Effectiveness in Disease and Injury Prevention HIV-Infection Prevention Messages for Injecting Drug Users: Sources of Information and Use of Mass Media -- Baltimore, 1989

In many urban areas in the United States, human immunodeficiency virus type 1 (HIV-1) seroprevalence rates for injecting drug users (IDUs) range from 10% to 65% (1). To examine whether the mass media could contribute to IDU-targeted HIV-infection prevention measures, CDC collaborated with investigators at Johns Hopkins University in studying 1) media use by and sources of HIV information for IDUs, 2) the airing of public service announcements (PSAs) that address acquired immunodeficiency syndrome (AIDS), and 3) the acceptability by broadcast media executives of various PSA prevention messages related to HIV and AIDS. This report summarizes findings of these studies. Sources of Information for IDUs

From February 1988 through March 1989, a cohort of 2921 IDUs was recruited through clinics, street outreach programs, and word-of-mouth in Baltimore through the AIDS Link to Intravenous Experiences (ALIVE) study. This volunteer cohort study of the natural history of HIV-1 infection in IDUs is one of a limited number of longitudinal evaluations of persons who are considered ``street IDUs'' (i.e., IDUs who may not be in drug treatment) (2). At the time of enrollment, 24% of the cohort's members were HIV-1 seropositive. Eligibility criteria included residency in the Baltimore metropolitan area, age greater than 17 years, and history of illicit drug injection during the previous 10 years. The median duration of injecting drug use was 12 years; 90% had injected illicit drugs during the year of enrollment, and 77% during the month before enrollment.

Cohort members are evaluated every 6 months. To obtain information on media-related questions, a structured questionnaire was administered to the 353 cohort members who were given a scheduled evaluation from October 30, 1989, through January 2, 1990; all 353 completed the questionnaire. The demographic characteristics of persons completing the media questionnaire were statistically similar to the composition of the entire cohort: 78% were male; 96%, black; 82%, currently unemployed; and 31%, without a permanent residence during the past year. The median age was 34 years (range: 20-62 years); 61% had a 12th-grade education or less and had not received a high school diploma. During the previous 10 years, 74% had received social welfare assistance, and 74% had been arrested.

Sources of AIDS Information. Of the 353 IDUs, 48% first learned about AIDS from television, and 25%, from their friends (Figure 1). Forty-seven percent of all respondents reported that they learned the most about AIDS from television, and 53% listed television as their most frequent current source of AIDS information. Women were more likely than men to have learned about AIDS from friends (31% vs. 23%), drug-treatment programs (9% vs. 4%), or health-care workers (6% vs. 2%), and less likely to have learned about it from television (44% vs. 50%) or newspapers (0% vs. 7%) (p less than 0.001; chi-square test for distribution).

Media Used. Participants watched television a median of 28 hours per week. Employed persons watched less television (21 hours vs. 28 hours; p less than 0.02). The amount of viewing did not vary with sex, age, level of education, permanent residence status (i.e., whether homeless), receipt of social welfare assistance, or prior incarceration status. Twenty-nine percent most often watched television between 6 a.m. and 4 p.m.; 24%, 4 and 8 p.m.; 32%, 8 and 11 p.m.; and 15%, after 11 p.m. More women than men watched television between 6 a.m. and 4 p.m. (55% vs. 21%); more men watched between 4 and 8 p.m. (27% vs. 12%) and between 8 and 11 p.m. (35% vs. 22%) (p less than 0.001 for all three time periods). Viewing times were not associated with age, education level, or permanent residence status.

Eighty-three percent of these IDUs listened to radio (median: 12 hours per week) and preferred ``Soul, R & B, Rap'' (40%), ``Top 40, Rock & Roll'' (19%), ``Jazz'' (13%), or ``Talk/News'' (7%). Participants were more likely to listen during the daytime and late night/early morning. Airing of AIDS PSAs

PSAs about AIDS have been disseminated by CDC's National AIDS Information and Education Program (the ``America Responds to AIDS'' campaign (ARTA)), the National Institute on Drug Abuse, and at least 20 nonfederal agencies and organizations (e.g., state health departments, private organizations, and television networks). Data are available on the airing of all AIDS television PSAs from the Broadcast Advertisers Reports of the Arbitron Ratings Corporation.* The Arbitron report presents the total number of PSAs aired by networks and monthly estimates of PSAs aired by Baltimore area television stations. During October-December 1989, 384 ARTA and 427 non-ARTA PSAs were aired. The PSAs were most frequently aired after 11 p.m. (527 (65%)), followed by 6 a.m.-5 p.m. (213 (26%)) and 8 p.m.-11 p.m. (61 (8%)). Acceptability for Airing of Prevention Messages to Media Executives

Researchers from CDC and ALIVE contacted media executives at the headquarters of four national television networks (ABC, CBS, Fox, and NBC), the nine Baltimore radio stations confirmed to have ``contemporary,'' ``rock n'roll,'' or ``black'' formats, and the six Baltimore area television stations listed in the Broadcasting Cablecasting Yearbook (3). Each executive was asked about the potential acceptability of various AIDS prevention messages.

Although messages regarding sexual abstinence were acceptable to network executives, executives for some Baltimore radio and television stations considered the messages inappropriate for their stations' audiences (Table 1). Messages concerning condom use were acceptable to two network executives and all local Baltimore radio and television executives. Some messages were viewed as acceptable if aired at times when children were less likely to see them or if aired within news or public service program formats rather than as PSAs. Messages concerning safer drug-use practices were unacceptable to all national networks but acceptable to some Baltimore television executives and all Baltimore radio stations. Reported by: L Solomon, DrPH, DD Celentano, ScD, D Vlahov, PhD, Depts of Epidemiology, Infectious Diseases Program, and Div of Behavioral Sciences and Health Education, Johns Hopkins School of Hygiene and Public Health, as part of the AIDS Link to Intravenous Experiences Study. The National AIDS Information and Education Program, Office of the Deputy Director (HIV), CDC.

Editorial Note

Editorial Note: Commercial advertising research suggests that only two to three exposures to a message are needed to enable message recall and induce behavioral responses by some portion of the target audience (4,5); however, similar research has not been directed toward public health messages, such as those concerning AIDS.

The findings in this report indicate that, during the 3-month study period, most AIDS PSAs were aired at times of low ALIVE participant viewership; however, more than 200 AIDS PSAs were aired during times when a high proportion of participants reported watching television. These data suggest that many IDUs in this cohort had commercially defined ``adequate exposure'' to AIDS PSAs. Although the content of these AIDS messages was directed at the general public, the messages are also important for IDUs. They provide education about the transmission and treatment of HIV infection, encourage self-risk assessment, solicit community mobilization to support the AIDS prevention effort, and reinforce social norms conducive to AIDS prevention. Because IDUs appear to be accessible through broadcast media, agencies and programs working with IDUs may wish to produce and distribute additional messages that target IDUs and their sex partners.

In Baltimore, the acceptance by media executives of messages regarding IDU-specific topics was substantial and was greater for radio than television. Executives at some Baltimore radio stations were potentially receptive to airing explicit prevention messages, including those concerning safer drug-use habits, in both PSA and longer program formats. Thus, although IDUs do not currently list radio as a principal source of information about AIDS, local radio is a medium that could be used to reach IDUs with more targeted and detailed AIDS prevention messages.

For at least five reasons, the use of mass media for IDU-directed AIDS prevention messages should be further considered and evaluated. First, the findings in Baltimore indicate that the broadcast media are a potentially effective means of reaching IDUs. Second, although alterations of addictive behaviors are difficult to induce, previous studies of another addictive behavior--smoking--can be interpreted as showing an independent effect of the media (6-9); this suggests a potential role for media in promoting sexual and drug-use abstinence and drug treatment for IDUs. Third, commercial research strongly supports the effectiveness of media in altering ``brand preference'' of consumer products (6). Similarly, although additional messages directed toward safer sex and/or drug-use behaviors may not attempt to stop drug use or promote sexual abstinence, they could lead to decreases in needle-sharing activity by IDUs and the number of sex partners they have --a potentially achievable goal (10). Fourth, use of the broadcast media can be cost-effective, even if the success rate is low, because of the large numbers of persons reached at relatively low cost (7,8). Finally, successful interpersonal communication (e.g., counseling and testing centers and street outreach programs) depends upon IDUs being aware of and having access to such programs. Targeted media messages aired at appropriate times during programs likely to be viewed by IDUs could assist in making IDUs aware of available outreach and health department programs.

References

1. Hahn RA, Onorato IM, Jones TS, Dougherty J. Prevalence of HIV infection among intravenous drug users in the United States. JAMA 1989;261:2677-84.

2. Vlahov D, Anthony JC, Munoz A, et al. The ALIVE study: a longitudinal study of HIV-1 infection among intravenous drug users: description of methods. In: Hartsock PI, Genser SG, eds. Longitudinal studies of HIV infection. Washington, DC: US Department of Health and Human Services, Public Health Service, Alcohol, Drug Abuse, and Mental Health Administration (in press). (National Institute on Drug Abuse research monograph).

3. Talshoff LB, ed. Broadcasting/cablecasting yearbook, 1988. Washington, DC: Broadcasting Publications, Inc., 1988.

4. Naples MJ. Effective frequency: the relationship between frequency and advertising effectiveness. New York: Association of National Advertisers, 1979.

5. Tellis GJ. Advertising exposure, loyalty, and brand purchase: a two-stage model of choice. Journal of Marketing Research 1988;25:134-44.

6. Wallack LM. Mass media campaigns: the odds against finding behavior change. Health Educ Q 1981;8:209-60.

7. Warner KE. Television and health education: stay tuned. Am J Public Health 1987;77:140-2.

8. Hornik RC. Channel effectiveness in development communication programs. In: Rice RE, Atkin CK, eds. Public communication campaigns. 2nd ed. Newbury Park, California: Sage Publishing, Inc., 1989.

9. Pierce JP, Macaskill P, Hill D. Long-term effectiveness of mass media led antismoking campaigns in Australia. Am J Public Health 1990;80:565-9. 10. Vlahov D, Anthony JC, Celentano D, Solomon L, Chowdhury N. Trends of HIV-1 risk reduction among initiates into intravenous drug use, 1982-1987. Am J Drug Alcohol Abuse 1991;17:39-48. *Use of trade names is for identification only and does not imply endorsement by the Public Health Service or the U.S. Department of Health and Human Services.

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