The Journal of Primary Prevention, Vol. 17, No. 2, 1996

HIV-AIDS Prevention Videotapes: A Review of Empirical Findings Seth C. Kalichman 1,2

The spread of the human immunodeficiency virus (HIIO epidemic demands that prevention reach large populations in short periods of time, goals that may be facilitated by videotape interventions. This paper reviews empirical studies that have tested the effects of HIV education and prevention videotapes. Although most videotapes are not based on psychological theories and most studies have suffered methodological limitations, research has shown that educational videotapes increase knowledge about HIV-AIDS and change attitudes related to HIV risk behavior. In general, videotapes have shown promising results at increasing readiness to change but have not demonstrated significant effects on HIV risk behavior. However, few videotape interventions have explicitly targeted risk reduction behaviors. In light of the empirical findings, a model is proposed for developing HIV prevention videotapes based on HIV risk behavior change theories. KEY WORDS: AIDS Risk; AIDS Prevention; videotape prevention.

Human immunodeficiency virus (HIV) infection prevention programs are designed to increase knowledge about HIV and AIDS, enhance personal risk sensitization, and influence risk behavior change. The rapid expansion of the HIV epidemic demands that effective prevention programs be quickly disseminated to community settings. Videotapes can play a key role in these efforts because video messages offer a means of distributing prevention to mass populations (Coates, 1990). Videotape technology is relatively inexpensive, serves as a nearly universal educational medium, is tPsychology Department, Georgia State University, Atlanta, Georgia. ZCorrespondence should be addressed to Seth C. Kalichman, Psychology Department, Georgia State University, University Plaza, Atlanta, GA 30303. 259 © 1996HumanSciences Press, Inc.

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capable of motivating precautionary actions, and ensures that correct and complete messages are uniformly received by target audiences. Videotapes have been used effectively with diverse health problems, such as diabetes (Brown, Duchin, & Villagomez, 1992), nicotine chewing gum for smoking cessation (Sutton & HaUett, 1988), smoking prevention (Telch, Miller, Killen, Cooke, & MacCoby, 1990), anticoagulant therapy (Stone, Holden, Knapie, & Ansell, 1989), sexually transmitted disease (STD) prevention (Healton & Messeri, 1993; Solomon & DeJong, 1986), and STD treatment adherence (Solomon, DeJong, & Jodie, 1988). Videotape-based HIV education and prevention efforts have become commonplace. Herek (1991) reviewed 34 AIDS education videotapes available through commercial and public information sources. Likewise, the National AIDS Clearinghouse lists dozens of videotapes that provide information about HIV and AIDS for use with a wide range of audiences. Recognizing the value of videotape as an effective intervention strategy, preventionists have included videotapes in the development of HIV prevention programs. Studies have been conducted to evaluate the effects of videotapes on prevention-related outcomes. The purpose of the present paper is to review the empirical investigations of videotape-based HIV-AIDS education and prevention interventions. Effects of videotapes on attitudes and behaviors of relevance to HIV risk and behavior change are highlighted. HIV prevention outcome variables typically consist of HIV-AIDS-related knowledge, HIV-AIDS attitudes and beliefs, and behavioral changes. These three outcomes are central elements of all current HIV-risk predictive models, including the Health Belief Model (Rosenstock, Strecher, & Becker, 1994), Theory of Reasoned Action (Terry, Gallois, & McCamish, 1993), the AIDS Risk Reduction Model (Catania, Kegeles, & Coates, 1990), the Information-Motivation-Behavior model (Fisher & Fisher, 1992), and the Stages of Change Model (Prochaska, Redding, Harlow, Rossi, & Velicer, 1994), all of which have been adopted by HIV prevention interventions. Following a brief overview of methodological issues in this literature, videotape research findings are reviewed, followed by suggested strategies for developing HIV prevention interventions that incorporate videotapes that target HIV risk behavior.

METHODOLOGICAL ISSUES HIV prevention interventions often include videotapes to deliver standardized educational information. Videotapes are usually a small fraction of a larger intervention and typically do not allow for an independent test of videotape effects. For example, Kalichman, Sikkema, Kelly, and

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Bulto (1995) showed a 15 minute segment of the videotape AIDS: What Everyone Needs to Know (Engle, 1990) as a part of a six hour prevention intervention for chronic mentally ill adults. Similarly, Wenger, Greenberg, Hilbourne, Kusseling, Mangotich, and Shapiro (1992) included an ll-minute segment of the videotape Sex, Drugs, and AIDS (Select Media, 1986) as part of a one hour AIDS education program, where half of the study participants also received HIV antibody testing. Wenger, Linn, Epstein, and Shapiro (1991) also showed Sex, Drugs, and AIDS to participants in a study testing the effects of HIV antibody testing on subsequent sexual risk behavior. Allen, Serufilira, Gruber et al. (1993), Allen, Serufilira, Bogaerts et al. (1992), and Allen, Tice et al. (1992) presented a 35-minute native language videotape to women in Rwanda Africa as part of an evaluation of HIV antibody testing. Again, these studies did not test videotape effects independant of other aspects of their respective interventions. Because my focus in this paper is on the effects of videotapes as interventions, studies that did not independently evaluate videotapes, such as those noted above, are not included in this review. The literature search for our review identified 12 studies that reported direct examinations of videotape interventions on I/IV-related outcome variables (see Table 1). We searched three computerized abstracting services (Psych-info, Med-line, and AIDS-line) crossing the key terms HIV, AIDS, video, and videotape. For all identified studies, requests were sent to authors for reprints and pre-prints of their videotape research, and information regarding the availability of the videotapes they used. Examination of these studies indicated four methodological issues: the role of theory in developing videotapes and formulating research questions; matching videotapes to target audiences; confounding experimental conditions; and matching videotape components to outcome evaluations. Theoretical Formulations

It is widely accepted that videotape interventions for HIV-AIDS prevention are most effective when based on models of HIV risk behavior change (Maibach & Cotton, in press; Winett, Altman, & King, 1990). However, because HIV-AIDS education videotapes were developed in response to an urgent educational need, they have tended to ignore theoretical principles of behavior change. Commercially produced videotapes are often used in studies that test the effects of prevention messages. However, four studies have tested HIV prevention videotapes developed on the basis of theoretical principles. Three of the four theory-based videotapes were derived from Bandura's (1986, 1989, 1994) social cognitive theory (Maibach

119 AfricanAmerican adolescents, Philadelphia

106 AfricanAmerican women in housing projects, Chicago

214 women health clinic patients, Worchester, MA

Stevenson, G a y & Josar, 1995

Kal~hman et al., 1993

Quirk et al., 1993

Sample

52 male, 59 female AfricanAmerican adolescents, Philadelphia

Authors

No formal theory

No formal theory

No formal theory

No formal theory

No formal theory

Theory

Locally produced rap videotape targeted to minority youth, peeradministered tape and reviewed brochures

Tape tailored for target audience compared to a sexethnicity matched nonculturally tailored tape and a standard condition (AIDS: What you need to know)

Experimental tape produced for target audience matched for language and culture

Video selected on basis of similarity (Don't forget about Sherrie) and dissimilarity to target population

Three tapes (Sex. drugs, and AIDS; AIDS: Beyond fear," AIDS: What you need to know) compared to a sex education tape (Where did I come from)

Videotape Conditions

Tape compared to information delivered by health professional

Content controlled by script tailoring, included 2 control groups to test effects of tailoring

Content matched on basis of script with all other features manipulated

Edited overlapping content on basis of raters; no controls for presenter or production variables

Random assignment to view one tape; no controls for content or other variables

Experimental Control Central Findings

Few differences between groups over time. Videotape affected knowledge about injection drug prevention but knowledge of sexual risk prevention was affected less than in the comparison group

All 3 tapes increased knowledge and changed attitudes; ethnicity matched conditions increased behaviors related to risk reduction at 2-weeks followup, cultural context tape increased HIV testing

Culturally tailored tape was more effective with adolescents who believed they knew a lot about AIDS relative to control group

Modest effects of both tapes on knowledge and beliefs with only slight differences between the two videotapes

All 3 tapes increased knowledge and attitudes relative to control tape but no differences between AIDS tapes

Table 1. Description of Videotape-Based H1V-AIDS Education and Prevention Studies

Stevenson&Davis, 1994

,

72 male and 72 females undergraduates, Oklahoma

,,,,

Lipson & Brown, 1991

....

gl" $ ga

No formal theory

No formal theory Social cognitive theory

103 STD clinic patients, Boston

182 STD clinic patients, Boston

138 ethnically diverse women, 3 California communities

11 single parent families; 35 2parent families with young adolescents, Roanoke, VA

Solomon & DeJong, 1989 Study 1

Ibid., Study 2

Maibach & Flora, 1993

Winett et al., 1992 Social cognitive theory

No formal theory

243 women health clinic patients, Augusta, GA

Ashworth et al., 1994

4 videotapes produced for use with target population based on formative research

Selected material edited from commercial tapes integrated with study produced segments

Same as study 1

(Lets Do Something Different)

Selected videotape based on content and apparent cultural appropriateness

(The Subject is AIDS)

Selected videotape based on apparent cultural content

Delayed intervetion condition served as a control until 6-months follow-up

Need to Know

3 experimentally controlled tapes: Information + modeling; time matched information + modeling + cognitive rehearsal; AIDS: What you

Same as study 1

Compared videotape to no intervention control group

Compared 3 different delivery systems without control for content: Videotape, face-to-face counselor, & pamphlets

Videotape intervention showed substantial efffects on teen & parent knowledge and teen problem solving skills; effects maintained at 6month follow-up and replicated by delayed intervention

Increased self-efficacy beliefs to change behavior, increased acquisition of condoms, & frequency of discussing AIDS with friends resulted from condition with cognitive rehearsal

Videotape resulted in greater rates of coupon redemption for free condoms

Videotape increased knowledge, positive condom attitudes, and ability to generate strategies for prevention compared to the control group

Videotape and counselor increased knowledge and intentions to change behavior but most effects were not maintained at follow-up ga,

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12 single parent families; 57 2parent families with young adolescents, Roanoke, VA

100 AfricanAmerican women clinic patients, Milwaukee

1,653 AfricanAmerican and Hispanic men & women, New York City

Kalichman & Coley, 1995

O'Donnell et al., 1995

Sample

Winett et al., 1993

Authors

No formal theory

Cognitive decision theory-Prospect theory

Social cognitive theory

Theory

Let's do something different; Videotape tailored for Hispanics, Porque Si

Random assignment to control group, or videotape, or videotape + discussion

Show?

Take It? What Does It

Experimental manipulation of theoretical principles in a tailored videotape; a scxethnicity control condition, & The H/V Test: Who Should

Content areas the same across 2 conditions with skills training manipulated; duration differences were not controlled

2 skills tapes produced for use with target population based on formative research; 2 education tapes

Loss-frame HIV testing tape; Gender-ethnicity matched tape; ethnicity matched tape

Experimental Control

Videotape Conditions

Table 1. Continued

Videotape increased knowledge, positive condom attitudes, and risk sensitization; additional increased sensitization when videotape was followed by group discussion

Matching tape presenters to target population characteristics increases intention to get tested and a loss-frame further increases probability of getting tested

Skills training condition increased skills knowledge and performance relative to control condition

Central Findings

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& Flora, 1993; Winett et al., 1992, 1993), and one study tested an HIV antibody testing promotion videotape based on Kahneman and Tversky's (1972, 1979) Prospect Theory (Kalichman & Coley, 1995). Thus, most tests of HIV-AIDS prevention videotapes have not been grounded in conceptual models of behavior change and have not tested basic theoretical principles. The lack of theory in this area hinders interpretation and synthesis of research findings. Reliance on atheoretical research has also inhibited the ability to build upon earlier research. Videotape interventions have not been linked to outcomes by theoretical principles and have not tested theory-based hypotheses. In contrast to theoretically-based face-to-face HIV prevention interventions (Kalichman, Carey, & Johnson, in press), videotape prevention appears ineffective and has called into question the value of mass media interventions.

Tailoring Videotapes Despite the need to tailor interventions to populations (Fisher & Fisher, 1992), most HIV-AIDS education and prevention videotapes have not embedded the culture of targeted groups. Researchers usually select commercially produced videotapes with some consideration of the relative appropriateness for use with a given population. However, characteristics of samples are frequently not reflected in the videotapes selected. For example, Ashworth et al. (1994) sampled African-American women (95% of the sample) while the videotape they used, The Subject is AIDS (Select Media, 1987), displayed 33% male presenter time and 60% non-AfricanAmerican (Herek, 1991). Similarly, Quirk, Godkin, and Schwenzfeier (1993) targeted ethnically diverse women and used a videotape that was predominantly male. Interventions that tailor videotape content and context to the gender, culture, and developmental characteristics of target populations have usually done so for the explicit purpose of testing the effects of manipulated elements (Kalichman et al., 1993; Stevenson & Davis, 1994; Stevenson, Gay, & Josar, 1995). These studies have produced their own experimental videotapes after gathering information about target populations through formative research. O'Donnell, Doval, Vornfett, and DeJong (1994) discussed procedures for producing tailored HIV prevention videotapes and methods for developing videotapes that closely approximate the characteristics of target populations. Over a five month period, O'Donnell et al. conducted 27 focus groups and interviews, collected surveys, and performed naturalistic observations with Hispanic men and women attending STD clinics in New York City. A body of rich information resulted and was sub-

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sequently incorporated into HIV-AIDS education videotape production. Because the tape targets Hispanic men and women in New York City it accurately takes into account the knowledge level, attitudes, and cultural context of that group. The tailored videotape was subsequently evaluated in an experimental field trial (O'Donnell, Doval, Duran, & O'Donnell, 1995). Although heralded as the type of work needed to develop maximally effective prevention videotapes, such extensive formative research is rarely used in HIV prevention studies and has not been incorporated in the majority of videotape intervention research.

Confounding Experimental Conditions Research to test the effects of HIV prevention videotapes has been characterized by three general study designs: (a) videotapes compared to other videotapes; (b) videotapes compared to non-videotape information delivery systems such as counseling; and (c) videos compared to no intervention control conditions. Studies that compare two or more commercially produced videotapes are confounded on multiple levels because numerous variables do not remain constant across videotape conditions. For example, Lipson and Brown (1991) and Stevenson and Davis (1994) compared videotapes that varied along several dimensions including duration of presentation, information content, date of production, presentation themes, presenter characteristics, use of graphics, and so on. Investigations that compare videotapes to other information delivery modalities, such as audiotapes or reading materials, have also been confounded. For example, in one study, Ashworth et al. (1994) compared three information conditions: (a) a commercially produced videotape, (b) a single counseling session, and (c) reading information pamphlets. Unfortunately, information content, context, and presenter characteristics were not controlled. Similar problems are found in other studies directly comparing videotapes with face-to-face counseling (e.g., Quirk et al., 1993). Experimental tests of manipulated videotape components have also compared multiple videotapes. For example, Katichman et al. (1993) and Stevenson et al. (1995) manipulated cultural context variables within a series of videotapes targeted to a specific population. In both studies, independant variables were manipulated within videotapes. Controls were included for presenter characteristics, tape duration, and other possible confounds. However, even these experiments were confounded by a number of factors including presentation and videotape production quality.

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Studies that compare videotapes to nothing (no intervention control groups) test intervention effects of videotapes but fail to provide information regarding mechanisms or explanatory principles. No treatment or delayed treatment control groups do, however, test videotape effects without the confounds noted above. Solomon and DeJong (1989) and Winett et al. (1992) provide examples of no intervention and delayed intervention control conditions, respectively. These studies show that videotapes do influence certain outcomes relevant to HIV prevention. Studies that test theoretically derived hypotheses have offered the greatest degree of experimental control. Kalichman and Coley (1995) and Winett et al. (1993) used experimentally controlled videotapes that kept most variables extraneous to theoretical manipulations constant across conditions. Maibach and Flora (1993) also carefully controlled all aspects of their experimental conditions, only altering a cognitive rehearsal component. However, Maibach and Flora's information control videotape differed in multiple ways from the other two conditions and suffered from confounds in content and context. Outcome Measures

Videotape interventions typically report measures of HIV-AIDS related knowledge and attitudes, and to a lesser extent behavior change. Measures of knowledge and attitudes vary across studies with respect to number of items, response formats, and item content. For example, some knowledge tests require true-false responses (e.g., Kalichman et al., 1993; Stevenson & Davis, 1994) while others use multiple choice formats (e.g., Winett et al., 1993). Some studies report total knowledge summary scores (e.g., Stevenson & Davis, 1994), and others report sub-scale scores such as disease-related knowledge, testing knowledge, and prevention knowledge (Kalichman & Coley, 1995). These measurement differences create problems when comparing and synthesizing study results. Although some measures have shown acceptable internal consistency, reliability coefficients are invariably derived from videotape study samples themselves without external confirmation (Ashworth et al., 1994; Solomon & DeLong, 1989; Stevenson & Davis, 1994). Furthermore, outcome measures are usually not directly linked to videotape intervention components. One exception to the problem of disjoint videotapes and measures is offered by Solomon and DeJong (1989) in a study that derived AIDS-related knowledge test items directly from tape content. Winett et al. (1992, 1993) also linked assessments to intervention components by using standardized role-play behavioral enactment measures to evaluate skills training vide-

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otapes. Thus, HIV prevention videotape studies that test theoretical principles also tend to match outcome measures to videotape elements.

EMPIRICAL FINDINGS HIV risk reduction models are built upon knowledge attitudes, perceptions, beliefs, and risk-related behaviors. These same dimensions have been the basis for the outcome variables assessed in videotape interventions. The three primary intervention outcomes (knowledge, attitudes and beliefs, and behaviors) are therefore reviewed.

HIV-MDS-Related Knowledge The explicit purpose of all commercially developed HIV-AIDS videotapes is to provide factual information to educate people about AIDS. Even videotapes that target specific behaviors, such as HIV antibody testing (e.g., The AIDS Antibody Test, San Francisco AIDS Foundation, 1987) or injection equipment cleaning (e.g., Needle Talk, New York City Department of Health, 1987), include basic educational components. All commercially developed videotapes evaluated thus far have increased knowledge when tested immediately after viewing. For example, 70% of viewers of the tape Lets Do Something Different responded correctly to 11 of 12 HIV-AIDS knowledge test items compared to only 7% of a no intervention control group (Solomon & DeJong, 1989); 98% of the videotape viewers responded correctly to the item "It is a good idea to use Vaseline for lubrication when using a condom" (F) in comparison to 53% of the control group. This same tape increased knowledge in a large sample of African-American sexually transmitted disease clinic patients (O'Donnell et al., 1995). Similarly, Lipson and Brown (1991) reported a 10% increase in knowledge among individuals who viewed any of three videotapes: Sex, Drugs, and AIDS (Select Media, 1986); Beyond Fear (American Red Cross, 1986); or AIDS: What You Need to Know (Future Vision, 1988). Studies that compare videotapes against face-to-face education show the two are nearly equally effective. For example, Ashworth et al. (1994) found that the videotape The Subject isAIDS (Select Media, 1987) increased knowledge to a similar degree as a counseling session with a nurse educator, and both the videotape and counseling session were more effective than reading an AIDS information brochure. The videotape condition, however, maintained increases in knowledge at two-months follow-up to a greater degree than did counseling. Quirk et al. (1993) reported similar results, where a five-

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minute rap music videotape increased knowledge to similar levels as a timematched counseling session. However, differences between videotape and counseling declined one-month later. Using videotapes produced for education and skills training with families, Wmett et al. (1992) developed a program based on social learning theory that consisted of four 30-minute videotapes. The intervention content focused on modes of HIV transmission, the link between substance use and HIV-risk, modeling problem solving skills, assertiveness skills, and role-play situations for families and adolescents. Families randomly assigned to participate in the home videotape intervention showed substantial increases in knowledge about HIV-risk, sexually transmitted diseases, and prevention actions that were maintained over six months and that were greater than those of a control group. Studies that tested cultural tailoring as an enhancement of information transfer do not show framing information in a culturally tailored context to increase gains in knowledge. In a study that tested the effectiveness of HIV-risk reduction videotape messages targeted to African-American women living in inner-city housing projects in Chicago, Kalichman et al. (1993) randomly assigned women to view one of three 20-minute AIDS information videotapes: (a) the first three segments of AIDS: What You Need to Know (Future Vision, 1988); (b) the exact same information and graphics used in AIDS: What You Need to Know but with ethnicity and sex of presenters matched to the study participants; and (c) the same basic HIV information as the other two conditions presented by the same three women as in the second condition, but with information couched in a context that stressed values and concerns relevant to African-American women. The results showed that all three tapes increased knowledge to similar degrees. However, the videotape that highlighted a socio-cultural context did result in significantly more women talking with friends about HIV and AIDS. Other experimental studies report minimal differences between videotapes matched in content but with manipulated contextual features (Stevenson & Davis, 1994; Stevenson et al., 1995). These findings have been disappointing given the theoretical importance of tailoring HIV-related information to maximize effects with specific subgroups (Fischhoff, 1989; Fisher & Fisher, 1992; Slovic, Fischoff, & Lichtenstein, 1982). However, contextual framing does influence other HIV prevention outcomes.

HIV-Related Attitudes and Beliefs

Attitudes and beliefs are typically expected to change as a result of AIDS education. Two attitudes targeted as outcomes in HIV-AIDS videotape studies are fear arousal related to risk sensitization and behavior

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change intentions. Anxiety and concern about AIDS are well documented responses to AIDS education videotapes, showing that videotapes can suco cessfuUy sensitize people to potential risks (Ashworth et al., 1994; Kalichman et al., 1993; O'Donnell et al., 1995, Stevenson & Davis, 1994). Unfortunately, the elements of videotapes that lead to increased concern have not been identified. One possible explanation is that fear messages that include vivid images of people with AIDS simply heighten anxiety. Alternatively, recognition of one's own risk may follow increased knowledge about HIV transmission and therefore raise anxiety. Behavior change intentions are strongly related to taking preventive actions (Terry et al., 1993). In one study, Quirk et al. (1993) found that a five-minute rap videotape increased intentions to discuss sexual histories with sex partners. Condom use intentions and attitudes toward condoms are also affected by viewing videotapes (Ashworth et al., 1994). For example, Solomon and DeJong (1989) reported changes in condom attitudes with 94% of viewers endorsing the statement '~amy man who refuses to use condoms is being selfish," as compared to 61% of a control group. Another attitude related to behavior change is self-efficacy, defined as "people's beliefs that they can exert control over their own motivation, thought processes, emotional states, and patterns of behavior" (Bandura, 1994, p. 26). In a study designed to test effects of a videotape on self-efficacy, Maibach and Flora (1993) found that a videotape produced for the study increased beliefs among women that they could discuss AIDS with sexual partners and friends, avoid risk producing situations, and use condoms. These effects were most pronounced when the videotape included cognitive rehearsal of behavioral skills, with changes in self-efficacy persisting over one-month. It should be noted that with the exception of Maibach and Flora's findings, attitude changes that follow videotape presentations are not typically maintained over follow-up assessments. Attitudes may therefore be primed by videotape presentations but maintenance may require more intensive presentations or repeated exposures.

Behavioral Changes Videotapes are typically evaluated for their effects on knowledge and attitudes with less attention to behavioral outcomes. For example, Quirk et al. (1993) did not find significant changes in behavior resulting from a brief educational rap videotape. Other studies that have tested longer videotape messages have, however, obtained more promising results. Solomon and DeJong (1989) reported that 80% of STD patients who viewed Lets Do Something Different redeemed at least one coupon to receive free con-

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doms compared to 70% of control participants, a small but statistically significant difference. O'Donnell et al. (1995) also found increased acquisition of condoms after viewing Lets Do Something Different. Using a similar coupon for condoms measure, Kalichman et al. (1993) found that 91% of women who viewed a videotape matched for gender and ethnic background and 88% of women who watched a culturally tailored tape requested condoms as compared to 50% of viewers of the videotape AIDS: What You Need to Know (Future Vision, 1988). Maibach and Flora (1993) also found that 26% of women who viewed a cognitive rehearsal skills training videotape increased their rate of obtaining condoms compared to 6% of women who viewed a behavioral modeling tape that did not include cognitive rehearsal, and no women who viewed AIDS: What You Need to Know (Future Vision, 1988). Condom coupon redemption, however, constitutes a proxy measure of risk behavior change because it is not known if women who received condoms actually used them. To date, only one study has reported behavioral outcomes of videotapes that were based on behavior change theory. Winett et al. (1992, 1993) found that a theoretically-based skills training videotape intervention resulted in significant changes in prevention-related behavioral skills. Adolescents and their parents both improved performance on skills role-play assessment measures of assertiveness and problem solving, with gains maintained six months after the intervention. Unfortunately, Winett et al. targeted adolescents at low behavioral risk rendering actual risk behavior change immeasurable. The two behavioral outcomes that are most reliably attributed to videotape interventions are (a) communicating with others about AIDS and (b) seeking HIV antibody testing. Kalichman et al. (1993) found that 95% of women who viewed a videotape matched to participant sex and ethnicity reported more conversations with friends about AIDS during a two-week follow-up interval compared to 88% of women who viewed a culturally tailored videotape message and 68% of women who viewed AIDS: What You Need to Know (Future Vision, 1988). Similarly, Maibach and Flora (1993) showed that women who cognitively rehearsed assertiveness skills as part of their videotape experience had more conversations with others about AIDS during a one-month follow-up period compared to no changes in conversations among women who viewed a modeling-only videotape and those who viewed AIDS: What You Need to Know. With regard to seeking HIV antibody testing, two studies have reported that videotapes influence testing decisions. Kalichman et al. (1993) found that 18% of women who viewed a culturally tailored message sought HIV testing during a two-week follow-up period compared to no women who viewed either of two control videotapes. To extend these findings, Kalichman and Coley (1995) reported that 37% of women who viewed ames-

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sage framed in a personalized context that emphasized the potential losses of not getting tested intended to get tested after viewing the tape and 63% of those women did get tested in a two-week period. This rate was significantly higher than the 23% of women who got tested after watching a gender-ethnicity control tape and none of the women who had intended to get tested after viewing The HIV Test: Who Should Take It? What Does It Show? (Cochran, 1993). These results are consistent with other studies that have used similar message framing techniques to promote other health-related behaviors (Meyerowitz & Chaiken, 1987).

SUMMARY OF EMPIRICAL FINDINGS Videotapes are a common component of HIV prevention interventions. Most commonly, videotape messages convey information about HIV transmission, attempt to dispel myths, emphasize the use of condoms, and challenge risk promoting attitudes. For the most part, videotapes are included in group interventions as a means of presenting standardized educational information as well as stimulating discussion. Studies have shown that videotapes improve knowledge, change attitudes, and increase readiness to reduce risk behavior. It is not surprising that HIV prevention videotapes have not resulted in behavioral risk reduction. Behaviors associated with HIV transmission are complex and tied to multiple personal, interpersonal, and biological factors. Videotapes have increased knowledge, influenced threat perceptions, and increased readiness to change, but have not resulted in behavior change. For example, Maibach and Flora (1993) showed that videotape modeling of cued cognitive rehearsal of behavioral risk management based on social-cognitive principles enhanced a sense of self-efficacy for self-protective control but did not reduce risk behaviors. However, Maibach and Flora's videotape was delivered in a single session that did not include performance feedback or social reinforcements. For behavior change to occur, it is necessary to provide experience through practice, corrective feedback, and socially reinforced efforts to change (Bandura, 1994), all of which are not possible through videotape procedures alone. SUGGESTIONS FOR VIDEOTAPE-BASED BEHAVIOR CHANGE INTERVENTIONS Despite the limited effects of videotape interventions on HIV risk behavior, videotape-based prevention can deliver components based on sound

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behavior change principles that are known to impact HIV risk behavior (Kalichman et al., in press; Kelly, Murphy, Sikkema, & Kalichman, 1993). Successful behavior change interventions share several key elements in common: (a) a foundation in social cognitive theory principles; (b) intensive and comprehensive skills training as needed to realistically change sexual behavior; (c) facilitation by trained group leaders providing personalized examples and guided group practice; and (d) tailoring of interventions for target populations. Thus, combining videotapes with facilitator and group interaction would increase the feasibility of delivering cognitive behavioral skills training interventions in cost effective and widely disseminatable formats. Each of the essential elements of a proposed videotape HIV prevention intervention is briefly described below.

Social Learning Theory Principles Social learning theory emphasizes outcome expectancies, self-efficacy beliefs, and reinforcement value for instituting behavior changes (Bandura, 1986, 1989, 1994). The theory also states that behavior change occurs as a direct result of observation and interpretation of behavioral performances. Processes involved in modeling and practicing behaviors are theorized to increase positive outcome expectancies, increase self-efficacy, and increase the probability of receiving reinforcement for initial behavioral enactments. Health-related behavior programs based on social learning theory generally target four interactive determinants of behavior (Bandura, 1994). First, behavior change requires accurate information to increase awareness and knowledge of risks associated with risk-producing practices. Second, individuals must possess social and self-management skills to allow for effective action. Third, behavior change requires enhancement of skills and the development of self-efficacy, usually accomplished through guided practice and corrective feedback of skill performance. Finally, behavior change entails creating social supports and reinforcements for efforts to change behavior (Bandura, 1994). Theories of HIV-risk behavior change have included these same social learning principles as necessary components. For example, the AIDS Risk Reduction Model (Catania et al., 1990) specifies information and behavioral skills necessary for risk reduction. Similarly, a three-factor model proposed by Fisher and Fisher (1992) consists of accurate information about HIV transmission and prevention, motivation to change risk-related behaviors, and behavioral skills for performing HIV-preventive actions. Thus, interventions built on cognitive behavioral principles integrate information, attitudes to enhance motivation to change behavior, development and re-

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inforcement of risk reduction behavioral skills, and self-efficacy to implement behavioral changes. As noted by Winett et al. (1990) most of these principles can be incorporated into videotape presentations.

Behavioral Skills Training Interventions based on cognitive behavioral procedures derived from social learning theory typically include risk education, threat sensitization, motivational enhancement to promote readiness to change, and skills training which includes an initial explanation of new skills, modeling performance, discussion of strengths, weaknesses, and feasibility of the model's performance, and providing opportunities to practice new skills with corrective feedback and social reinforcement (B.andura, 1986). To date, videotapes have primarily been used to provide information about HIV-AIDS in educational formats. However, Bandura (1994) argued that videotape is a powerful medium for transmitting skills through modeling to large numbers of viewers. Models that are matched with characteristics of targeted populations and who convey effective behavioral strategies increase self-efficacy beliefs and positively influence judgements of personal abilities to exert control by taking action (Bandura, 1986, 1994).

Personalized Practice Videotapes alone, however, are unlikely to effect behavior change because practice in simulated situations that provides feedback and social supports cannot be accomplished. Winett et al. (1990) proposed a paradigm by which skills training may be implemented using videotape presentations. Specifically, videotape presenters can explain the rationale for a new skill, model its performance, discuss the model's performance, and review skill implementation feasibility. Although practice cannot be accomplished through videotape, viewing sessions can be followed by opportunities for interactive skills practice. Implementing videotape interventions based on social learning theory will require interactive components, where facilitators guide individuals through personalized behavior change, work through problem solving barriers to change, and practice skills with corrective feedback.

Tailoring for Target Populations Interventions based on social learning theory and cognitive behavioral principles must be couched in socially, culturally, and personally relevant

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terms and situations. If skills training applications are to be effective, it is essential that they make sense in the context of an individual's lifestyle and social relationships. To discern personally relevant contextual information, it is recommended that intervention research be preceded by descriptive studies, both quantitative and qualitative, in order to elicit information about the socio-cultural factors that are related to HIV-risk producing situations (Fisher & Fisher, 1992; Winett et al., 1990). Effective HIV prevention interventions are those which adapt intervention content, descriptions of risk-producing situations, behavior change examples and situational roleplay scenarios to match cultural, developmental, gender, and sexual orientation characteristics of participants, such that interventions fit the expectations and life situations of participants. In the case of videotape interventions, presentations should be tailored for cultural, developmental, and gender appropriateness, salience, and relevance (Kalichman et al., 1993; Stevenson & Davis, 1994). Unlike face-to-face interventions which can be adjusted by group facilitators for alignment with participant characteristics, videotapes are standardized and must therefore be tailored. It is also necessary for behavioral models to be similar to target population characteristics in order to enhance self-comparisons that provide the basis for influencing self-efficacy and behavior change (Bandura, 1986). Therefore, to achieve maximum salience and personal relevance, videotape interventions should be tailored to populations (Skinner, Strechef, & Hospers, 1994).

RECOMMENDATIONS FOR PREVENTION PRACTICE Practitioners interested in using videotapes in HIV prevention programs can rely on a few strategies when selecting and presenting prevention messages. Videotapes that are tailored to target populations will be most effective when presenters are matched to audience gender and ethnic background. In addition, cultural competence is a key feature of effective video messages. To achieve cultural competence, messages must be historically accurate, contextually appropriate, and personally relevant (Stevenson & Davis, 1994). Videotapes should also be targeted to attitudinal or behavioral outcomes. For example, programs that seek to promote HIV antibody testing can be enhanced by testing-information videotapes, but could be hampered by tapes that emphasize condom use. Thus, messages that are linked to targeted outcomes will likely show more favorable results than videotapes that transmit broad educational messages. Videotapes can also be enhanced when integrated into group discussions. Interpersonal contact after viewing can increase the effects of videotapes on risk sensitization

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and motivation to change risk behavior (O'Donnell et al., 1995). Practitioners can preview tapes before using them in practice, usually through a loan or previewing service. Resources for identifying and accessing AIDS videotapes are also available, including the catalogues from the National AIDS Information Clearinghouse (800-458-5231), the VideoAIDS catalogue (Herek, 1991), and health educators at local health departments.

CONCLUSIONS Several studies have shown that group HIV prevention interventions that are grounded in social learning theory result in reductions of HIV-risk behaviors across diverse at-risk populations. Research has suggested that videotape presentations increase knowledge and alter risk-related attitudes that increase readiness to reduce HIV risk behaviors. Videotapes have the potential for wide-scale dissemination and may be inexpensively implemented by community-based service agencies (Allen et al., 1992; Healton & Messeri, 1993). The public health impact of videotape interventions will likely be meaningful when the effects are projected over mass distribution to high-risk populations (Winett et al., 1990). Most HIV prevention programs using videotapes have not resulted in behavioral changes that would reduce risk for HIV infection. However, most efforts have not included cognitive behavioral skills training and have not been based on theoretical principles of behavior change. Cognitive behavioral HIV prevention interventions based on social learning principles can be delivered by videotape and community facilitators. Such interventions would be expected to reduce high-risk behaviors because they will apply behavioral skills training techniques including modeling, guided practice, and corrective feedback. Given the increasing demands placed on service agencies with limited resources, it is essential that effective behavior change technologies be affordable and readily transferred to community settings. Videotape provides a realistic medium for community-based service organizations to implement behavioral skills training on a massive scale.

ACKNOWLEDGMENTS Preparation of this paper was supported by a National Institute of Mental Health (NIMH) Center Grant #P30 MH52776 and NIMH Grants R03-MH53057 and R01-MH53780.

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