While these stages may not accurately describe the behavior change process in all situations or different cultures, they do suggest a strategic framework for developing communication programs. These stages suggest that information dissemination alone does not constitute an effective prevention program. Enhanced awareness and knowledge of health risks are important preconditions for change; however, knowledge in and of itself has never proved the chief motivator for change. The model also demonstrates that a program that starts with skills (e.g., how to use a condom) before individuals accept that they may be at risk is also likely to fail. In summary, in order for their behavior to change, individuals must perceive the following: They are at personal risk Changing their behavior will result in benefits that are relevant to them social norms will support their actions at each stage of behavioral change they have the skills and resources needed to make the changes Contemporary Marketing Principles A behavior change communication program should also draw upon contemporary marketing principles. The most consistently effective of these is targeting campaigns to carefully selected segments of a larger audience. Audience segmentation is based on selected variables such as demographics (e.g., age and gender), health status (STD- or HIV-positive), geographic dispersion and values. Targeting allows planners to select appropriate messages, message sources and channels for each audience segment. Social marketing, defined as the integration of communication and marketing techniques to change behavior, provides a sound framework for creating effective communication programs. The following outlines social marketing principles: Segmenting the target audience by variables including age, sex, socioeconomic levels, psychographics (i.e., attitudes, values, outlook) Audience research to assess attitudes, perceptions, knowledge and behavior Concept development and pretesting to ensure that communication strategies and materials are effective and relevant Messages targeting various segments of the audience, because one message rarely moves everyone Communication that offers benefits meaningful to the audience Accessibility to needed products and services (e.g., latex condoms, STD diagnosis and treatment) through local commercial and non-commercial outlets The close relationship between social marketing and efforts to sell commercial products is intentional. According to a leading expert, "the more a social change campaign resembles a commercial product campaign, the more successful it is likely to be."4 The key is to determine the needs and desires of the audience, then deliver message and products that offer real benefits. Many social change campaigns fail because the message is not meaningful or relevant and consequently not motivating to members of the target audience. The following section outlines a framework for developing effective strategies in order to reach people with messages about STDs. It is based on the contributions from many disciplines including social marketing, mass communication, health education and the social sciences. Strategies for Reaching People With Messages About STDs In order to reach people with messages about STD prevention, a communication plan should be developed that includes the following action-based steps:5 Defining the problem (situation analysis) Setting the objectives Identifying the target audience Developing key messages Selecting channels of communication Pretesting messages/materials Producing and disseminating Implementing the program Evaluating the results Receiving feedback to improve communication These steps are described in greater detail below. 1. Defining the Problem (Situation Analysis) An assessment of the available data on the prevalence, type and rate of transmission of STDs is instrumental to understanding the problem and what needs to be done about it. Information about social, cultural, economic and political factors is also important in understanding the environment that provides the context for behavior change. Organizations and individuals who control locally available resources and services need to be identified because they could have influence over the availability of products and services related to STD prevention and control. Their decisions and actions could determine whether: adequate quantities of drugs, condoms and other supplies are available; antibiotics can be purchased over the counter for STD treatment; educational materials are available in local languages to facilitate comprehension; STD prevention and condom promotion messages can be advertised through print and broadcast media; and, staff are trained to provide patient education and counseling. Information should also be collected on the sexual practices and norms of the population to identify specific attitudes or behaviors that may help or hinder behavior change. For example, data could be collected on the prevalence of condom use versus the number of unprotected sexual exposures, and the types of sexual behaviors that might promote the spread of STD. This information might be available from the results of an overall program assessment or from anthropological studies conducted in the area. If not, it could be collected through focus group discussions, in-depth interviews, KABP (knowledge, attitudes, beliefs and practices) surveys or mini-surveys. Other key questions to consider include the following: Which community is most affected by this problem? What programs and services are currently addressing the problem and how effectively? What other external factors (e.g., religious) may affect how the problem will need to be addressed? 2. Setting the Objectives The objectives of an STD communication strategy should be clear, time-specific, measurable and attainable. They should contribute to the overall program goals and be achievable with in-country resources (identified in the situation analysis). First, the desired change or changes must be identified: A change in knowledge, behavior or attitude? A change in the level of knowledge about STD transmission, prevention or treatment? Increase in the number of trained STD counselors or workers skilled in providing health education to clients? Increased condom access and use? Fewer repeat STD cases? Improved STD referrals and partner notification? The following are examples of objectives: After a discussion with an STD counselor, 80 percent of clinic attendees can demonstrate comprehension of STD treatment messages by explaining correctly in their own words (a) why it is important to take a full course of treatment, and (b) why partner treatment is necessary. STD messages will be illustrated in seven newly designed and pretested posters in six appropriate languages and distributed to all health posts and private clinics in the country by April. 3. Identifying the Target Audience Target audiences are groups of people who have common characteristics related to disease transmission and control. The purpose of segmenting a large, general audience into smaller, more focused target groups is to develop specific messages that are relevant to the needs of each particular group.6 Targeted primary audiences may include groups such as adolescents, commercial sex workers (CSWs), military personnel, factory workers, transport workers and drug users. Other groups commonly targeted for STD and HIV/AIDS prevention programs are health care workers and teachers who can be intermediaries to primary audiences. Group characteristics tend to be identified by the following: High-risk behaviors, such as those of people with multiple sex partners, men who have sex with men, people who engage in commercial sex activities or who share drug-using paraphernalia Demographic factors such as age, sex, occupation, location, level of education and income Psychographics (attitudes, values, outlook) Ethnicity, language and sexual orientation Organizational or institutional structures, such as health care facilities, factories, churches, cooperatives, school systems, prisons and the military 4. Developing Key Messages Below are examples of questions that program planners can ask in order to learn more about the members of a particular target audience. The answers to these questions will help planners design more relevant, applicable and effective STD prevention messages and dissemination strategies for influencing this group. What do members of this target audience know about STDs? What are their concerns about STDs? What behaviors put them at risk for STDs? What do they do to avoid infection from STDs? Do language, literacy and/or cultural barriers exist that need to be overcome? What are some of their common attitudes about how STDs are acquired? What are the special needs of this group? Who are the leaders or who has influence in this group? In addition to quantitative research (surveys), qualitative research (focus groups and interviews) can help answer key questions about a target group. Focus groups and interviews are effective methods for developing appropriate messages and for pre-testing program materials. Led by trained moderators, about six to ten people, who are typical of the target audience, have structured discussions. Moderators use a set of open-ended questions to promote discussion about the subject matter as well as participants' thoughts, feelings, values and beliefs. A variety of possible messages are identified from these discussions, and three to five of the most important messages are selected for emphasis. Presenting a few key messages at a time gives audience members a sense of confidence as they learn new things. The messages chosen should help target audiences understand the group-specific benefits of following health-promoting recommendations. For example, the advantages of using a condom might be valuable to a group of commercial sex workers (CSWs) for different reasons than for a group of adolescents. Focus group studies have shown that CSWs are more interested in condoms because it reduces their contact with seminal fluid and the need for frequent washing and douching. On the other hand, school age adolescents fear pregnancy and, outside of abstinence, see condoms as a way of ensuring that they will be able to complete their studies. A thorough understanding of audience attitudes and beliefs and careful pre-testing are essential to ensuring that messages are effective. For example, in some cultures acquiring gonorrhea is a sign that a young boy has become a man. Messages to increase condom use in such cultures might be more effective if, rather than emphasizing the fact that condoms can prevent gonorrhea, they emphasize other benefits. These might include protection against STDs that can cause infertility, produce unhealthy babies or require costly diagnosis and treatment. Careful attention should be paid to message development to ensure that messages are not misinterpreted or lead to unintended results. In some situations, efforts to reduce STDs with messages discouraging vaginal intercourse have resulted in increases in anal infections among young girls. This illustrates the importance of research and an understanding of the attitudes, knowledge and practices of the target group for the purpose of designing messages that lead to beneficial outcomes. 5. Selecting Channels of Communication The choice of communication channels will depend on many factors, including the program objectives and the target audience's access to and preference for a particular channel. For example, the mass media are very effective in promoting a general understanding of a problem or issue, whereas interpersonal channels are effective in changing specific and individual attitudes and behavior. Mass media can be used to broaden the reach and impact of STD prevention and control. Clinic-based interpersonal interventions can be used to counsel patients about behaviors that cause STDs, promote the use of latex condoms and other safer sex practices, identify the symptoms of STDs and provide available treatments. The following are information channels that are suitable for delivering STD messages: Mass media including television, radio, films, videotapes, drama, music, billboards, music, newspapers and magazines. Within these formats, messages can be embedded in the story lines of radio, TV, film, music and dramas; or STD awareness can be raised through news coverage or through clinic advertisements in a newspaper, etc. Small media including pamphlets, posters, flip charts, displays, models, T-shirts, matchbooks, hats, stickers, booklets and audiocassettes. Some of these channels are used to provide information (e.g., pamphlets, booklets); and others are used to remind people of earlier learning and previous decisions (e.g., T-shirts, stickers). They are complementary sources of information that help keep the STD issue on both private and public agendas. Institutional and interpersonal networks including schools, factories, youth clubs, women's groups, unions, professional associations, religious organizations, social groups, families, etc. Information disseminated through these groups by peer educators or by visiting "experts" can be very influential in supporting people to make risk behavior changes. Health service delivery systems including patient education programs in clinics; public health nurses; HIV counseling and testing centers; and condom distribution centers. In addition, in some cases pharmacies can be effective channels through which to deliver STD prevention messages. Peer education is an approach that can be considered a channel or an intervention. Messages disseminated among peers often have more credibility, immediacy and impact than more formal and distant channels. Peer educators have worked successfully among truck drivers, adolescents, CSWs, men who have sex with men, athletes, university students, health workers, teachers, military recruits and informal groups such as clinic attenders, taxi passengers and bar patrons. Program planners should use several channels to reinforce STD prevention messages. To illustrate, a person reads an article about the consequences of STDs in the newspaper. Then he hears a radio advertisement about STD diagnosis and treatment, discusses it with a friend and calls a telephone hotline to find out more. Next, the individual goes to a clinic, picks up an informational leaflet in the waiting room and talks to a counselor before deciding to get tested. In this illustration, the comprehensive communication campaign focused on a variety of channels including newspapers, radio, peers, a hotline, leaflets and counseling. For a real impact on knowledge, attitudes and behaviors, multiple exposures to prevention messages are needed. Another example further illustrates this concept. A video dealing with sexuality could be viewed by a group of young people. Then, there could be a group discussion about key issues raised by the program, followed by role-playing exercises. Similarly, a radio talk show could be designed to stimulate interaction with the audience by encouraging listeners to telephone the radio station and ask questions. As media formats continue to evolve, there are an increasing number of opportunities to include media with interpersonal communications. Approaches that involve peer-based community education, reinforced by media and institutional interventions, are especially effective in changing attitudes and social norms and in teaching new behaviors. Decisions about which channels of communication to "mix and match" should be based on their ability to inform, motivate and support the target audience's change toward STD preventive behavior. 6. Pre-testing Messages/Materials It is important to give members of the target audience an opportunity to respond to message concepts, materials and delivery formats before they are finalized. This helps to ensure that the proposed channels are appropriate and that the messages are understandable to those they are intended to reach. Pre-testing and resulting adaptations may need to be done several times before the materials are truly effective. The content and delivery of messages can be pretested through individual interviews or focus groups. The person conducting the interview or focus group should ask "open-ended" questions that probe for more information, and should avoid leading questions that might influence participants' responses. Examples of pre-test questions: What is this message telling you? Is this important to you? Why or why not? Who do you think should hear these messages? Where, how? What do you like/dislike about the messages/materials? While one person conducts the focus group or interview, an observer should record what people say and how they react. These notes will be useful during an analysis of the results. In pre-testing, it is important to get responses to content and presentation, including the format, color(s), style and other design elements of materials or other media. The text and images used in print materials should be pre-tested separately to identify any problems specific to either component. The results of this participant pretesting should provide the basis for any changes in messages, materials and/or delivery methods. Although one or two comments may not reflect the thoughts or feelings of an entire target audience, messages and materials should be revised and tested again if a considerable number of pre-test participants find them incomprehensible, irrelevant or unacceptable. 7. Producing and Disseminating Now that you know what you want to say and how it should be said, you are ready for production. Regardless of whether you decide to record a song for play on the radio, print a brochure or organize a theater troupe to travel across the country, you must invest in the actual "production" of the product to be distributed. Depending on the product, persons skilled in producing it (writers, artists, singers, actors, printers, advertisers, etc.) will need to be hired and arrangements made to use their services. You will need to know if there is a fee for these services. When the final product is ready, you must market and distribute it. Too often, well-designed and pretested messages and materials are not effectively disseminated to the target audience. What are the best locations for placing messages/materials in order to reach the target audience? Select the ones where audience members gather. For example, this may include bars, stores, markets, places of worship, clinics, worksites, etc. Find out whose permission is needed to gain access to these places and approach them by telephone or letter. Distribution should be coordinated with the assistance of community leaders and other influential individuals and groups. Because this facet of the communication process requires the cooperation or participation of many people, it is essential to involve them throughout the process of developing the communication strategy. It is important to build these partnerships from the very beginning of the communication plan. In addition to extending the reach and credibility of the program, it will increase the likelihood that the community leaders will be supportive during the critical distribution phase. If you have made a careful assessment of your resources during the first step of this process (see "Defining the Problem (Situation Analysis)"), you will be prepared to successfully carry out the distribution of the materials. Consider contacting private and non-governmental organizations that work with the same target audience, as well as religious institutions, social/cultural groups, professional organizations, labor unions, schools, universities, newspapers, television and radio stations. Ask yourself if any of these groups/individuals need special training to use the materials. Attention to this detail at this stage may prevent costly and valuable materials, guidebooks, videos, etc., from being stored on the shelf or in a warehouse and not properly used. 8. Implementing the Program A multi-dimensional, comprehensive STD prevention campaign will have a more powerful and long-lasting impact than a single exposure, one-dimensional approach. A well-planned communication strategy will schedule complementary and mutually reinforcing activities at appropriate intervals. To increase the program's effectiveness, when creating an overall strategy it's useful to include other program components such as one-on-one counseling, partner notification and provide training events. Make sure that the communication campaign is carefully coordinated with the rest of the program. If the campaign is promoting something that can't be delivered, this could have a negative effect on the STD prevention goals. For example, a communication campaign designed to increase the number of STD clients would need to be matched by the clinic's ability to handle an increased client load. Are staff members trained and available in sufficient numbers to provide services? Are there sufficient supplies (condoms, etc.) to meet the new demand? It is important to capitalize on opportunities provided by different parts of the STD prevention program. Publicizing a training event, for example, could offer an opportunity for print, radio and television media coverage, including interviews with prominent participants. This, in turn, becomes an opportunity to inform audiences about the STD program. To take full advantage of this event, a campaign to increase awareness about the importance of partner notification or to introduce new STD treatments could be launched at the same time. 9. Evaluating the Results Evaluation is frequently cited at the end of the communication process, but it should be built into the communication program as it is being designed. Based on key questions, evaluation helps determine whether and how well the project is achieving its goals and objectives. Has the campaign resulted in people changing their attitudes, behaviors and practices? In assessing the effectiveness of a communication campaign, there are three basic types of evaluation: process, outcome and impact. Each of these has its own set of questions. Process examines the steps involved in implementing the program (e.g., the number of people who were reached). The following are possible indicators: Print coverage and estimated readership Number of educational materials distributed Number of speeches/presentations and audience sizes Number of other organizational and professional contacts Outcome describes the immediate effects of the program (e.g., who responded to the STD prevention campaign). Consider the following: Knowledge gained and attitudes changed. Short-term behavior shifts Policy or other institutional changes Impact, the most comprehensive, focuses on the long-range effects of the program (e.g., whether STD incidence was reduced as a result of the program). Consider the following: Changes in morbidity and mortality Long-term maintenance of desired behavior Rates of recidivism 10. Receiving Feedback to Improve Communication The answers to the questions in the previous section will help identify the project's strengths and weaknesses. As shown in the examples below, "mid-course corrections" can be made to improve the activities and increase the likelihood of their success. Any changes should be communicated to the audience. If staff members report that no one is using the clinic, the facility may have to change its hours to accommodate the needs of its key audiences. Audience members should be made aware of the new schedule. If people are not taking the educational materials provided, the distribution methods should be assessed. Are they left in conspicuous places? Are they available where the key audiences congregate? Should they be distributed personally by the health care providers or by peers? Are people too embarrassed to be seen with them? Would a new design be more appealing or attractive? If clients are not coming back for follow-up visits, do the health care providers need more training in counseling, patient education or interpersonal skills? If nurses are too busy for one-on-one counseling, can group counseling be implemented; are peer counseling sessions a reasonable alternative? Answering such questions early in the project will lead to refinement of the communication strategies and increase the effectiveness of the overall program. Conclusion If properly planned and implemented, communication programs both within and outside of the clinic setting can make an important contribution to STD prevention and control activities. In the past several decades, strategies were based on personal beliefs or moral judgments. More recently, however, strategies have been developed within thoughtful frameworks containing key communication elements that will lead to more successful results. It is important to keep the following in mind: Effective communication campaigns are based on audience research combined with creative approaches to reaching those audiences. Behavior change models such as the AIDS Risk Reduction Model provide a consistent point of view for communication aimed at changing behavior that contributes to STD transmission. Messages can be delivered through a variety of communication channels, but the available channels must be carefully analyzed during the planning stages to determine which will be most effective in reaching target audiences. Social marketing techniques can be used to "sell" the idea of behavior change for prevention and/or treatment of STDs. Communication campaigns for STD control and prevention need not rely on expensive materials or the latest in technological innovations to be successful. There are many options available to produce the desired goal of changing behavior. Above all, the complex tasks of addressing an issue as sensitive as STDs and promoting changes in behaviors that are often deeply ingrained and personal must be approached with a comprehensive, systematic plan that maximizes impact. References Brandt A. No magic bullet: a social history of venereal disease in the United States since 1880. New York: Oxford University Press, 1985. Catania J, Coates T, et al. Predicting risk behavior with the AIDS risk reduction model in a random household probability sample of San Franciscans: the AMEN Study. In: Abstract book from the sixth international conference on AIDS. San Francisco, California: Abstract ThD 768; 1990. Prochaska J, et al. In search of how people change: applications to addictive behaviors. American Psychologist 1992; 47(9):1102—1114. Kotler P. Social marketing: changing public behavior by persuasion. New York: Free Press, 1989. Health communication takes on new dimension at CDC. Public Health Reports 1993; 108(2). Family Health International. Planning and pre-testing: The key to effective AIDS education materials. Network 1991;12(1). Suggested Readings Manoff R. Social marketing: new imperative for public health. Praeger Publications, 1995. Baeker T, et al. Designing health communication campaigns: what works? Sage Publications, 1992. Rice RE, Atkin C, eds. Public communication campaigns. 2nd ed. Newbury Park, California: Sage Publications, 1989. The impact of media campaigns on health behavior. Johns Hopkins University, 1992. Stop AIDS Campaign. Swiss Public Health Department, 1992. Green EC. AIDS and STDs in Africa: bridging the gap between traditional healing and modern medicine. Westview Press, 1994. Edgar, T, et al. AIDS: a communication perspective. Lawrence Erlbaum Associates Publishers, 1992. Graeff J, et al. Communication for health and behavior change. A developing country perspective. Academy for Educational Development, Inc. Jossey-Bass Publishers, 1993. Developing health and family planning print materials for low-literate audiences: a guide. Washington, DC: Program for Appropriate Technology in Health, 1989. Making health communication programs work: a planner's guide. U. S. Department of Health and Human Services, NIH publication no 92-1493, April 1992.