Using Protection Motivation Theory to Predict Condom Usage and Assess HIV Health Communication...

Running Head: PREDICTING CONDOM USE AND ASSESSING HIV COMMUNICATION

Using Protection Motivation Theory to Predict Condom Usage and

Assess HIV Health Communication Efficacy in Singapore

1 May O. Lwin,

2Andrea J. S. Stanaland and Desmond Chan

1 May O. Lwin is Associate Professor at the Division of Public and Promotional

Communication, Wee Kim Wee School of Communication and Information, Nanyang

Technological University, 31 Nanyang Link, WKWSCI Bldg Singapore 637718

Tel: (65) 6790 6669, Fax: (65) 67924329, Email: [email protected]

2Andrea J. S. Stanaland is Assistant Professor of Marketing, College of Business and

Economics, Radford University, Box 6917, Radford, VA, 24141

Tel: 540-831-6497, Email: [email protected]

Desmond K. Chan is on the teaching faculty at Catholic Junior College, Singapore.

Email : [email protected]

The authors would like to gratefully acknowledge the assistance of Chen Chengji and

Yang Xinrong who were students at Nanyang Technological University at the time of

research. We are also grateful to the editor and the anonymous reviewers for their

guidance throughout this review process.

mailto:[email protected]



Predicting Condom Use 2

ABSTRACT

The number of individuals infected with HIV/AIDS continues to rise in Asia. Condom

use is considered to be the first line of defense against AIDS (UNAIDS, 2006). Using the

Protection Motivation Theory (Rogers, 1983), this research aims to first understand the factors

affecting condom usage intention among homosexual and heterosexual men in Singapore, and

then to utilize those findings to assess the efficacy of HIV-directed health communications. We

collected survey data from 484 men and analyzed the data using hierarchical regression and

structural equation modeling. We found self-efficacy to be a significant predictor for both

groups of men, together with perceived severity for homosexuals and response efficacy for

heterosexuals. Next, we analyzed HIV-directed condom usage communication materials and

found that the use of threat appeal themes is more commonly used than themes promoting self-

efficacy. Implications for health communications and policy are discussed.

INTRODUCTION

It has been nearly 25 years since human immunodeficiency virus (HIV) first struck the

world of medical science. HIV, the cause of the Acquired Immunodeficiency Syndrome

(AIDS), has since resulted in a worldwide epidemic that has claimed more than 25 million lives

(Ministry Of Health Singapore, 2006). In Asia, where the spread of HIV started later than the

rest of the world, expanding prevention programs to slow the spread of the disease remains a

serious challenge (Ruxrungtham, Brown & Phanuphak, 2004). Sexual transmission still

remains the main mode of HIV transmission among Singaporeans, accounting for 90% of the

cases in 2005, and a considerable increase in homosexual transmission has also been observed

in a review of the HIV infected cases from 1994 to 2003 (Sen et al., 2006). More recently,


Singapore has also seen an uptick in overall HIV infections, with a 12% increase from 2005-

2006 and an 18% increase from 2006-2007 (Mesenas, 2008).

The increased number of infections no doubt serves as a reality check for Singapore,

which struggles in its policies between viewing HIV/AIDS as a disease and the morality of the

issues surrounding HIV. This is especially pronounced for the homosexual population. Mathi

(2006) suggests that the taboo on homosexuality and casual sex has rendered outreach and

health communication programs ineffective in targeting these groups that perhaps most require

education to protect themselves. There is also a consequent lack of trust from homosexual

groups to participate in the education programs because of Singapore‘s conservative

environment. The fight against HIV/AIDS is also challenging in the heterosexual context.

Local newspaper The Straits Times has reported that some Singaporean men, both married and

single, frequent neighboring Batam‘s shores every weekend to visit commercial sex workers

(Tan, 2004). In some of these cases, the men practiced unprotected sex which exposes them to

the risk of HIV as well as sexually transmitted infections.

Most preventive measures that tackle the spread of HIV/AIDS rely on risk avoidance

and/or risk reduction. Risk avoidance refers to practices that abstain from risk behaviors. Some

personal interventions include abstinence and keeping to one partner. Risk reduction refers to a

modification of existing risk behavior through safety precautions such as the use of condoms.

Published systematic reviews and meta-analyses of condom use studies have shown that when

condoms are used consistently and correctly, they are 80% to 95% effective in reducing the risk

of HIV infections (Hearst & Chen, 2003; Pinkerton & Abramson, 1997; Weller & Davis, 2004).

Condom use also has been shown to be more effective in HIV prevention than the reduction of

number of sexual partners (Reiss & Leik, 1989). It is thus imperative that health


communicators understand the factors that influence an individual‘s formation of HIV-

protective behavioral intentions regarding condom use and how those factors might be utilized

to create targeted communication strategies. Protection Motivation Theory-based interventions

have been shown effective in many health information contexts (Fry & Prentice-Dunn, 2005).

As condom use has been identified as the first line of defense against AIDS (UNAIDS, 2006),

the current research seeks to examine the strength of theory-based Protection Motivation factors

to predict the intention to use condoms among heterosexual and homosexual men in Singapore

and to assess the efficacy of HIV-directed communication in Singapore along PMT dimensions.

LITERATURE REVIEW

Protection Motivation Theory (Rogers, 1983) is a stress-coping theory that is used to

study the effects of threatening health information on intended behaviors, and has been used to

predict condom use (Boer & Mashamba, 2005; Tanner et al., 1989). PMT postulates that when

a person is confronted with a health threat, two mediating cognitive processes - threat appraisal

and coping appraisal - are evoked. Threat appraisals can be described as the evaluation of the

seriousness of the threat (perceived severity) and likelihood of suffering from it (perceived

vulnerability). The threats may include physical harm, social threats, economic costs, and

danger to oneself and others. Faced with a threat, the person will attempt to cope with it.

Coping appraisal is the assessment of the effectiveness of the possible responses to the threat

(response efficacy), in this case the use of condoms, as well as the evaluation of the personal

ability to effectively perform the desired response (self-efficacy). The two appraisal processes

determine whether or not a person will respond with a maladaptive coping response or an

adaptive coping response. Maladaptive coping responses can include feelings of hopelessness,

wishful thinking, avoidance, or fatalism, among others (Rippetoe & Rogers, 1987) and result in


the adoption of maladaptive behaviors. In the current context, adaptive behavior would be

reflected by the intention to use condoms, while maladaptive behavior would be deciding not to

use condoms. Supporting the usefulness of studying such adaptive intentions, meta-analyses

have shown that intention is a strong predictor of condom use and behavior (Sheeran & Orbell,

1998).

There has been widespread support for the relationships theorized in PMT. In their

extensive review of PMT-related research, Rogers and Prentice-Dunn (1997) report that prior

research has shown that increases in severity or vulnerability (or both) lead to higher intentions

for adaptive behavior and that increases in response efficacy and self-efficacy also lead to

higher intentions for adaptive behavior. Rogers (1983) similarly proposed those main effects,

but also proposed that an interaction effect will occur between the two types of appraisals: a

high threat appraisal will lead to adaptive coping response under conditions of high coping

appraisal (a person recognizes a threat and is capable of responding appropriately), but high

threat appraisal under the condition of low coping appraisal might actually lead to maladaptive

coping response. In other words, an individual who recognizes the threat of HIV but feels

powerless to properly protect himself from the virus (i.e., proper condom use) would be less

likely to form intentions toward that adaptive behavior.

The additive model holds within each appraisal process. When combining

components between the two processes, second-order interaction effects

occur…It is assumed that if response efficacy (or self-efficacy) is high, severity

and/or vulnerability will have a simple main effect on intentions; if response

efficacy (or self-efficacy) is low, increments in severity and/or vulnerability will

either have no effect or a boomerang effect, actually reducing intentions to

comply with the recommendations. (Rogers 1983, p. 170)


The possibility for backlash against health information is echoed in Witte‘s (1992)

Extended Parallel Processing Model, a model developed to explain why fear appeals are

sometimes rejected. Witte argues that the threat x efficacy interaction is critical to

understanding message rejection. She also distinguishes between fear, a negatively-valenced

emotion, and threat, an external stimulus variable that may or may not be known by the

individual. EPPM focuses on two processes, danger control, which leads to message acceptance,

and fear control, which leads to message rejection. Witte thus summarizes EPPM (Witte, 1992,

p. 338) as follows:

When people fear an applicable and significant threat, and when they perceive a

response that would feasibly and effectively avert the threat, they are motivated

to control the danger (protection motivation) by thinking of strategies to avert the

threat (adaptive outcomes). When danger control processes are dominating,

individuals respond to the danger, not to their fear. Conversely, when perceived

threat is high, but perceived efficacy is low, fear control processes are

initiated…they become motivated to cope with their fear (defensive motivation)

by engaging in maladaptive responses (e.g., denial). When fear control

processes are dominating, individuals respond to their fear, not to the danger.

The heavy emphasis placed on fear by the EPPM makes it particularly suitable for health

communication contexts where levels of fear are manipulated in order to influence behavior.

The current research does not attempt to manipulate levels of threat or fear per say, but

examines the impact of the components of the threat appraisal on intended behavior, thus we

follow Protection Motivation Theory for this research.

Condom use has also been shown to differ based on men‘s sexual orientation. Studies

have indicated that discrimination and homophobia have increased sexual risks for gay men

through unprotected sex and inconsistent condom use (American Foundation for AIDS research,


2006). Further, Scott-Sheldon et al. (2006) found that homosexual men associated condoms

with sexual and sensual connotations while heterosexual men associated condoms with their

preventive capabilities and impact on relationships. These differences suggest the need to treat

heterosexual and homosexual men as two distinct groups when it comes to studying protection

motivation and designing interventions to encourage condom use.

STUDY 1

According to prior work using PMT, strong threat and coping appraisals will elicit

stronger protection motivation. In their meta-analysis of PMT research, Floyd et al. (2000, p.

407) concluded that ―increases in threat severity, threat vulnerability, response efficacy, and

self-efficacy facilitated adaptive intentions or behaviors.‖ On the other hand, strong threat

appraisals may, instead of evoking a protection motivation, elicit a maladaptive behavior that is

focused on reducing anxiety in the form of avoidance or denial, especially when coupled with a

low coping appraisal (Rogers & Prentice-Dunn, 1997). If a person feels that he or she is

capable of successfully coping with a threat, then as the threat increases, so should the person‘s

intention to perform the adapting coping behavior. Supporting this idea, Rippetoe and Rogers

(1987, p. 601) stated that ―although a threat prompts an individual to act to protect him-or

herself, the most crucial factor in determining what specific coping strategies an individual uses

is the coping information received and resulting coping appraisals.‖ They found that high levels

of response-efficacy and self-efficacy strengthened adaptive coping strategies.

Because of the need for interventions to be tailored to different segments to increase

their effectiveness, we will test hypotheses on both homosexual and heterosexual groups.

An interaction effect between the threat and coping appraisals was postulated by Rogers

as part of the PMT model (1983), and there has been some support for that interaction in the


literature. Rippetoe and Rogers (1987) found a significant interaction between self-efficacy and

coping in the context of the threat of breast cancer. The reported that ―enhancing people‘s

belief in their own ability to perform the recommended health practice increased their intentions

to use the practice and engage in a rational problem-solving approach. On the other hand, not

believing in one‘s ability to perform the response engendered feelings of hopelessness about

being able to stay healthy‖ (Rippetoe and Rogers 1987, p. 602). Thus women responded with

intentions to perform adaptive coping behavior (breast self-examinations) when they believed

they would be able to successfully do so. Similarly, Sturges and Rogers (1996) found that in

the context of tobacco use, adolescents and young adults only responded with adaptive coping

behaviors if they believed they could cope effectively with the danger (by refraining from

tobacco use).

We therefore expect a significant threat appraisal x coping appraisal interaction such that:

H1: under high levels of coping appraisal, increasing threat appraisals will lead to

intentions to perform adaptive coping behaviors (use of condoms), but

H2: under low levels of coping appraisal, increasing threat appraisals will lead to

intentions to perform maladaptive coping behaviors (not using condoms).

METHODOLOGY

Measures

All constructs were measured using multi-items scales that were adapted from existing

scales. Respondents answered questions on seven-point Likert scales ranging from 1 (strongly

disagree) to 7 (strongly agree).

Perceived Severity. Perceived severity (SEV in the model) refers to how people

perceive the seriousness of the consequences of the disease (Boer & Seydel, 1996). Expanding


the scale used by Boer, Seydel and Stalpers (1993), we utilized a total of four questions for this

measure (e.g., ―HIV infection is a serious problem‖). A higher score indicates that the

respondent perceives HIV to be more severe.

Perceived Vulnerability. Perceived vulnerability (VUL) refers to the expectancy of

being exposed to the threat (Rogers & Prentice-Dunn, 1997). It may be assessed by the chance

of contracting the disease or the vulnerability of contracting the disease. The scale was adapted

from past PMT studies (Boer, Seydel, & Stalpers, 1993; Van der Velde & Van der Pilgt, 1991),

with a total of four questions (e.g., ―It is possible that I can contract HIV unknowingly‖). The

higher the score, the higher is the perceived vulnerability.

Response Efficacy. Response efficacy (EFF) refers to the beliefs of whether adopting a

particular response will be effective in reducing the disease threat (Rogers & Prentice-Dunn,

1997). In a study by Boer et al. (1993), response efficacy of mammographic behavior was

assessed with four questions on a 3-point scale. The four items formed a reliable scale of 0.67.

These questions were adapted to suit the HIV context. Four questions were used to assess

respondents‘ perception of how effective they deem using condoms is in protecting themselves

from HIV (e.g., ―Using condoms will protect me against becoming infected with HIV‖). A high

score indicates that respondents perceive that using condoms is effective in protecting

themselves from HIV.

Self-efficacy. Self-efficacy (SE) refers to the beliefs of whether one can perform the

coping response confidently and successfully (Rogers & Prentice-Dunn, 1997). Lwin & Saw‘s

(2007) four-question 7-point scale to assess self-efficacy with respect to myopia prevention

behavior was adapted to the HIV context. The construct of four questions measures the belief


that the respondent is able to execute a recommended behavior successfully (e.g., ―It is easy to

use condoms‖). A higher score indicates that the respondents have higher self efficacy.

Protection Motivation. Protection motivation refers to the development of an intention

to adopt a protective behavior (Hodgkins & Orbell, 1998). It was thus operationalized as a

person‘s behavioral intention to use condoms to protect themselves from HIV. We adapted four

questions from Lwin & Saw‘s (2007) protection motivation four-item measure (e.g., ―I intend to

use condoms to protect myself from getting HIV‖), with higher scores indicated greater levels of

protection motivation.

Sample

Surveys were then given to participants recruited through convenience sampling and

snowballing. We visited a number of locations where heterosexuals or homosexuals gather (e.g.

bars, social clubs) and had our contacts who visit those establishments introduce us to their

friends whom in turn referred us to other respondents. This was a preferred method (over other

methods such as random sampling) due to the sensitive nature of the topic and difficulty in

identifying sexual orientation. Participants who are currently residing in Singapore were

considered eligible, with a total of 500 men recruited for the study. After omission of

respondents with incomplete or missing data, the final sample consisted of 484 men (N=484),

where 219 reported being homosexual and 265 are heterosexual. Most of the respondents were

aged 20-24 years old (45.2%). The sample‘s racial mix consisted of 79.1% Chinese, 11.8%

Malay, 7.8% Indian and 1.3% others (e.g. Eurasian, Caucasian). The racial profile of the

respondents is roughly consistent with the younger unmarried male demographic composition

of the Singapore population (Statistics Singapore, 2006).


Measures were tested for unidimensionality by subjecting each construct to exploratory

factor analysis, involving principal component analysis and varimax rotation. Indicators that

had low factor loading were eliminated (per Hair et al., 2006, the factor loading for each item

must be at least .5). The internal reliability of all constructs was then assessed per the

recommended Cronbach‘s alpha of .70 (Nunally, 1978). Items with low reliability or with low

item-total correlations were eliminated, leaving each antecedent variable with three items while

the dependent variable remained at four (see Table 1). Convergent validity was examined using

the correlation of each item with its hypothesized scale. To confirm convergent validity, the

Pearson correlation coefficient should be .40 or above (Montazeri, Vahdaninia, Ebrahimi, &

Jarvandi, 2003), and all indicators satisfied the criterion.

Hierarchical Regression

To test for the hypothesized interactions, we ran a hierarchical regression analysis with

intention as the dependent variable (see Table 2) to analyze the interaction effect between threat

and coping with regards to protection motivation. The scores for severity and vulnerability were

pooled to get a measure of threat appraisal, while response-efficacy and self-efficacy were

combined to obtain a measure of coping appraisal. Each variable was then centered. Threat and

coping appraisals were then entered into the regression model first, followed by the interaction

term threat x coping. The two main variables were found to significantly predict intention (F

change = 97.516, p < 0.000), accounting for 28.8% of the variance. As for the interaction

between threat and coping, the F value increment when this variable was added to the model

was not significant (F change = 0.071, p > 0. 1). We also ran similar analyses for homosexuals

and heterosexuals separately, but as shown in Table 2, the interaction effects were also found to

be insignificant. The hypothesized interaction was thus not supported.


Despite its theoretical rationale, support for this interaction has not been widespread in

the literature. Rogers and Prentice-Dunn (1997, p. 119) report that ―threat and coping appraisal

variables have been found to interact in about one half of the studies in which both classes of

variables have been tested. The interactions tend to appear when the threat manipulation is

especially strong‖. This suggests that the interaction effect described under conditions of high

threat appraisal and low coping appraisal might only appear under extreme threat conditions.

We did not attempt to manipulate a strong fear appeal in this study, perhaps explaining the lack

of the significant threat x coping interaction.

However, prior research has found significant main effects (Wurtele & Maddux, 1987;

Lwin & Saw, 2007), thus we will next consider the influence of each of the components,

perceived severity and perceived vulnerability (for threat appraisal), and response efficacy and

self-efficacy (for coping appraisal), on the level of protection motivation aroused. Research has

shown that increases in severity or vulnerability (the components of threat appraisal) will lead to

greater intentions to adopt adaptive behavior (Floyd, Prentice-Dunn & Rogers, 2000).

Protection motivation is also enhanced by the belief that the behavior (condom usage) is

effective in reducing the risk (response efficacy) and the expectation that one can execute the

behavior confidently (self-efficacy). Both response efficacy and self-efficacy have been shown

to strengthen intentions for adaptive behavior (Boer & Mashamba, 2005; Rippetoe & Rogers,

1987; Lwin & Saw, 2007; Wulfert & Wan, 1993). Thus, as each of the four cognitive

mediating variables increases in strength, greater protection motivation should be aroused,

leading to greater protective behavioral intentions. We therefore proceeded to test for main

effects for each sample.


ANALYSIS AND RESULTS

SEM is used next in this study because it can explicitly account for measurement error

in the explanatory variables as opposed to traditional multivariate procedures (Hair et al., 2006),

and is considered to be particularly useful for health communication research (Stephenson,

Holbert & Zimmerman, 2006). We used AMOS 7.0 and SPSS to run the data analyses for

Study 1.

Measurement Models

CFA was performed to validate the scales used in measuring the latent constructs to

inspect for the presence of any offending estimates (Hair et al., 2006). We split up the CFA

analysis of the population into homosexual and heterosexual groups because of the adequacy of

sample size (nhetero= 265, nhomo= 219).

Goodness-of- fit. CFA was performed on the five PMT constructs for both homosexual

and heterosexual males. Fit indices were satisfactory for the homosexual model (χ2

= 177.4; d.f.

= 94,p = .00; RMSEA = .064 (90% CI = .049, .078); CFI = .951) and excellent for the

heterosexual model (χ2

= 132.3; d.f. = 94, p = .00; RMSEA = .039 (90% CI = .022, .054); CFI

= .977). Figures 1 and 2 represent the CFA models for homosexual and heterosexual subjects

respectively.

Reliability and Convergent Validity. The CFA models were subsequently tested for

construct reliability (CR) and variance extraction (VE) to examine if the indicators were

sufficient in representing their representative constructs (Moorman, 1995; Oliver & Bearden,

1985). Variance extraction is used as a measure of convergent validity (Ping, 2005). Fornell and

Larcker (1981) recommended that for a construct to display convergent validity, the variance

explained by the construct must be greater than the measurement errors. Based on the SEM


construct reliability formula and the variance extracted measure given by Garver and Mentzer

(1999), calculations were performed. For both groups, CR results ranged from .74 to .90 while

VE results ranged from .49 to .70. The results for the constructs of both groups met the

recommended values for CR and VE (Fornell & Bookstein, 1982; Fornell & Larcker, 1981).

This confirmed the internal consistency of the constructs and that the respective indicators truly

represented the constructs.

To ensure that the indicators accurately measure the latent constructs that they are

supposed to measure, the individual factor loading for each construct was used to determine

convergent validity. Using the standardized loading from Maximum Likelihood Estimates for

each indicator, a critical ratio of 1.64 or higher indicates that the estimates are significant at p

< .05 (two-tailed; Hair et al., 2006). All the constructs within the models for both groups had

critical ratios higher than 1.64 and thus were statistically significant for their constructs.

The null models for both groups were first tested but the absolute, incremental and

parsimonious fit measures for the models of both groups were unsatisfactory. Model

respecification was thus carried out, drawing upon information from the modification indices as

well as construct correlation. The modifications were made based on theoretical grounds.

Severity and vulnerability constructs were correlated theoretically as established by Melamed et

al. (1996) while response efficacy and self-efficacy were correlated theoretically as coping

appraisals (Rogers & Prentice-Dunn, 1997). Figures 1 and 2 present the fitted models for both

homosexual and heterosexual males respectively. There was satisfactory model fit for the

homosexual PMT model (χ2

= 174.5; d.f. = 83, p = .00; RMSEA = .071 (90% CI = .056, .086);


CFI = .938) and excellent model fit for the heterosexual PMT model (χ2

= 152.0; d.f. = 98, p

= .00; RMSEA = .046 (90% CI =.031,.059); CFI = .968).

Structural Models

Testing for main effects was carried out using the final fitted SEM models for both

groups. For the homosexual subjects, only perceived severity (SEV PM =..15) and self-

efficacy (SE PM =.60) were significantly (p<0.05 and p<0.001, respectively) and positively

related to their condom usage intention. In contrast, only the heterosexual subjects‘ response

efficacy (EFF PM =.23) and self-efficacy (SE PM = .43) were significantly (p < .001) and

positively related to their condom usage intention. Self-efficacy turned out to be the strongest

predictor of protection motivation for both groups. Finally, comparison of the effects between

the homosexual males and the heterosexual males on the various dimensions measured shows

that homosexual men have higher perceived self-efficacy and severity as compared to

heterosexual men, while heterosexual men have higher perceived response-efficacy than

homosexual men.

STUDY 2

With Study 1 having identified self-efficacy as a strong predictor of condom usage

intention for homosexual and heterosexual men in Singapore, we next move to the second

objective of systematically describing the themes of the HIV-directed social marketing

communication targeting those populations in order to assess their efficacy. A content analysis

was thus set up to code the local HIV-directed print materials in terms of the utilization of

themes that are relevant to each PMT dimension – severity, vulnerability, response-efficacy and

self-efficacy (Rogers, 1983).

Defining Sample and Unit of Analysis


The mass HIV education campaigns by Singapore‘s Health Promotion Board (HPB) and

voluntary community organization Action for AIDS (AFA) included putting up posters,

distributing pamphlets and spreading information through television and newspapers (Quek &

Li, 2002). Materials such as pamphlets are often the medium of choice when health care

organizations provide information about a health care topic (Kline & Mattson, 2000). We look

at the specific HIV-directed print materials that target men in Singapore, including posters,

pamphlets, booklets and postcards.

METHODOLOGY

A total of 35 HIV-directed materials were sourced from HPB and AFA. Materials in the

final sample (N=28) were selected based on what was provided by the two organizations for

members of the public and whether they were published between year 2000 and 2007. As two

of the pamphlets were targeted at women specifically, they were excluded from the sample.

Five HIV-directed materials, which were dated before the year 2000, were also excluded from

the final sample and were later used to train the coders. Themes were operationalized as the

broad unifying ideas conveyed by the pictures, phrases or sentences in the HIV-directed

material.

Coding Categories

We categorized the themes found in the materials into four broad dimensions to reflect

PMT constructs: severity, vulnerability, response efficacy, and self efficacy. The general

information dimension includes the theme that gives background information about HIV/AIDS.

The social support dimension give discussions and dramatizations on social support norms to

avoid unsafe sex as well as encourage contact between readers and health care support groups

and professionals (Catania, Kegeles & Coates, 1990; Fishbein, Middlestadt, & Hitchcock, 1994).


The severity dimension has themes that relate to depictions of the seriousness and the negative

outcomes of HIV/AIDS to the person and loved ones (Brouwers & Sorrentino, 1993) while the

vulnerability dimension has themes encouraging the readers to consider their susceptibility to

HIV infection (Boer & Seydel, 1996). The response efficacy dimension relates to the themes on

measures that are labeled as effective in avoiding the negative outcome of contracting HIV

infection (Boer, Seydel, & Stalpers, 1993). This is done through providing information on HIV

transmission and the effectiveness of the measures in reducing the risk of transmission. The

self-efficacy dimension relates to the themes on measures that help the person to believe he or

she can practice risk reduction confidently (Boer, Seydel, & Stalpers, 1993). Each theme was

explicitly stated in terms of its scope in the codebook so that it could be reliably coded by two

independent raters.

Coding Procedures

Prior to coding the final sample, two coders were trained in the use of coding categories

with other materials not found in the final sample. Both of the raters needed to be proficient in

English and Chinese because of the presence of these two languages in the materials in the final

sample. Two raters independently rated the HIV-directed material and coded it for the presence

or absence of themes (Yes/No). A third rater would be consulted if there was any disagreement.

The general reliability scores (Perreault and Leigh, 1989) for individual items ranged from 0.9

to 1.0, as listed in Table 4. Any discrepancies in coding were resolved through discussions

among the coders and the supervising researcher.

RESULTS

Prevalence of the themes noted are listed in Table 4. Of the PMT-related themes studied,

the response efficacy theme was the most represented (69%) while the self efficacy theme was


the least represented (21%). The severity and vulnerability themes were both found in 64% of

the materials. Hence we deduce that the local HIV-directed materials targeting men focused

more on highlighting threat appraisals and condom effectiveness than providing information on

how to use condoms and negotiate condom use confidently. In the severity dimension, the most

common theme was that of HIV‘s fatality (43%). Other themes pertaining to severity like

‗HIV-related diseases‘ and the ‗incurability of HIV‘ were present in 39% of the materials. In the

vulnerability dimension, it was most commonly stressed that ‗HIV symptoms are not visible‘

and that one cannot tell whether a person has HIV by judging how healthy a person looks (57%).

Under the response efficacy dimension, the themes specific to the effectiveness of

keeping to one partner, condoms, abstinence in preventing HIV infections, were present in 46%,

69% and 7% of the materials respectively, with the theme of ‗effectiveness of condom‘ being

the most represented amongst all the other themes in response efficacy. In comparison, all the

themes in the self efficacy dimension were represented much less. ‗General statements on the

practice of safe sex (non-condom specific)‘ and ‗information on HIV testing‘ in the response

efficacy dimension were present in only 29% of the materials, while the theme of ‗condom

usage depiction and condom negotiation skills‘ were present in only 21% of the materials.

DISCUSSION

In Study 1, we found perceived severity and self-efficacy to be significantly and

positively related to the condom usage intention of homosexual subjects. Despite the increasing

rate of HIV sexual transmission among homosexual men in Singapore (MOH, 2006), perceived

vulnerability and response efficacy had no relationship to our subjects‘ intention to use

condoms. One possible explanation is that within the homosexual population, the risk of

contracting HIV and the effectiveness of condoms in HIV prevention are so widely appreciated


that ceiling effects might weaken the impact of perceived vulnerability on intentions to use

condoms. In contrast, response efficacy and self efficacy had a positive impact on the condom

usage intention in heterosexual subjects. For this group, however, perceived severity and

vulnerability toward HIV/AIDS did not drive their intention to use condoms. One reason for

this could be that those variables drive intentions to keep to one partner rather than the intention

to use condoms. It is also possible that subjects discount the risk of contracting HIV within the

heterosexual population.

Self efficacy turned out to be the strongest predictor of condom usage intention for both

groups. This finding supports other applied PMT studies which also found self-efficacy to be

the strongest predictor of protection motivation (Floyd, Prentice–Dunn, & Rogers, 2000; Lwin

& Saw, 2007; Wurtele & Maddux, 1987). The finding would suggest that self-efficacy deserves

greater emphasis in health communications and policies to drive condom usage intention.

However, Study 2, which involved a content analysis of the HIV-directed materials targeting

both groups, found the specific theme relating to the demonstration and depiction of condom

usage and negotiation skills under the self-efficacy dimension to have a lower presence in the

materials than the themes for threat appraisals. We suggest the emphasis on threat appraisals in

the materials might be misdirected since self-efficacy exhibited stronger associations with

protection motivation for both groups. Albarracỉn et al. (2005) further supported this

recommendation through their meta-analysis of 354 HIV-prevention interventions. They found

that interventions which stressed educational information and behavioral skills training were

more effective than those that used fear appeals.

HIV social marketing campaigns and health communications can be based on the

significant focal points of the PMT model for each group. Kotler (1975) suggests that


successful social marketing requires the identification of target groups and the fixing of key

communication messages and channels to maximize the target group response. The findings

from Study 1 indicate that health communicators in Singapore should clearly segment the

homosexual male group from the heterosexual male group because each requires an emphasis

on different communication messages to increase condom usage intentions. The findings from

Study 2 suggest a further need to reinforce the focus on self-efficacy towards condom usage in

the present HIV-directed materials.

For homosexual men, the HIV prevention communication message should focus on self-

efficacy of condom use and the severity of HIV. The potential communication channels for

message dissemination can be health agencies, gay support groups and affiliates as well as

educators since in Singapore‘s context, it would be difficult for government policy makers to

reach out to this group as homosexual activities are not accepted by the community at large

(Cutter et al., 2004). Health agencies such as HPB and AFA can promote HIV-directed

materials that specifically target the local gay community and focus on the severity of HIV as a

fatal disease. It is also important to communicate that condom use is easy and affordable and

emphasize the demonstration of condom usage in the HIV-directed materials.

For heterosexual men, the HIV prevention communication message should focus on the

effectiveness of condom usage in combating HIV transmission and also the demonstration and

depiction of correct condom use and condom negotiation skills. The potential channels for

message dissemination can include health agencies, education in schools, National Service and

hospitals. Based on our findings, health agencies should emphasize the message that condoms

are simple, easy and affordable rather than use fear appeals in the promotional materials and

campaigns for heterosexual men.


In their meta-analysis of PMT research, Floyd, Prentice-Dunn and Rogers (2000, p. 422)

concluded:

Although all of the PMT variables exerted moderate effects in general,

some may be more important in one area of protection versus another.

Understanding the relative impact of the key variables associated with the

targeted protective behavior would be important in formulating treatment

interventions and persuasive communications. Reviews of specific health areas

must be used to determine the emphasis placed on different PMT variables

particular to that area (e.g., cancer prevention or adherence to medical-treatment

regimens). Such information may help to pinpoint areas for intervention, or at

the very least to identify obstacles to improved health or safety.

Similarly, Gilbert et al. (1998, p. 651) observe that the literature has ―begun to consider how

features of both the person and the situation shape the influence of the predictors specified by

PMT.‖ Our results support the idea that similar health-protective behavior (i.e., condom use)

can be differentially influenced by PMT components depending on characteristics of the

individual or population. In this case, different aspects of the PMT model were predictors of

condom usage intentions for homosexual versus heterosexual men.

Our study might also serve as a baseline study on the condom usage intention of men in

Singapore and future research should carry out longitudinal studies to measure condom usage

behavior and intentions. Weinstein and Nicolich (1993) encourage research to examine

temporal effects in the relationship between perceptions of risk and resulting risk behaviors.

The stability of the measures of protection motivation over longer periods should be a focus for

future research (Boer & Seydel, 1996). It would be appropriate to re-calibrate the model used in

the current research to capture the post-adoption period and determine how PMT components

relate to ongoing protection behaviors. It should also be considered that the effectiveness of the


interventions and the strategies behind them may be dependent on past condom use behavior,

age, ethnicity and other demographic factors (Albarracỉn et al., 2005).

In conclusion, the current research makes its contribution to the health communication

literature in several areas. First, we tested an omnibus model based on Protection Motivation

Theory using structural equation modeling. We believe that using Structural Equation

Modeling in this study is a strength because of SEM‘s usefulness in ―understanding

communication as a complex set of relations between variables‖ (Stephenson et al. 2006, p.

159). Second, we compared the omnibus models from samples representing two distinct

populations—homosexual men and heterosexual men. Although the anticipated interaction

between threat and coping was not found to be significant, our results showed that in fact

different PMT variables were significant in predicting condom usage for the different groups.

As mentioned, this also supports the contention in the literature that the predictive strength of

various PMT components might vary by individual, population, or other contextual differences.

Finally, we used the findings from our study 1 model to subsequently evaluate the potential

efficacy of publicly-available condom-promotion health communication materials in Singapore.

Rather than merely making recommendations based on our initial findings, we attempt to close

the loop by using those findings to assess actual health communication initiatives. Overall, we

found a PMT-based model effective in differentiating between the messages that might be most

effective in influencing protective behavioral intentions among homosexual and heterosexual

men in Singapore, and recommend that changes be made to existing communication materials

in order to effectively reach those groups.


FIGURE 1: Final-fitted PMT Model for Homosexual Male Subjects.


FIGURE 2: Final-fitted PMT Model for Heterosexual Male Subjects.


TABLE 1: Constructs Loadings and Reliability

Constructs Item

Coding Item Descriptions

Factor

Loading

Severity SEV 1 HIV infection is a serious problem 0.76

SEV 2 Being HIV positive will incur the risk of a

weakening immune system and high medical bills.

0.87 0.81

SEV 3 Being HIV positive will most likely induce social

stigmatization.

0.82

Vulnerability VUL 1 It is possible that I will ever get HIV. 0.78

VUL 2 The chance that someone of my age in comparable

conditions gets HIV is rather large.

0.65 0.71

VUL 3 It is possible that I can contract HIV unknowingly. 0.71

Efficacy EFF 1 Using condoms ensures that I am protected against

HIV.

0.87

EFF 2 The use of condoms is effective in preventing

HIV.

0.86 0.88

EFF 4 The use of condoms reassures me that I am safe

from HIV.

0.88

Self-efficacy SE 1 It is easy to use condoms. 0.84

SE 3 I am not afraid to use condoms. 0.83 0.87

SE 4 I am able to use condoms effectively. 0.89

Protection

Motivation

INT 1 I intend to use condoms on myself or the other

party every time there is penetrative sex.

0.85

INT 2 I intend to use condoms to protect myself from

getting HIV.

0.81 0.87

INT 4 I would ensure the other party or I have a condom

to use before penetrative sex.

0.87

INT 5 I intend to use a condom regardless of how the

other party feels.

0.83


TABLE 2: Hierarchical regression results for threat, coping and threat x coping variables

*p < .05; **p < .01; ***p < .001

TABLE 4: Presence of PMT Themes in HIV-directed Materials

Dimensions Presence

of themes

(N=28)

Specific themes within each

dimension

Presence

of specific

themes in

materials

Perrault‘s

Index of

reliability

(Ir)

Severity

(Threat Appraisal)

64% Severity—Fatality 43% 1.00

Severity—AIDS related illnesses 39% 0.96

Severity—no cure or vaccine 39% 0.96

Vulnerability

(Threat Appraisal)

64% Everyone susceptible to contracting

HIV

43% 0.96

Ambiguity of partner‘s sexual

history/HIV status

54% 0.96

HIV symptoms are less visible 57% 0.93

Identification of specific risk groups 36% 0.93

Response Efficacy

(Coping Appraisal)

69% Effectiveness of condom use in

reducing HIV incidence

69% 1.00

Self-Efficacy

(Coping Appraisal)

21% Demonstration or depiction of

condom use and condom

negotiation skills

21% 0.96

Intention

Combined

(n = 484)

Homosexuals

(n = 219)

Heterosexuals

(n = 265)

Block 1

Coping .476*** .495*** .419***

Threat .160*** .144* .134*

Block R2 .288*** .214*** .326***

Block 2

Threat-Coping .010 .059 -.075

Block R2 .000 .005 .003

Total R2 .289*** .219*** .329***


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