Introduction
A social marketing approach can reach broad target audiences with the kinds of health-relevant messages, services, and products that are likely to appeal to specific segments of those audiences [1]. Social marketing techniques such as audience segmentation and the revision of products, concepts, and services on the basis of consumer feedback have resulted in the community-wide alteration of risk behaviors [2,3].
Many of the successful examples of social marketing have come from developing countries, where, before the marketing campaigns, levels of relevant knowledge had been minimal and concrete products (e.g. contraceptives or vaccines) had been in short supply [4-7]. However, social marketing approaches have led to demonstrable gains even when the 'product' being promoted was an attitude or a behavior, or when the barriers to responding to campaign messages were psychological or cultural [8-10].
When the target audience is adolescents in the United States and the health issue is HIV prevention, social marketing campaigns face particularly formidable challenges. Although the number of new HIV infections in adults may be decreasing, estimates indicate that HIV infection rates are stable or even increasing for subgroups of young people [11]. One possible explanation for the disparity is that standard prevention messages have not worked as well with youth as they have with adults. In addition, people outside the adolescent audience (e.g. parents and other adult gatekeepers) can restrict access to key communication channels and other resources necessary for the promotion of safer sex to adolescents [12,13]. Despite the challenges, it is extremely important to test promising approaches to the prevention of HIV infection among adolescents, because the majority of young people are sexually active by the 12th grade [14], an estimated 50% of new HIV infections occur in young people under 25 years of age [15], and current rates of sexually transmitted diseases (STD) such as gonorrhea and chlamydia are highest among adolescents aged 15-19 years [16].
Project Action, a demonstration program in Portland, Oregon, USA, showed that adequate groundwork for condom social marketing to adolescents could be laid by community mobilization [17]. As a result of presentations about Project Action to dozens of community groups, the installation of 230 condom vending machines was permitted in local venues where adolescents congregated.
The Prevention Marketing Initiative (PMI) Local Demonstration Project [18,19] extended the model used in Portland by organizing coalitions of volunteers from local communities. The coalitions not only supported but also planned and implemented social marketing campaigns in five local communities. It was hoped that the PMI coalitions (which included members of the adolescent audience from the outset) would secure and retain community support for the HIV prevention campaigns, provide information about local adolescents, learn to mount effective social marketing programs, and become a continuing source of prevention expertise.
In the five US sites that participated in PMI (Nashville, Newark, northern Virginia, Phoenix, and Sacramento), coalition members came from several community sectors. The PMI coalitions received technical assistance in social marketing, epidemiology, and behavioral science from national partners, including the Academy for Educational Development and Centers for Disease Control and Prevention (CDC). Here we describe the results of a survey that was conducted in the Sacramento PMI site to assess the extent of exposure to the campaign and to evaluate its effectiveness in changing adolescent HIV risk behavior.
Methods
Setting
Sacramento is a city of 400 000 people in a six-county metropolitan area, with a total population of 1.5 million [20]. Less than 2 h driving time from San Francisco, an epicenter of the US AIDS epidemic, Sacramento is the capital of the State of California. The average per capita income of residents of the area is above US$20 000, and their most common occupation is government service (29%). Agriculture employs a substantial proportion of the population (19.7%), and attracts some seasonal migrant workers. Approximately 60% of the population is white; African Americans and Asian/Pacific islanders each account for approximately 9% of the population. Spanish speakers constitute 11.4% of the residents of Sacramento County and 35.8% of residents of neighboring Yolo County.
At the time of the PMI campaign, the Sacramento schools provided basic information about HIV, but did not offer the multi-session educational interventions that have been shown to change HIV risk behavior among adolescents [21]. A state-wide social marketing campaign that emphasized the risk and consequences of HIV infection ended before the launch of PMI.
Although California does not report HIV cases, some information about risk can be inferred from rates of other STD [22]. In 1996, the rate of gonorrhea was 127.2 cases per 100 000 individuals in Sacramento, whereas the national rate was 119.5 per 100 000. Similarly, the 1996 rate of chlamydia was somewhat higher in Sacramento (327 per 100 000) than in the USA as a whole (318.6 per 100 000). Throughout the country, rates of both diseases were and continue to be several times higher among adolescents than among all age groups combined.
Intervention activities
The Sacramento PMI coalition narrowed the target audience to sexually active adolescents aged 14-18 years, who use condoms inconsistently. The coalition also selected 15 zip codes (13 zip codes in Sacramento County and two zip codes in Yolo County) where rates of STD and pregnancy among adolescents were high (e.g. 1750 reported cases per year of chlamydia per 100 000 individuals 14-18 years of age when the overall rate for Sacramento County was 700 per 100 000) as the target zip codes in which PMI intervention activities were to be implemented. On the basis of 1990 US Census figures and behavioral information from the school-based 1995 Youth Risk Behavior Survey [23], it was estimated that between six and 10 thousand sexually active teens who had used condoms inconsistently lived in these target zip codes. The behavioral objective was consistent and correct use of condoms with all partners (especially main partners) in all situations. The coalition used the strategic planning techniques of social marketing to design the campaign components.
The program was called Teens Stopping AIDS, and the name helped tie together the various intervention elements. The name was printed in a distinctive logo on all promotional materials. In addition, component campaign elements were linked by a telephone number provided on all print materials and radio spots. The program logo and all intervention materials and procedures were submitted to adolescent review panels before their use by the program.
Individual components of the program included:
Radio public service announcements
Over the course of the year-long campaign, two thousand 30 s spots were aired on the four stations that were most popular with local adolescents. The stations were differentially preferred by white, African American and Latino youth. Radio air time was purchased; the spots were massed during several-week periods at times of day with the highest teen listenerships according to ARBITRON ratings.
The radio spots featured music and adolescent actors of varying ethnic backgrounds. The spot aired for the first 6 months developed the theme, 'You've got dreams - don't lose them', and appealed to group norms with the message, 'It's OK to carry and use condoms; me and my friends do'.
Informed by the baseline round of data from the survey described herein [24], two new spots were broadcast during the second half of the year. In the version tailored for girls, a group of girls discovers condoms in one member's backpack. She insists that it is important for girls to carry condoms, prompting a raid on her condoms and peals of laughter. In the 'male' spot, a boy hears from his girlfriend that they 'have to talk'. He worries that she is going to end the relationship, and is relieved to learn that she wants him to promise to use condoms when and if they have sex. He assures her that he agrees with her concerns wholeheartedly, and she tells him how much she cares about him.
Posters and small promotional materials
Posters were displayed in many high schools, in retail outlets and community centers, and on the sides of city buses. The posters depicted adolescents of varying ethnic backgrounds and the 'You've got dreams' slogan. Each poster also featured the 'Teens Stopping AIDS' logo and the automated telephone information number described below. Hats, mugs, dog-tags, T-shirts, temporary tattoos, and condom packets were all marked with the project logo. These were distributed at workshops and at community events such as concerts.
Skills-building workshops
Workshops were conducted for small groups of adolescents. They lasted for 6 or 7 h and included lectures, discussions, role-playing, video tapes, and a behavioral contract to reach out to three friends with the basic PMI messages. Delivered by youth-serving community-based organizations (CBOs), the workshops employed young people as co-facilitators. Adapted from the curriculum 'Be Proud! Be Responsible'[25], the workshops were designed to be entertaining as well as informative, and were held in a variety of community settings, one of which (a youth hostel) was reportedly intriguing to local teens. Other settings included health clinics/centers, schools, apartment buildings, community centers, community based organizations, and churches.
Peer outreach
Workshop graduates pledged to convey to at least three friends two scripted prevention messages: 'It's OK to refuse unsafe sex' and 'Talk to your partner about condom use'.
Telephone information line
An automated telephone line (800-TEEN) was established. From the recorded message, adolescents could get HIV facts and other information, such as where to get free condoms and how to sign up for a workshop. The recording used an adolescent's voice, included upbeat music, and offered a directory option for parents.
Sampling procedures
Survey data were collected in five cross-sectional rounds from December 1996 to October 1998. In each round, anonymous telephone interviews were conducted with a random sample of adolescents aged 15-18 years (the age range for which Office of Management and Budget approval had been secured) from the 15 target zip codes. The baseline round was completed 6 months before the implementation of the intervention, and the remaining rounds were conducted over a one year intervention period. The sample sizes ranged from 248 to 303, the response rate ranged from 64 to 70%, parental refusal rates ranged from 22 to 25%, teen refusal rates ranged from 5 to 8%, and 3-6% of adolescents were not interviewed because of scheduling problems. These rates are comparable to those reported for other telephone phone surveys of adolescents, such as the Youth Civic Involvement component of the 1996 National Household Educational Survey (NHES:96) [26]. In that study, the rate of parent refusal for adolescents to participate after parental interview was 25.6% and the adolescent refusal rate was 9.2%[26].
The telephone numbers came from two sources: (i) a random sample of a commercially available list of households likely to include adolescents; and (ii) numbers generated by a random digit dialling (RDD) procedure. Approximately two-thirds of the sample for each round was list-based, and list-based numbers from all 15 zip codes were included in every round. The RDD procedure was valuable in investigating bias that might have been introduced by use of the list, but it was time consuming and costly, so we used an RDD sample from only one zip code per survey round. The RDD zip code was changed for each round; the five zip codes chosen for RDD sampling had the largest adolescent populations, producing the most precise estimates possible with available resources, and covering a substantial portion of the target audience.
When we compared the demographic characteristics of the RDD subsample with those of the list-based subsample, a number of age and race differences emerged. For example, for the total sample of 1402 adolescents, the RDD subsample included a significantly larger percentage of minority adolescents (57.5 versus 50.3%, n = 1361, P < 0.05) than did the list-based subsample. We adjusted for these demographic differences in later analyses.
Interview procedures
The procedures for data collection followed a protocol approved by the Institutional Review Board of the Battelle Memorial Institute and subsequently approved by CDC. All households in the sampling frame (for RDD zip codes, this meant all residential households in the zip code) were sent letters addressed to 'Parent of a Teen' that described the upcoming survey. Each mailing contained a stamped refusal postcard addressed to 'Teen Health Study Director'. The postcards did not require names but did require that parents supply a telephone number so that they could be removed from the sample if they wished to be.
During initial telephone calls, households were screened for eligibility. Any household with at least one adolescent aged 15-18 years and that had not returned a refusal postcard was eligible. After determining that a household was eligible, we asked to speak with a parent before we spoke with an adolescent under 18 years of age. The parent answering the phone was given a brief description of the study and was told that it would involve a telephone interview with the adolescent that was intended to be confidential. The parent was then asked to give verbal consent for the adolescent's participation. Verbal assent was later obtained from underage adolescents whose parents had consented. Adolescents aged 18 years were asked directly to consent to participate. In households with two or more eligible adolescents, the adolescent whose birthday was the most recent was selected. No names were collected, so it was not possible to link the interview data and the names of the respondents. To ensure that no adolescent was interviewed more than once, telephone numbers of respondents in each round were eliminated from subsequent rounds, and adolescents were asked before the interview whether they had already participated in the study.
Using a computer-assisted telephone interview system, interviewers read questions aloud from a computer terminal and entered the responses directly into the computer. Each interview lasted approximately 20 min. This technology prevented problems such as illegible handwriting, deviations from skip patterns, and the entry of out-of-range code values. In addition, telephone interviews have been reported to yield more accurate information than face-to-face interviews [27,28].
Measures
Condom use with main partner at last intercourse
Adolescents were asked to respond yes or no to the question, 'When you and your steady or familiar partner had sex the last time, did you (your partner) use a condom?' At baseline, 70% of respondents reported having only one partner, and 82% of those with more than one partner said that they had used a condom the last time they had sex with a non-main partner.
Condom carrying
Adolescents were asked to respond yes or no to the question, 'The last time you left the house, did you carry a condom with you?'
Intention to use condoms with main partner
Adolescents were asked, 'When you and your steady or familiar partner have sex in the future, do you intend to use (have your partner use) a condom every time?' Response options were a four-point Likert scale anchored by definitely not and definitely yes (mean 3.22, SD 0.92, range 1-4).
Attitudes toward condoms
Attitudes toward condoms were assessed by the Condom Attitude Scale - Adolescent Version [29], which was modified for use in telephone interviews by reducing the original four-category response scale to true or false. Cronbach's alpha for the modified scale was 0.72 (mean 43.59, SD 2.59, range 28-46). CAS-A subscales include relationship safety, perceived risk, interpersonal impact, safety, effect on sexual experience, and promiscuity; they are not sufficiently reliable to be used as individual measures.
Subjective norm
The authors of the Theory of Reasoned Action (TRA) [30] emphasize an aspect of the broad notion of norms that they call the subjective norm. According to TRA, a person cares about the opinions of a limited set of people regarding any given behavior. The people with opinions that matter are called salient referents. The subjective norm is the person's summary impression of the opinions of salient referents concerning the behavior in question.
Following procedures recommended by Azjen and Fishbein [30], we constructed a six-item scale for subjective norm. Three items measured the subject's normative belief about each of three referents (friends, parents, and sex partners) identified as salient in earlier elicitation research within the TRA paradigm [31]. Respondents were asked, 'How important do your friends (parent, sex partner) think it is that you use a condom every time?' After each of these questions, the respondent was asked about motivation to comply with that referent's wishes: 'When it comes to using a condom, how important to you are your friends' (parents', sex partner's) opinions?' Response options for all six items were 'not important at all', 'not very important', 'fairly important', and 'very important'.
The normative belief score was multiplied by the score on motivation to comply for each of the three referents. These three products were then summed to obtain a score for a variable labelled subjective norm [32] (mean 35.45, SD 10.07, range 6-48).
Self-efficacy in avoiding unsafe or unwanted sex
The degree to which adolescents considered themselves able to avoid unsafe or unwanted sex was measured by an 11-item scale. Some questions concerned barriers to condom use (e.g. you might not be in the mood to use a condom, there might not be any condoms around, or you might have to ask a partner you'd been with for a long time to start using condoms). Other questions described barriers to refusing sex (e.g. someone you were attracted to or dating was pressuring you to do something sexual that you didn't want to do). The respondent was asked to rate (on a four-point scale) his or her level of confidence about overcoming the barrier. Cronbach's alpha was 0.79 (mean 39.00, SD 4.78, range 18-44).
Dosage
Exposure to Teens Stopping AIDS was measured by a variable called 'dosage'. Some intervention components were more intensive than others, but there was no a priori standard for assigning particular weights to the various components. A conservative measure was thus developed by assigning one point on a dosage scale for reported exposure to the program through each of the following channels: (i) a radio public service announcement; (ii) print media or other promotional materials such as T-shirts; (iii) a friend's mentioning Teens Stopping AIDS; (iv) a PMI workshop graduate's delivery of the message: It's okay to refuse unsafe sex; (v) a PMI workshop graduate's suggestions for ways to talk about condoms with a partner; (vi) a skills-building workshop provided by Teens Stopping AIDS; and (vii) a telephone call to the hotline. Cronbach's alpha for the dosage scale was 0.65 (mean 1.11, SD 1.39, range 0-6).
Demographics
Demographic variables included respondent's sex, age, and race. Separate race variables were created for Black, Hispanic, and other minorities; White was the reference category.
Random digit dialling
A design variable was included among the predictors to detect possible effects due to the source of a telephone number. The value of the variable indicated whether an adolescent's telephone number had been generated from RDD or had came from a commercially available list.
Analysis
We used a two-part analytic strategy. In the first part, we determined whether there was a significant, increasing, linear trend in dosage over the five survey rounds. For each round, we calculated the proportion of adolescents who were exposed to the PMI intervention through at least one channel. We then adjusted the five resulting proportions for age, sex, and race, using the 1997 Sacramento County Population Estimates as an external standard [33]. A chi-square analysis for the comparison of proportions from several independent samples [34] was used to examine the adjusted proportions for trend characteristics.
In the second part of the analysis, we combined the five samples to examine the effects of dosage on various outcomes. Logistic regression models were estimated to test whether dosage predicted condom use and condom carrying when the effects of demographic and design variables were controlled. Finally, ordinary least squares regression models were estimated to test whether dosage predicted intention to use condoms, attitudes toward condoms, subjective norms, and self-efficacy. sudaan version 7.5 (Research Triangle Institute, Research Triangle Park, NC 27709, USA) was used to take possible deviations from a random sample into account.
Estimating the change in the proportion of adolescents who reported condom use at last sex with main partner over the course of the survey period required adjusting the rates of condom use for age, sex, and race. Again, we used the updated census estimates for Sacramento County as an external demographic standard.
Results
Trend in percentages of adolescents exposed to Prevention Marketing Initiative
The radio stations estimated that up to 7000 adolescents were reached by the radio spots. The information line received 2300 calls; the volume of calls increased markedly during periods when the radio spots were being aired. Workshops were delivered to 894 adolescents. Workshop recruitment was less successful during the summer months and may have been less intense towards the end of the project when staff were transitioning into other positions. On the basis of local transit company estimates of ridership in various age groups, transit ads were thought to have reached between 2600 and 4000 teens. This mix of exposures was achieved by a program with an annual budget of approximately US$250 000, including staff salaries, operating expenses, creative materials development contracts and purchased air time, but excluding evaluation research costs.
By round 5, approximately 70% of adolescents in the sample reported exposure to the campaign through at least one specific channel (Fig. 1). False reporting of exposure did not seem to be a problem. In round 1, before the PMI interventions were launched, fewer than 5% of adolescents had 'heard of PMI'. Chi-square analysis revealed a significant increasing trend in the percentage of adolescents exposed to Teens Stopping AIDS over the five rounds (χ2slope 335.22, df 1, P < 0.005), but this trend was not linear (χ2linearity 57.38, df 3, P < 0.005). The rate of increase in exposure levels slowed over time. The same trend was observed without adjustment for age, race, and sex, and also when the sample was restricted to sexually active adolescents with main partners. Table 1 describes the characteristics of adolescents in the total sample (n = 1402).
Logistic regression
When we held sex, age, race, and RDD zip code constant statistically, dosage was a significant predictor of condom use at last intercourse with main partner (Table 2). Similarly, dosage predicted condom carrying.
As found in earlier research, males and African Americans were more likely than females or Whites to report using a condom or condom carrying. Older adolescents were less likely than younger adolescents to report using a condom. There were no effects caused by the source of phone number (i.e. RDD versus list).
Using tests of interactions between dosage and sex, age, and race, we found no significant demographic differences in the effect of dosage on condom use or on condom carrying. We also tested interactions between dosage and a history of pregnancy, STD, or drug use. The effect of dosage on condom use was smaller for adolescents who reported ever using drugs (P < 0.05).
Linear regression
Holding other variables constant, a higher dosage score was associated with stronger intention, stronger subjective norms, and greater self-efficacy (Table 3).
Estimated change in condom use
The adjusted rates of reported condom use with main partners (that is, independent of exposure to the PMI program) were 68.6% for round 1 and 72.9% for round 5. This is an increase of 4.3 percentage points, or a 13.7% reduction in the proportion of adolescents engaged in risk behavior. At some intermediate timepoints, levels of reported use were even higher, reaching an adjusted maximum of 77.6%.
Discussion
The percentage of Sacramento adolescents who reported exposure to the Teens Stopping AIDS intervention increased significantly over the 1½ year long survey period. Eventually, well over half of the local adolescent population was exposed to program messages through at least one information channel. The more channels through which an adolescent was exposed to PMI messages, the more likely he or she was to have used a condom at last sex with a main partner; the odds that condom use would be reported increased 26% with each additional channel. After statistical adjustments made the survey rounds comparable, we observed a modest, community-wide increase in reported levels of condom use with main partners, regardless of direct exposure to the program. Too few adolescents reported having more than one partner for a statistical analysis of change in that measure, and condom use with other partners was relatively high from the outset of the intervention, but there may have been some additional program benefit in terms of condom use with non-main partners.
According to a case study of the project [35], there was no organized community resistance to, or negative publicity about, the PMI program. Three factors probably accounted for this lack of negative reaction to the dissemination of straightforward prevention messages to adolescents: (i) active support from the local volunteer coalition; (ii) public release of information about the program only after thorough scientific, operational, and media relations groundwork; and (iii) the fact that the electronic media channels that provided the best access to the adolescent audience (e.g. rock and rap radio stations) were not preferred by most adults.
These results are consistent with theories of health communication that maintain that prevention messages are more effective when they are delivered through multiple channels [36]. They are also consistent with findings from a number of studies in other health domains; in general, multi-component preventative interventions have been more effective than have single prevention strategies [37,38]. Adolescents from various subgroups may attend to, trust, or prefer different channels of information on sexual topics, and the separate channels may reinforce each other [39]. Evidently, the messages disseminated by the PMI program were effective, highlighting the importance of careful audience research when dealing with a domain as complex as adolescent sexuality [40,41].
Because this study did not include a control or comparison site, several alternative hypotheses could be advanced to explain the findings. However, there are credible counter-arguments for each of these hypotheses. The behavioral findings were not likely to have been caused by some other influence because, according to a case study, no contemporaneous event or influence could have accounted for the findings. Exposure to the program was associated with increased levels of the theoretical determinants of condom use (e.g. norms), so there was a plausible psychological mechanism for the association between exposure to the PMI intervention and condom use [39]. The results were not simply a reflection of a nationwide secular trend; according to the Youth Risk Behavior Survey, conducted every other year by CDC, adolescents in the US reportedly increased their condom use at last sex by 2.4 percentage points between 1995 and 1997 [42] - half the change associated with exposure to the Teens Stopping AIDS intervention in twice the time. The national rate of condom use for youth in school in 1995 [23] was lower than the PMI baseline rate, suggesting that the increase observed in PMI was not a statistical artefact of regression to the mean. Finally, there was no interaction between intention to use a condom in the future and reported dosage level, so the program was not effective just among adolescents who were already predisposed toward condom use. When the dosage variable was reconstructed to exclude wholly self-selected exposures (i.e. calling the information hotline and participating in a workshop), the dosage effect remained significant (OR 1.28, P < 0.01).
The limitations of the study were largely those inherent in the telephone survey method. The sample excluded adolescents from households without a telephone, a subgroup that may be at disproportionate risk of HIV infection. However, out-of-school youth have been shown to be at elevated behavioral risk of HIV infection [43], and dropouts and those with frequent absenteeism (who constituted 4.2 and 13% of the present sample, respectively) were included in our survey. Some bias may have been introduced by the fact that the most of the interviewers were women. Although the survey procedure assured anonymity, adolescents may have been reluctant to answer honestly when sensitive questions were posed by a live interviewer over the phone [44]. Finally, the phone survey was expensive and labor intensive [45], and resulting sample size limitations prohibited statistical analyses on high-risk subgroups of adolescents.
There was evidence that the effect of the program may have begun to diminish somewhat by the end of the year. Social marketing theory suggests that, if a campaign is to compete successfully for the attention of adolescents over the long run, it must be refreshed periodically with new strategies that are guided by continuing audience research. The initial novelty and salience of condom advertisements featuring adolescents may have been difficult to match in subsequent offerings. How long a given 'marketing mix' of strategies retains optimal effectiveness and how different a refreshed mix should be are some of the major unanswered questions about this approach.
We also need to learn more about how to reach adolescents who do not tend to be exposed to prevention messages through a program like PMI, and to study the cost-effectiveness of social marketing relative to other HIV prevention approaches [46]. The present evaluation was not designed to address the cost-effectiveness issue in a formal way. However, in its final year, PMI did reach a large group of adolescents with a budget that is not atypical of prevention programs in the United States. Furthermore, it appeared to achieve positive results across a number of audience segments, including those characterized by histories of pregnancy and STD.
The PMI exposure dosage effect was less pronounced among adolescents who used drugs. Although the number of drug-using subjects was too small to examine possible explanations statistically, there may have been a 'ceiling effect'; 75% of drug-using teens reported condom use at baseline. In order to have a major impact on the sexual risk behaviors of drug-using adolescents, it may well be necessary to supplement the most intensive interventions in the PMI marketing mix (e.g. the multi-session skills-building workshops) with wholesome alternative leisure time activities, individual attention from caring adults, and, in some cases, drug treatment [47].
Some might argue that, rather than targeting the general population of young people with a prevention marketing campaign, scarce prevention resources should be devoted wholly to addressing the needs of youth at particularly high risk. However, it is not always possible to identify high-risk youth, and individual young people move into and out of high-risk status. Moreover, the stigma that can be attached to services earmarked for 'troubled' youth may offset the value of the services. Offering a range of coordinated HIV prevention services like the information line, workshops, peer outreach, and media placements offered in PMI makes it possible to deliver key messages to young people regardless of their school attendance, and to link high-risk individuals to additional services as appropriate.
Planning and mounting prevention marketing interventions for the first time was very challenging for the PMI site coalitions, but all five sites completed the process successfully and the project generated technical assistance products that should facilitate future efforts (see website at http://www.cdc.gov/hiv/prevresearch.htm). The Sacramento and Nashville sites were able to sustain their programs with local funding after federal demonstration support ended [48]. Because this model is effective and can be sustained, multi-faceted, community-based, coalition-driven social marketing interventions should be strongly considered by communities that are concerned about HIV infection among adolescents.
References
1. Kotler P, Andreasen A. Strategic marketing for nonprofit organizations, 4th ed. Englewood Cliffs, NJ: Prentice Hall; 1991.
2. de Guzman EM, Cabanero-Verzosa C, Hernandez JRS, Seidel RE, Reodica CN. Launching a social marketing project for immunization in Metro Manila. In:Notes from the field in communication for child survival. RE Seidel (editor). Washington DC: Academy for Educational Development; 1993. pp. 87 -94.
3. Hernendez JRS, de Guzman EM, Cabanero-Verzosa C, Seidel RE. From idea to mass media: teaching mothers the concept of dehydration. In:Notes from the field in communication for child survival. RE Seidel (editor). Washington DC: Academy for Educational Development; 1993. pp. 69 -78.
4. Davis J, Agha S. Contraceptive social marketing in Pakistan: a new system for assessing the impact of price increases on condom sales and consumption in a low-resource setting.Innovations in Social Marketing Conference Proceedings 1997, 11-15.
5. Kaseka N, Jones D, Kalambay K, et al. Contribution of a public mass-media and AIDS information campaign in AIDS knowledge, condom use and HIV seroincidence among employees of a large business in Kinshasa, Zaire. International Conference on AIDS, 19-24 July 1992. 8 :D478 [Abstract no. PoD 5546].
6. Margo G, MacDonald G, Schneider A, Dayrit M, Abad M, Consunji B. The importance of social marketing techniques in creating effective media campaigns on AIDS. International Conference on AIDS, 16-21 June 1991. 7 :456 [Abstract no. W.D. 4273].
7. Sekou D, Saihou C, Amie C, Theophilus G. A multidimentional approach to promote awareness of AIDS in the Gambia. International Conference on AIDS, 4-9 June 1989. 5 :861 [Abstract no. W.E.P.8].
8. Centers for Disease Control and Prevention. Tobacco use among middle and high school students - Florida, 1998 and 1999. MMWR 1999, 48: 248 -253.
9. Cohen DA, Farley TA, Bedimo-Etame JR. et al. Implementation of condom social marketing in Louisiana, 1993 to 1996. Am J Public Health 1999, 89: 204 -208.
10. Dubois-Arber F, Jeannin A, Konings E, Paccaud F. Increased condom use without other major changes in sexual behavior among the general population in Switzerland. Am J Public Health 1997, 87: 558 -566.
11. Rosenberg PS, Biggar RJ. Trends in HIV incidence among young adults in the US. JAMA 1998, 279: 1894 -1899.
12. Guttmacher S, Lieberman L, Ward D, Radosh A, Rafferty Y, Freudenberg N. Parents' attitudes and beliefs about HIV/AIDS prevention with condom availability in New York City public high schools. J School Health 1995, 65: 101 -106.
13. Kirby D. Comprehensive school health and the larger community: issues and a possible scenario. J School Health 1990, 60: 170 -177.
14. Centers for Disease Control and Prevention. Youth risk behavior surveillance - United States, 1997. MMWR 1998, 47 (SS-3) : 1 -89.
16. Centers for Disease Control and Prevention. Sexually transmitted disease surveillance, 1997. Atlanta, GA: Centers for Disease Control and Prevention; 1998.
17. Blair J. PSI/Project Action: impact on teen risk reduction. Report prepared for Population Services International. Washington, DC; 1995.
18. Kennedy MG. (Editor) Special issue: CDC's Prevention Marketing Initiative Project, Social Marketing Quarterly, Vol. VI, No. 1, March 2000.
19. Centers for Disease Control and Prevention. HIV/AIDS prevention. Atlanta, GA: Centers for Disease Control and Prevention; 1998.
22. Centers for Disease Control and Prevention. Sexually transmitted disease surveillance 1996. Atlanta, GA: Centers for Disease Control and Prevention; 1998.
23. Centers for Disease Control and Prevention. Youth risk behavior surveillance - United States, 1995. MMWR 1996, 45 (SS-4) : 1 -83.
24. Mizuno Y, Kennedy, Kennedy, MG, Seals BF, Myllyluoma, Myllyluoma, J. Predictors of teens' attitudes toward condoms: gender differences in the effects of norms. J Appl Soc Psychol 2000, 30 (7): 1381 -1395.
25. Jemmott LS, Jemmott JB, McCaffree KA. Be Proud! Be Responsible! Strategies to empower youth to reduce their risk for HIV infection. New York: Selected Media, Inc.; 1996.
26. National Center for Education Statistics. National Household Education Survey of 1996. Data file user's manual, vol 1. Washington DC: US Department of Education; 1997.
27. Groves RM, Miller PV, Cannell CF. Differences between the telephone and personal health interview surveys. Hyattsville, MD: National Center for Health Statistics. DHHS Publication no. [PHS]87-1380; 1987. pp.11-19.
28. Weeks MF, Kulka RA, Lessler JT, Whitmore RW. Personal versus telephone surveys for collecting household health data at the local level. Am J Public Health 1983, 73: 1389 -1394.
29. St Lawrence JS, Reitman D, Jefferson KW, Alleyne E, Brasfiled TL, Shirley A. Factor structure and validation of an adolescent version of the Condom Attitudes Scale: an instrument for measuring adolescents' attitudes toward condoms. Psychol Assessment 1994, 6: 352 -359.
30. Azjen I, Fishbein M. Understanding attitudes and predicting social behavior. Englewood Cliffs, NJ: Prentice Hall; 1980.
31. Middlestadt SE, Bhattacharyya K, Rosenbaum J, Fishbein M, Shepherd M. The use of theory based semistructured elicitation quesionnaires: formative research for CDC's Prevention Marketing Initiative. Public Health Rep 1996, 3 (Suppl. 1) : 18 -27.
32. Fishbein M, Middlestadt SE, Hitchcock PJ. Using information to change sexually transmitted disease-related behaviors: an analysis based on the theory of reasoned action. In:Preventing AIDS: theories and methods of behavioral interventions. DiClemente RJ, Peterson JL (editors). New York: Plenum Press; 1994. pp. 61 -78.
33. Mausner JS, Bahn AK. Epidemiology: an introductory text. Philadelphia: W.B. Saunders Company; 1974.
34. Fleiss JL. Statistical methods for rates and proportions, 2nd ed. New York: John Wiley and Sons, Inc.; 1981.
35. Hare ML, Orians CE, Kennedy MG, Goodman KJ, Wijesinha S, Seals BF. Lessons learned from the PMI case study: the community perspective. Soc Marketing Q 2000, 6: 54 -65.
36. National Cancer Institute. Making health communication programs work: a planner's guide. Bethesda, MD: National Institutes of Health. NIH Publication no. 92-1493; 1992.
37. Farquhar JW, Fortmann SP, Flora JA. et al. Effects of communitywide education on cardiovascular disease risk factors: the Stanford Five-City Project. JAMA 1990, 264: 359 -365.
38. Pentz M, Dwyer J, MacKinnon D. et al. A multi-community trial for primary prevention of adolescent drug abuse: effects on drug use prevalence. JAMA 1986, 261: 3259 -3266.
39. Rogers E. Diffusion of innovations. New York: Free press; 1962.
40. Eyre SL, Read NW, Millstein SG. Adolescent sexual strategies. J Adolesc Health 1997, 20: 286 -293.
41. Joffe H. AIDS research and prevention: a social representational approach. Br J Med Psychol 1996, 69: 169 -190.
42. Centers for Disease Control and Prevention. Trends in sexual risk behaviors among high school students - United States, 1991-1997. MMWR 1998, 47: 749 -752.
43. Centers for Disease Control and Prevention. Health risk behaviors among adolescents who do and do not attend school - United States, 1992. MMWR 1994, 43: 129 -132.
44. Nicholls WL, Baker RP, Martin J. The effect of new data collection technologies on survey data quality. In: Survey measurement and process quality. Lyberg L, Biemer P, Collins M, DeLeeuw E, Dippo C, Shwarz N, Trewin D (editors). New York: John Wiley and Sons. 1997: pp. 221 -248.
45. Myllyluoma J, Greenberg P, Wolters C, Kaifer P. Assessing community-wide outcomes of prevention marketing campaigns through telephone surveys. Soc Marketing Q 2000, 6: 23 -32.
46. Holtgrave DR. Public health communication strategies for HIV prevention: past and emerging roles. AIDS 1997, 11 (Suppl. A) : S183 -S190.
47. Dryfoos JG. Adolescents at risk: prevalence and prevention. New York: Oxford University Press; 1990.
48. Kennedy MG, Stover DL, Tormala ZL. Using social marketing to raise funds for prevention programs. Soc Marketing Q 2000, 6: 44 -53.
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