Theory and Method

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Understanding and Promoting Sexual and Reproductive Health Behavior: Theory and Method a

William A. Fisher Ph.D. & Jeffery D. Fisher Ph.D.

b

a

Department of Psychology and Department of Obstetrics and Gynaecology, Social Science Centre 6430 , University of Western Ontario , London , Ontario , Canada , N6A 5C2 b

Department of Psychology , University of Connecticut , 406 Babbidge Road, Storrs , CT , USA Published online: 15 Nov 2012.

To cite this article: William A. Fisher Ph.D. & Jeffery D. Fisher Ph.D. (1998) Understanding and Promoting Sexual and Reproductive Health Behavior: Theory and Method, Annual Review of Sex Research, 9:1, 39-76 To link to this article: http://dx.doi.org/10.1080/10532528.1998.10559926

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Understanding and Promoting Sexual and Reproductive Health Behavior: Theory and Method


WILLIAM A. FISHER & J E F F R E Y D. FISHER Scientists and clinicians are concerned with a spectrum of sexual and reproductive health behaviors, including sexual function (e.g., Heiman & Meston, 1997; Wincze & Carey, 1991), STD/HIV preven tion (e.g., C a t a n i a , Kegeles, & C o a t e s , 1990; W a s s e r h e i t , A r a l , Holmes, & Hitchcock, 1991), contraceptive utilization (e.g., Byrne, Kelley, & Fisher, 1993; Morrison, 1985), reproductive cancer screen ing (e.g., McCaul, S a n d g r e n , O'Neill, & Hinsz, 1993; M o n t a n o & Taplin, 1991), and sexual adjustment to aging, illness, and disability (Basson, 1997; Myerowitz & Hart, 1995; Sha'ked, 1981). Sexual and reproductive health behaviors—acts which avert sexual and repro ductive h e a l t h distress or e n h a n c e sexual a n d reproductive func tion—share a great deal in common, including common antecedents, common consequents, and common intervention pathways for promo tion of health behavior change (W. Fisher, 1990a, 1990b). In this arti cle, we p r e s e n t a t h e o r e t i c a l f r a m e w o r k for u n d e r s t a n d i n g t h e psychological determinants of sexual and reproductive health behav iors and a methodology for creating theoretically based and empiri cally targeted interventions to promote such behaviors across health behaviors and populations of interest. All Together N o w : S e x u a l a n d R e p r o d u c t i v e H e a l t h B e h a v i o r s C o m p r i s e a C o m m o n C a t e g o r y of A c t s The spectrum of sexual and reproductive health behaviors repre sents a common category of conceptually related acts for a number of significant r e a s o n s . F i r s t a n d foremost, sexual a n d reproductive health behaviors, whether they involve sexual function promotion, contraceptive utilization, STD/HIV prevention, reproductive cancer screening, or sexual adaptations to aging, illness, or disability, repre sent sexualized behavioral events. Each of these sexual and reproduc tive h e a l t h behaviors h a s acquired sexual m e a n i n g as a r e s u l t of social ascription (e.g., Gagnon & Simon, 1973; H e n s l i n & Biggs, 1978), individual learning (e.g., W. Fisher, Byrne, Kelley, & White, 39


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W. A. FISHER AND J. D. FISHER

1988; Mosher & Cross, 1971), and the sexual and reproductive biology a n d physiology ( M a s t e r s & J o h n s o n , 1966; R o s e n & Beck, 1986) involved in all of the acts and adjustments in question. As sexualized acts, sexual and reproductive health behaviors are all influenced by a common set of determinants of sexual behavior, including information, motivation, and behavioral skills factors (J. Fisher & Fisher, 1992a; W. Fisher, 1990a, 1990b; W. Fisher, Byrne, et al., 1988), and all are poten tially modifiable via common intervention pathways focusing on chang ing these factors in efforts to promote sexual and reproductive health (J. Fisher & Fisher, 1992a; W. Fisher & Fisher, 1993). As one example of t h e s u b s t a n t i a l commonalities involved in sexual a n d reproductive h e a l t h b e h a v i o r s , it is n o t e d t h a t a c t s a s d i v e r s e as condom u s e , diaphragm use, pelvic examination, breast self-examination, and breast feeding of infants are all sexualized acts involving exposure and manip ulation of sexual and reproductive anatomy. All of these acts occur or fail to occur a s a function of i n d i v i d u a l differences in e m o t i o n a l responses to sexual cues or erotophobia-erotophilia, a n d a common approach to promoting these acts would involve efforts to reduce nega tive emotional responses to sexual cues as a means of motivating perfor mance of this category of behaviors (W. Fisher, Byrne, et al., 1988; W. Fisher, Byrne, & White, 1983; Kelley, 1983). Finally, sexual and repro ductive health behaviors form a category of reciprocally influential acts, with performance of one sexual or reproductive h e a l t h act affecting present and future performance of other such acts. For example, oral contraceptive use often affects STD/HIV preventive behavior, because oral contraceptive use is associated strongly with cessation of condom use and with rapid escalation in STD infection rates (MacDonald et al., 1990). Via feedback processes (Byrne, 1977; W. Fisher, 1986), the out come of one sexual or reproductive health behavior (e.g., oral contracep tion, cessation of condom use, and STD infection) can influence future performance of other acts within this category (e.g., future condom use and possibly future sexual function; W. Fisher & Tudiver, 1990). Understanding Sexual and Reproductive Health Behavior A variety of theoretical approaches have been applied in efforts to conceptualize determinants of sexual and reproductive health behaviors (see J. Fisher & Fisher, in press, for a review of these theories). Some approaches to understanding reproductive health behaviors, such as the Health Belief Model (Rosenstock, 1991), Social-Cognitive Theory (Bandura, 1997), the Theory of Reasoned Action (Fishbein & Ajzen, 1975),


SEXUAL AND REPRODUCTIVE HEALTH BEHAVIOR

41

the Theory of Planned Behavior (Ajzen, 1991), and the Transtheoretical Model (Prochaska & Velicer, 1997) have been developed outside of the domain of sexual and reproductive health and applied within it (e.g., Bandura, 1992; Basen-Enquist, 1992; Fishbein & Middlestadt, 1989; Montano & Taplin, 1991; Prochaska, Redding, Harlow, Rossi, & Velicer, 1994; Rosenstock, Strecher, & Becker, 1994). Other theories, such as the Sexual Behavior Sequence (Byrne, 1977), t h e AIDS Risk Reduction Model (Catania et al., 1990), and the Information-Motivation-Behav ioral Skills Model (J. Fisher & Fisher, 1992a) have been developed and applied specifically within the area of sexuality and reproductive health and may have special relevance for behavior in this domain (e.g., Cata nia, Coates, & Kegeles, 1994; J. Fisher, Fisher, Williams, & Malloy, 1994; Kelley, Smeaton, Byrne, Przybyla, & Fisher, 1987). Theoretical approaches to u n d e r s t a n d i n g sexual a n d reproductive health behavior can be characterized in terms of their degree of specifi cation, comprehensiveness, parsimony, empirical support, and ease of translation into health promotion intervention strategies (J. Fisher & Fisher, in press). For example, with respect to specification, the Health Belief Model, Social-Cognitive Theory, a n d the AIDS Risk Reduction Model do not completely specify relationships among the multiple con structs t h a t are assumed to determine sexual and reproductive health b e h a v i o r s , w h e r e a s t h e T h e o r y of R e a s o n e d Action, t h e T h e o r y of Planned Behavior, the Sexual Behavior Sequence, and the InformationMotivation-Behavioral Skills Model specify precisely the relationships assumed to exist among the proposed determinants of sexual and repro ductive health practices. In terms of comprehensiveness, theories such as the Health Belief Model, t h e Theory of Reasoned Action, a n d t h e Theory of P l a n n e d Behavior focus on a relatively narrow range of constructs t h a t are pri marily motivational in nature, whereas approaches such as Social-Cog nitive Theory, t h e Sexual Behavior Sequence, a n d t h e InformationMotivation-Behavioral Skills Model r e p r e s e n t conceptually b r o a d e r accounts of t h e r a n g e of factors t h a t are a s s u m e d to be involved in understanding and promoting sexual and reproductive health. With respect to parsimony, several conceptualizations t h a t have been applied to sexual and reproductive health behavior posit a multiplicity of potentially overlapping constructs and processes t h a t have not been subject to multivariate testing and confirmation (e.g., the Transtheoreti cal Model, t h e Sexual Behavior Sequence, t h e AIDS Risk Reduction Model). Others utilize a smaller number of empirically independent con-


42


structs in efforts to account for sexual and reproductive health behavior (e.g., the Theory of Reasoned Action, the Theory of Planned Behavior, the Information-Motivation-Behavioral Skills Model). With respect to empirical support—success in predicting and in some cases changing sexual and reproductive health behaviors—some of the theories are relatively untested (e.g., the AIDS Risk Reduction Model), some have been tested and fared poorly (e.g., the Health Belief Model), and some have received considerable empirical support in predicting and/or changing sexual and reproductive health behaviors (the Theory of Reasoned Action, the Theory of Planned Behavior, Social Cognitive Theory, the Sexual Behavior Sequence, and the Information-MotivationBehavioral Skills Model; see Albarracin, Johnson, Fishbein, & Muellerleile, 1998; J. Fisher & Fisher, in press; W. Fisher, Byrne, et al., 1988; and Rye, 1998, for reviews and discussions of relevant literature). Finally, with regard to ease of translation into sexual and reproduc tive health promotion interventions, some of the theories provide gen eral guidance concerning foci for intervention a t t e m p t s (e.g., Health Belief Model, Social Cognitive Theory, the Sexual Behavior Sequence). Other theories suggest specific strategies such as matching intervention content to stage of readiness to change sexual and reproductive health behaviors (e.g., the Transtheoretical Model, the AIDS Risk Reduction Model). Still other theories are fairly directly translatable into sexual and reproductive health interventions in t h a t they specify the content domains to be focused upon in intervention attempts and the method ologies to be used to create theoretically based and empirically targeted interventions to change sexual and reproductive health behaviors (The ory of Reasoned Action, Theory of Planned Behavior, Information-Moti vation-Behavioral Skills Model). In this article, we utilize the Information-Motivation-Behavioral Skills Model (J. Fisher & Fisher, 1992a; W. Fisher & Fisher, 1993) as a concep t u a l basis for u n d e r s t a n d i n g and promoting sexual and reproductive health behavior. The Information-Motivation-Behavioral Skills approach was selected on the basis of its specification, comparative parsimony, com prehensiveness, empirical support, relevance to this content domain, and ease of translation into intervention strategies for promoting sexual and reproductive health behaviors across health behaviors and populations of interest (see J. Fisher & Fisher, 1992a, and W. Fisher & Fisher, 1993, for detailed discussion of t h e p a r a m e t e r s of this model; see J. Fisher & Fisher, in press, for comparative discussion of the parameters of alterna tive conceptualizations of sexual and reproductive health behavior). In


43

the following sections of this article we present the Information-Motivation-Behavioral Skills approach to understanding and promoting sexual and reproductive health behavior, empirical evidence which h a s been adduced for this approach, and suggestions for directions for future research and application of this conceptualization.


Understanding Sexual and Reproductive Health Behavior: An Information-Motivation-Behavioral Skills A p p r o a c h The Information-Motivation-Behavioral Skills (1MB) model (J. Fisher & Fisher, 1992a; W. Fisher & Fisher, 1993) conceptualizes the psycholog ical determinants of sexual and reproductive health behavior (Byrne et al., 1993; W. Fisher, 1997; Health Canada, 1994; Misovich, Martinez, Fisher, Bryan, & Catapano, 1998). The model originated as an account of the determinants of HIV preventive behavior (J. Fisher & Fisher, 1989) and is based on analysis and synthesis of theory and research in the HIV prevention a n d social psychological l i t e r a t u r e s (J. F i s h e r & Fisher, 1992a). The theory focuses comprehensively on information (e.g., Miso vich, Fisher, & Fisher, 1996; U.S. Department of Health and H u m a n Ser vices, 1988), motivation (e.g., Fishbein & Ajzen, 1975; W. Fisher, Byrne, et al., 1988) and behavioral skills (e.g., Kelly & St. Lawrence, 1988; Schinke, 1984) factors which are conceptually and empirically linked to the performance of sexual and reproductive health behaviors (e.g., Byrne et al., 1993; J. Fisher & Fisher, 1992a; Misovich, Martinez, et al., 1998) but which often are dealt with in isolation in research concerning these behaviors (J. Fisher & Fisher, 1992a, in press). The 1MB model specifies the determinants of sexual and reproductive health behaviors and the relationships among them, and provides a generalizable methodology for translating this approach into theoretically based and empirically tar geted interventions for the promotion of sexual and reproductive health across health behaviors and populations of interest (J. Fisher & Fisher, 1992a; W. Fisher, 1997; W. Fisher & Fisher, 1993). The 1MB model asserts t h a t sexual and reproductive h e a l t h infor mation, motivation to act on this information, and behavioral skills for acting on it effectively, are fundamental determinants of the initiation and maintenance of sexual and reproductive health behaviors. Accord ing to the model, an individual's sexual and reproductive h e a l t h infor mation and motivation work primarily through his or her behavioral skills to affect sexual and reproductive h e a l t h behavior. In essence, sexual and reproductive h e a l t h information and motivation stimulate the development a n d application of sexual a n d reproductive h e a l t h



44

behavioral skills, which are used to initiate and to maintain sexual and reproductive h e a l t h promotion behaviors over time. The model also asserts t h a t in cases in which complicated or novel behavioral skills are not required for the performance of sexual and reproductive health behaviors, there may be direct links between sexual and reproductive health behavior information or motivation and the performance of sex ual and reproductive health behaviors. For example, a woman who is adequately informed about oral contraception and adequately moti vated to use this method may be in a position to adopt it more or less directly and without performing complicated or novel behaviors. In this case, direct links between information a n d motivation and behavior would be observed. In contrast, a woman who is adequately informed about condoms and adequately motivated to use t h e m may still have to execute complicated a n d novel behaviors to e n s u r e t h a t her p a r t n e r uses condoms consistently. In this case, the woman's information and motivation with respect to condom use would be expressed primarily through her application of behavioral skills with the aim of securing p a r t n e r cooperation in condom use. Finally, the 1MB model specifies t h a t sexual and reproductive health behavior information and motiva tion are relatively independent constructs, because individuals who are well-informed about these behaviors are not necessarily well motivated to practice them, a n d individuals who are well motivated are not neces sarily well-informed about how to do so. The constructs and relation ships of the 1MB model of sexual and reproductive health behavior are presented in Figure 1. r / * /

/

\ SEXUAL AND REPRODUCTIVE HEALTH INFORMATION

V

> SEXUAL AND REPRODUCTIVE HEALTH BEHAVIOR SKILLS

V i \ \».


1 SEXUAL AND REPRODUCTIVE HEALTH MOTIVATION

> ^ Figure 1. The Information-Motivation-Behavioral Skills Model of Sexual and Reproduc tive Health Behavior (After J. Fisher & Fisher, 1992a; W. Fisher & Fisher, 1993).



45

The 1MB model's information, motivation, and behavioral skills con structs are regarded as generalizable determinants of sexual and repro ductive h e a l t h behaviors across h e a l t h behaviors a n d populations of interest (J. Fisher & Fisher, 1992a; W. Fisher & Fisher, 1993; see also Byrne et al., 1993; Health Canada, 1994; Misovich, Martinez, et al., 1998). It is asserted, however, t h a t these constructs will have specific content that is relevant to specific sexual and reproductive health behaviors and to particular populations at risk. T h u s , within t h e 1MB approach, it is assumed that specific sexual and reproductive health information, motiva tion, and behavioral skills will be most relevant to understanding and pro moting sexual function, or condom use, or cervical cancer screening. Further, specific information, motivation, and behavioral skills content concerning each of these behaviors will be maximally relevant to men, or women, or adolescents, or women over age 40, or African-Americans or Hispanic-Americans, and so on. Similarly, the 1MB model assumes t h a t specific constructs of the model, and specific causal paths among them, will emerge as more or less powerful determinants of specific sexual and reproductive health behaviors within specific populations of interest. The 1MB approach articulates a methodology for eliciting sexual and reproductive health information, motivation, and behavioral skills con t e n t t h a t is maximally r e l e v a n t to t h e promotion of specific h e a l t h behaviors within specific populations of interest (J. Fisher & Fisher, 1992a, 1996; W. Fisher & Fisher, 1993). According to the 1MB model, identification of specific information, motivation, and behavioral skills content relevant to a specific sexual and reproductive health behavior in a specific population, and identification of the constructs which most strongly influence the practice of this behavior in this population, pro vides critical information for targeting health promotion interventions to improve performance of particular behaviors within particular target populations (J. Fisher & Fisher, 1992a; W. Fisher & Fisher, 1993). The 1MB model has been employed as an account of the psychological determinants of HIV preventive behavior across diverse populations at risk including gay men (J. Fisher et al., 1994), minority youth (W. Fisher, Williams, Fisher, & Malloy, in press), persons with severe mental illness (Carey, Carey, & Kalichman, 1997; Carey, Carey, Weinhardt, & Gordon, 1997), and individuals in close relationships, who modally eschew HIV preventive behavior (Misovich, Fisher, & Fisher, 1997). The model has also been used to conceptualize d e t e r m i n a n t s of adolescent contraceptive behavior (Byrne et al., 1993; see also W. Fisher, 1990a, 1990b), STD risk and prevention (W. Fisher, 1997; see also W. Fisher, 1990a, 1990b), and

46


sexual and reproductive health promotion behavior in general (Health Canada, 1994).


Information

and Sexual and Reproductive

Health

Behavior

The 1MB model asserts t h a t information t h a t is relevant to the prac tice of sexual and reproductive health behavior is a critical prerequisite of the initiation and maintenance of such behavior. The combination of ignorance of information t h a t is relevant to the performance of sexual and reproductive health behavior and reluctance to provide such infor mation in educational or clinical settings is associated with sexual and reproductive health neglect (e.g., Allgeier, 1983; Byrne et al., 1993; Misovich, Fisher, & Fisher, 1996, 1998; Hennig & Knowles, 1990; Morrison, 1985; Salazar & Carter, 1994). Across sexual and reproductive h e a l t h behaviors and populations at risk, ignorance, misinformation, a n d cognitive processing strategies t h a t obstruct preventive behavior are ubiquitous. For example, with respect to adolescent contraception, across eight different samples, it h a s been found t h a t fewer t h a n half of all teenagers can correctly iden tify t h e fertile period of t h e m e n s t r u a l cycle (Morrison, 1985), and researchers have also shown t h a t teens often lack a level of cognitive development t h a t is sufficient for them to accurately anticipate the risk of pregnancy or to foresee t h e future consequences of contraceptive neglect (Cvetkovich & Grote, 1983; Mindick & Shapiro, 1989; Oskamp & Mindick, 1983; Paikoff, 1990). With respect to STD/HIV prevention, ignorance of critical information about preventive behavior and cogni tive processing strategies t h a t obstruct prevention are also exceedingly common (e.g., Hammer, Fisher, Fitzerald, & Fisher, 1996; Offir, Fisher, Williams, & Fisher, 1993; Williams et al., 1992). For example, among sexually active minority high school s t u d e n t s who reside in an area with high adolescent HIV rates, some 70% believed t h a t "making sure you don't have too many sex p a r t n e r s will protect you from HIV" (W. Fisher, Misovich, Fisher, & Lewis, 1998). And, in samples of heterosex u a l college m e n a n d women ( H a m m e r et al., 1996; Williams et al., 1992), gay male affinity group members (Offir et al., 1993), and HIV+ m e n a n d women (J. Fisher, Kimble, Misovich, & Weinstein, 1998; J. Fisher, Misovich, Kimble, & Weinstein, in press), widespread reliance on cognitive heuristics t h a t are patently inaccurate (e.g., "known part ners are safe partners," "anyone who would have unprotected sex with me is a l r e a d y HIV+") quite often s u b s t i t u t e d for actually effective STD/HIV preventive behaviors, such as condom use. In the same sam-



47

pies, widespread reliance on implicit theories of risk, which assert t h a t it is possible to detect and avoid risky partners on the basis of exter nally observable cues, such as dress and demeanor, also commonly sup planted objectively effective STD/HIV preventive behaviors. In a similar fashion, information deficits also exist with respect to reproductive cancers. For example, few are aware t h a t cervical cancer is caused by h u m a n papillomavirus, t h a t h u m a n papillomavirus is a sexu ally transmitted pathogen, and t h a t condoms are not highly effective in preventing h u m a n papillomavirus transmission (Ferenczy, 1997; Health Canada, 1998). With regard to a spectrum of other sexual and reproduc tive health concerns, widespread ignorance exists with respect to many basic behaviorally relevant facts, including the fact t h a t most women are not coitally orgasmic without direct clitoral stimulation (e.g., Hyde, 1994), t h a t vaginal lubrication is scanty and sexual function may conse quently be i m p a i r e d a m o n g p o s t p a r t u m women who breastfeed (W. Fisher & Gray, 1988; Masters & Johnson, 1966), t h a t hepatitis B is a sexually transmitted disease for which a vaccine is available (Health Canada, 1998), and t h a t prevention of mother to child transmission of HIV via pharmacological therapy and cesarean section delivery is now possible (W. Fisher et al., 1998). It should be emphasized t h a t clinicians who provide sexual and repro ductive health care are also often ignorant of basic information about these topics (W. Fisher, Grenier, et al. 1988), including apparent lack of awareness of the link between onset of oral contraceptive use, offset of condom use, and STD risk (MacDonald et al., 1990); lack of awareness t h a t STD/HIV prevention should extend beyond condom use to include cervical cancer screening and hepatitis B vaccination (Health Canada, 1998); and lack of awareness of the base rates of behaviorally driven reproductive health threats, such as contraceptive neglect and unsafe sex in their practices (Epstein et al., 1998; W. Fisher, Silcox, & Kohn, 1992). Completing the picture of informational obstacles to sexual and repro ductive health behavior is the fact t h a t educational interventions in this area are often constructed, intentionally or unintentionally, so as to ensure t h a t sexual a n d reproductive h e a l t h ignorance will be main tained. Specifically, it has been observed t h a t sexual and reproductive health education often provides information t h a t is completely irrelevant to the actual practice of preventive behavior, incomprehensible, frighten ing, sexist, and frankly dangerous, in t h a t it provokes patterns of sexual and reproductive health risk behavior rather t h a n promoting prevention (Byrne, 1983; J. Fisher & Fisher, 1992a; W. Fisher, 1990a; W. Fisher &



48

Fisher, 1993). Sexually active high school students may be exposed to abstinence-based curricula, to details of the biochemistry of the phases of the m e n s t r u a l cycle, and to descriptions of fetal development across three trimesters of gestation, b u t they may never receive behaviorally relevant information about where to acquire and how to use the methods of contraception they need to use to prevent pregnancy (e.g., Byrne et al., 1993; W. Fisher, 1990a; Kirby, Korpi, Barth, & Cagampang, 1997; Yarber & McCabe, 1981, 1984). Sexual and reproductive health information may also be presented in an incomprehensible fashion which is unlikely to be understood (W. Fisher, 1990a, W. Fisher & Fisher, 1993). It may be gratuitously frightening and involve fear-arousing communications that are unaccompanied by easy-to-implement and fear-reducing prevention recommendations (W. Fisher, 1990a; Leventhal, 1970). Sexist sexual and reproductive h e a l t h information which unjustifiably emphasizes or ignores the role of men or women in sexual and reproductive health has historically been in evidence (Rindskopf, 1981) as has heterosexist and homophobic sexual and reproductive health information. Finally, frankly dangerous information which is capable of provoking patterns of sexual and reproductive health risk is also commonly in evidence (W. Fisher, 1990a). Sexual and reproductive health information which may be trans lated into patterns of risky behavior may come from prestigious public h e a l t h authorities such as the U.S. Surgeon General (e.g., pamphlets s t r e s s i n g t h a t "known p a r t n e r s are safe p a r t n e r s , " mailed to every household in the U.S.; U.S. Department of Health and H u m a n Services, 1988). Such information may come from the mass media, as in cover sto ries in Cosmopolitan ("A Doctor Tells Why Most Women are Safe From AIDS," January, 1988) and Newsweek ("The End of AIDS?," December 2, 1996), and some may come from special interest groups ("Don't be AIDS' Next Victim—Condoms will NOT Protect You," Anonymous, 1993). According to the 1MB analysis, sexual and reproductive health infor mation t h a t is irrelevant to the personal practice of preventive behavior, incomprehensible, frightening, sexist, and/or likely to be translated into risky practices is antithetical to the performance of sexual and reproduc tive health behaviors. In contrast, relevant and understandable informa tion about sexual and reproductive health behavior t h a t is easy for the individual to implement in his or her social ecology is more likely to pro mote performance of sexual and reproductive health behaviors. Motivation

and Sexual and Reproductive

Health

Behavior

The 1MB model asserts t h a t motivation to enact sexual and reproduc-



49

tive health behaviors rests on personal motivation (attitudes towards the personal practice of sexual and reproductive health behaviors; cf. Ajzen & Fishbein, 1980; Fishbein & Ajzen, 1975; Fishbein & Middlestadt, 1989); social motivation (social norms or perceptions of social support for the performance of sexual and reproductive health behaviors; cf. Ajzen & Fishbein, 1980; Fishbein & Ajzen, 1975; J. Fisher, 1988); and emotional responses to sexual cues (Byrne et al., 1993; W. Fisher, 1984; W. Fisher, Byrne, et al., 1988) which are expected to generalize and determine avoidance or approach of sexual and reproductive health behaviors. Considerable evidence exists to suggest t h a t p e r s o n a l a t t i t u d e s , social norms, and affective responses to sexuality motivate a range of sexual and reproductive health behaviors. With respect to attitudes and social norms concerning t h e personal practice of specific sexual a n d reproductive h e a l t h b e h a v i o r s , t h e findings a r e t h a t a t t i t u d e s a n d norms are consistently associated with contraceptive use (e.g., Davidson & Jaccard, 1979; W. Fisher, 1984; Jaccard & Davidson, 1972), mammography and breast self-examination intentions and behavior (e.g., Howe, 1981; Lierman, Kasprzyk, & Benoliel, 1991; McCaul et al., 1993; Misovich, Martinez, et al., 1998; Montano & Taplin, 1991; Ronis & Kaiser, 1989; Van Ryn, Lytle, & Kirscht, 1996), pelvic examination (e.g., Hennig & Knowles, 1990; Hill, Gardner, & Rassaby, 1985) and testicular selfexamination (e.g., Brubaker & Wickersham, 1990; McCaul et al., 1993) intentions, and condom use and related safer sexual behaviors in the era of AIDS (e.g., Albarracin et al., 1998; Basen-Enquist, 1992; Chan & Fishbein, 1993; W. Fisher, Fisher, & Rye, 1995; Rye, 1998). According to the 1MB model, emotional responses to sexuality are also expected to generalize and to determine avoidance or approach of sexual and reproductive health behaviors (Byrne et al., 1993; W. Fisher, 1990b; W. Fisher, Byrne, et al., 1988; W. Fisher et al., 1983). Findings consistently indicate t h a t erotophobia-erotophilia, t h e disposition to respond to sexual cues with negative to positive affect, is a significant d e t e r m i n a n t of s e x u a l a n d r e p r o d u c t i v e h e a l t h b e h a v i o r s (e.g., W. Fisher, Byrne, et al., 1988; W. Fisher et al., 1983; see Gerrard, 1982, for evidence t h a t sex guilt, a related construct, functions in a similar fash ion). For example, erotophobic (compared to erotophilic) individuals are less able to talk about sex (W. Fisher, Miller, Byrne, & White, 1981) and less able to learn about (W. Fisher et al., 1983), acquire (W. Fisher, Fisher, & Byrne, 1977), and use (e.g., W. Fisher, 1984; W. Fisher et al., 1979; Gerrard, 1982; Kelley et al., 1987) contraception. Erotophobia-ero tophilia of mothers is associated with avoidance or approach of sexual


50


activity during pregnancy, speed of resumption of coitus postpartum, and duration of breastfeeding of infants, and erotophobia-erotophilia of fathers is associated with their absence or presence in the delivery room at the time of the birth of their child (W. Fisher & Gray, 1988). Eroto phobia-erotophilia is also correlated with avoidance or approach of such reproductive h e a l t h behaviors as b r e a s t self-examination and pelvic examination (W. Fisher, Byrne, et al., 1988; W. Fisher et al., 1983). In addition, erotophobia-erotophilia of husbands and wives is strongly cor related (W. Fisher & Gray, 1988; Lemery, 1983; Smith, Becker, Byrne, & Przybyla, 1993), and it h a s been found t h a t erotophobic (compared to erotophilic) parents are less likely to teach their children accurate infor m a t i o n a b o u t s e x u a l i t y a n d r e p r o d u c t i o n (Lemery, 1983; Yarber & Whitehill, 1981). Further, husband-wife discrepancies in erotophobiaerotophilia are associated with sexual dissatisfaction in both partners, and erotophobic (compared to erotophilic) spouses had less accurate per ceptions of their p a r t n e r s ' sexual enjoyment (Smith et al., 1993). It is important to note t h a t erotophobia-erotophilia h a s been found to have effects on reproductive health behaviors over and above simultaneously e s t i m a t e d effects of a t t i t u d i n a l a n d n o r m a t i v e influences on such behavior (W. Fisher, 1984). In addition to effects of emotional responses to sexuality on individu al's sexual and reproductive health behavior, it should be stressed t h a t erotophobia-erotophilia h a s a significant impact on the practices of sex ual and reproductive h e a l t h professionals. Yarber and McCabe (1981, 1984) found t h a t sex education teachers who were relatively erotophobic avoided t e a c h i n g a b o u t controversial (e.g., sexual orientation) a n d behaviorally relevant (e.g., where to get and how to use contraception) topics a t the middle-school and high-school levels. Researchers have also found t h a t erotophobic medical s t u d e n t s , n e a r i n g completion of their studies, knew less about medical aspects of sexuality t h a n their erotophilic counterparts; reported less willingness to t r e a t individuals with sexual concerns; and were unlikely to acquire additional informa tion about medical aspects of sexuality despite attending educational sessions devoted to this topic (W. Fisher, Grenier, et al., 1988). Evidence is t h u s consistent with the 1MB model's assertion t h a t attitudes and norms regarding the personal performance of sexual and reproductive h e a l t h behaviors, a n d generalized emotional responses to sexuality, serve as i m p o r t a n t d e t e r m i n a n t s of sexual a n d reproductive h e a l t h practices across a range of such behaviors and for the general public and professionals alike.


51


Behavioral Skills and Sexual and Reproductive Health Behavior According to the 1MB model, behavioral skills for performing a sequence of sexual and reproductive health promotion acts will deter mine whether an individual will be able to engage in sexual and repro ductive health behaviors effectively. Behavioral skills consist of objective skills for the performance of sexual and reproductive health promotion acts (e.g., Byrne, 1983; W. Fisher, 1990a; Kelly & St. Lawrence, 1988) and self-efficacy for enacting such behaviors (e.g., BanTable 1 Sexual and Reproductive Health Behavior Sequence

Self-Acceptance of Sexuality and Reproduction (e.g., "I am a legitimately sexual being with legitimate reproductive health needs")

I

Creating Personal Sexual and Reproductive Health Agenda (e.g., "I want to remain uninfected, unassaulted, unpregnant and to avoid or detect reproductive cancers") Bringing up, Negotiating Prevention/Promotion Exiting Unsafe Situations (e.g., "Can we talk?" / "Here, put this condom on" / If you don't stop, it is called rape!")

I Public Prevention/Promotion Acts (e.g., see MD, buy condoms, report abuse, etc.)

i

Consistent Practice of Prevention/Promotion, Self- Partner-Reinforcement (e.g., feeling relief, expressing thanks)

I

Shifting Prevention/Promotion Scripts (e.g., abstinence -+—► coitus)


52


dura, 1989, 1997; see also Ajzen, 1985, 1991), and the two appear to be correlated (Williams et al., 1998). Objective skills and self-efficacy for performance of a sequence of relevant acts are required for initiation and maintenance of sexual and reproductive health behavior (Byrne, 1983; W. Fisher, 1990a, 1990b; W Fisher & Fisher, 1993; see Table 1). As can be seen in Table 1, self-acceptance of sexuality and reproduc tion is an initial step in the sequence of acts required to effect sexual and reproductive h e a l t h behavior. Unless a n individual is capable of accepting the fact t h a t he or she is a sexual being with sexual health (e.g., sexual function, coercion avoidance) and reproductive health (e.g., contraception, STD/HIV prevention) needs, sexual a n d reproductive health behaviors are unlikely to take place. Assuming acceptance of sexuality and reproduction has occurred, an individual m u s t create a sexual and reproductive health agenda (e.g., "I wish to r e m a i n uninfected, u n p r e g n a n t , a n d u n a s s a u l t e d " ) t h a t is appropriate to the individual's sexual and reproductive health needs at a particular point in time. To implement this agenda, individuals must be capable of (and m u s t believe they are capable of) actions such as uni l a t e r a l l y practicing sexual a n d reproductive h e a l t h behaviors (e.g., engaging in breast or testicular self-examination), negotiating with a p a r t n e r to ensure cooperation in sexual and reproductive health prac tices (e.g., assertively requesting desired changes in sexual activity type or frequency, or requesting cooperation in contraceptive and condom use to prevent conception and infection). If such negotiations fail, the indi vidual m u s t be skilled at exiting situations in which sexual and repro ductive health solutions cannot be acceptably negotiated. In addition to sexual and reproductive health actions undertaken unilaterally or coop eratively with sexual partners, it is also frequently necessary to engage in public sexual and reproductive h e a l t h behavior acts which involve disclosure of one's sexuality and reproductive health concerns to other individuals. P u r c h a s i n g a self-help book concerning sexual function, acquiring condoms a t a pharmacy, or m a k i n g an a p p o i n t m e n t for a gynecological or urological examination all involve a degree of the pub lic expression of one's sexuality and reproductive function. In order to maintain sexual and reproductive health behaviors over time, an individual m u s t possess the ability to reinforce the self and the p a r t n e r for performance of sexual and reproductive health behaviors. An individual skilled at vicariously reinforcing the self ("It's been years since I've worried about unsafe sex") and the partner ("You make it so easy for me to talk about what I like when we make love") is theorized



53

to be more likely to maintain sexual and reproductive health behaviors over time t h a n one who lacks such skills (W. Fisher, 1990a). In addition, an individual m u s t be skilled a t shifting sexual and reproductive health behavior scripts appropriately as needs change over time. Thus, among individuals who have a stable and m a t u r e enough relationship to enter tain the responsibilities and risks associated with the following approxi mation of safer sexual behavior, it is appropriate to shift from condom use to monogamy as a safer sex strategy after a window period, mutual HIV a n t i b o d y t e s t i n g , a n d d i s c u s s i o n of m a i n t e n a n c e of m u t u a l monogamy and rules for handling any violations of m u t u a l monogamy which may take place. It is inappropriate to shift from condom use to monogamy as a safer sex strategy after a brief period of "getting to know" one's partner (cf, Misovich et al., 1996) or for young couples in whom relationship stability is low and rates of p a r t n e r exchange are high. Other shifts will be age related and may involve movement at a particular age to a routine of prostate specific antigen t e s t i n g or to mammography as mechanisms for the early detection of reproductive cancers. Objective skills and self-efficacy for this sequence of health promotion acts should facilitate effective enactments of the range of sexual and reproductive h e a l t h behaviors under discussion, including pregnancy prevention, STD/HIV prevention, sexual coercion prevention, reproduc tive cancer screening, and sexual function promotion behaviors. Tables 2, 3, a n d 4 i l l u s t r a t e specifications of t h e sexual a n d r e p r o d u c t i v e h e a l t h p r o m o t i o n b e h a v i o r s e q u e n c e for p r e g n a n c y p r e v e n t i o n , STD/HIV prevention, and sexual function promotion. It should also be noted t h a t a parallel sequence of sexual and reproductive health promo tion behavioral skills can be acquired and applied by clinicians to stim ulate client or p a t i e n t e n a c t m e n t of sexual a n d reproductive h e a l t h behaviors. This set of clinician behavioral skills includes (a) skills for establishing environmental, nonverbal cues to signal to clients t h a t the clinician is a n a p p r o a c h a b l e , k n o w l e d g e a b l e , a n d n o n j u d g e m e n t a l address to which to bring sexual and reproductive health concerns; (b) verbal skills for taking a history to assess clients' sexual and reproduc tive health risk behaviors and for intervening to promote prevention; and (c) clinician skills for self-evaluation and accessing continuing pro fessional education in this area (see Table 5). Clinicians' skilled practice of these behaviors is expected to stimulate clients' or patients' own prac tice of sexual and reproductive health behavior. Considerable evidence exists t h a t supports t h e suggestion t h a t t h e


54


skilled performance of acts such as these is associated with the practice of sexual and reproductive health behaviors in the areas of adolescent contraception (e.g., W. Fisher, 1983, 1990a, 1990b; Kirby, Barth, Leland, & Fetro, 1991; Schinke, Blythe, & Gilchrest, 1981) and HIV prevention (J. Fisher, Bryan, & Fisher, 1998a, 1998b; J. Fisher & Fisher, 1992a; Kelly & St. Lawrence, 1988; Kirby & DiClemente, 1994). Objective skills involved in breast self-examination have also been linked with ability to effectively enact this behavior (e.g., Clarke, Hill, Rassaby, White, & Hirst, 1991; Friedman, Nelson, Webb, Hoffman, & Baer, 1994; Murray & McMillan, 1993; Salazar & Carter, 1994). Reviewers of the Table 2 Sexual and Reproductive Health Behavior Sequence: Pregnancy Prevention

Self-Acceptance of Sexuality and Reproduction "I am sexually active"

J

Setting Personal Sexual and Reproductive Health Agenda "I want to prevent pregnancy" \ Bringing up, Negotiating Sexual and Reproductive Health Issues "Can we talk. .. ?", Setting limits; Discussing contraception

I

Public Prevention/Promotion Acts Visit birth control clinic, pharmacy

I

Consistent Sexual and Reproductive Health Prevention/Promotion, Self- Partner-Reinforcement Consistent abstinence or contraceptive use, feelings of relief, expression of thanks \ Shifting Prevention/Promotion Scripts Abstinence -* ► Protected Coitus



55

literature have also identified sexual and reproductive health behav ioral skills training as a key characteristic of effective behavior change interventions in areas of HIV prevention and adolescent pregnancy pre vention (e.g., J. Fisher & Fisher, 1992a; Kirby & DiClemente, 1994), and the practice of sex therapy focuses on the acquisition of an array of relevant behavioral skills (e.g., Heiman & LoPiccolo, 1988). Individual interventions that have heavily emphasized skill build ing have had a significant impact on sexual and reproductive health behaviors (e.g., Kelly & St. Lawrence, 1988; Kirby et al., 1991; Schinke et al., 1981), and in prospective research that has focused on Table 3 Sexual and Reproductive

Health Behavior Sequence: STDIHTV

Prevention

Self-Acceptance of Sexuality and Reproduction "I am sexually active"

i Setting Personal Sexual and Reproductive Health Agenda "I want to prevent infection"

I Bringing up, Negotiating Sexual and Reproductive Health Issues "I want to have sex with you, and I enjoy it more if it's safe ..." \ Public Prevention/Promotion Acts Condom purchasing, HIV testing, Pap testing, Hepatitis B vaccination, etc.

I

Consistent Sexual and Reproductive Health Prevention/Promotion, Self- Partner-Reinforcement Consistent practice, feelings of relief, expression of thanks

Shifting Prevention/Promotion Scripts Abstinence -< ► Protected Coitus


56


t h e e n a c t m e n t of specific behaviors (e.g., accepting one's sexuality a n d t h e fact t h a t one might soon be sexually active; asking a p a r t n e r to use a condom), it h a s been documented t h a t performance of such behaviors is associated with future e n a c t m e n t of sexual and repro ductive h e a l t h practices, such as condom use (W. Fisher, 1984) and HIV prevention (J. Fisher, Bryan, & Fisher, 1998b). Similarly, percep t i o n s of self-efficacy for t h e p e r f o r m a n c e of r e p r o d u c t i v e h e a l t h behaviors have been associated with m a m m o g r a p h y screening (Montano & Taplin, 1991), b r e a s t self-examination (Misovich, Martinez, et al., 1998; McCaul et al., 1993; Ronis & Kaiser, 1989; Van Ryn et al., 1996), t e s t i c u l a r self-examination i n t e n t i o n s ( B r u b a k e r & WickerTable 4 Sexual and Reproductive

Health Behavior Sequence: Sexual Function

Promotion

Self-Acceptance of Sexuality and Reproduction "I am a legitimately sexual being"

I Setting Personal Sexual and Reproductive Health Agenda "I want to act to improve our sexual function"

I

Bringing up, Negotiating Sexual and Reproductive Health Issues "I've been thinking .. . Can we try . . . ?"

I

Public Prevention/Promotion Acts Acquiring information, Seeking treatment

I

Consistent Sexual and Reproductive Health Promotion, Self- Partner-Reinforcement Feelings of satisfaction, expression of thanks

I

Shifting Prevention/Promotion Scripts Improved sexual function ► Maintaining behavior


57

sham, 1990), and condom use and related safer sexual behaviors in the era of AIDS (Albarracin et al., 1998; Rye, 1998). In accord with the assertions of the 1MB model, objective behavioral skills and a sense of self-efficacy appear to be significantly implicated in the per formance of a range of sexual and reproductive health behaviors.


Empirical Support for the 1MB Approach to Understanding Sexual and Reproductive Health Behavior Empirical support for the relationships proposed by the 1MB model has been accumulated in extensive research concerning the association of information (e.g., Misovich et al., 1996; Morrison, 1985; Williams et al., 1992), motivation (e.g., Albarracin et al., 1998; Brubaker & Wickersham, 1990; W. Fisher, Byrne, et al., 1988; W. Fisher et al. 1995; Montano & Taplin, 1991), behavioral skills (e.g., J. Fisher et al., 1996; Kelly & St. Lawrence, 1988; Schinke, 1984) and a category of sexual and reproductive health behaviors including adolescent contraception, HIV prevention across diverse populations, mammography screening behavior, and the like (see preceding discussion). Empirical support for the 1MB model has been also adduced in direct multivariate tests of the model which simultaTable 5 Reproductive

Health Promotion

Scripts

Clinician Behaviors

Client/Patient Behaviors

Environmental Cues

Self-Acceptance of Sexuality and Reproduction

I Verbal Messages

Continuing Education

Creation of User-Friendly Referral Network

Creating Personal Sexual and Reproductive Heatth Agenda

I I

Negotiating Sexual and Reproductive Health

Public Sexual and Reproductive Health Promotion^revention Acts

1 Consistent Sexual and Reproductive Health Promotion/Prevention Self- and Partner- Reinforcement

Sexual and Reproductive Health Service Audit

I Evaluating Consequences / Shifting Scripts


58


neously estimate the relationships of information, motivation, behavioral skills, and behavior in the context of HIV preventive behaviors across pop ulations at risk (e.g., J. Fisher et al., 1994; J. Fisher, Bryan, & Fisher, 1998c; W. Fisher et al., 1998) and in research on the 1MB model and breast self-examination behavior (Misovich, Martinez, et al., 1998). In multivariate tests of the 1MB model for the prediction of HIV pre ventive behavior, consistent empirical support for the proposed direct a n d m e d i a t e d r e l a t i o n s h i p s of information, motivation, behavioral skills, and behavior h a s been reported (see J. Fisher & Fisher, in press, for a review of this literature). In an initial study, J. Fisher et al. (1994) applied the 1MB model to explain HIV preventive behavior among het erosexual university students. Structural equation modelling revealed that, in this sample, HIV prevention information and HIV prevention motivation w e r e s t a t i s t i c a l l y i n d e p e n d e n t factors, information a n d motivation were each related to HIV prevention behavioral skills, and HIV prevention behavioral skills were related to HIV preventive behav ior per se, confirming each of the 1MB model's theorized relationships (see Figure 1). In addition, in accord with the 1MB model, a direct link between motivation and preventive behavior was observed in the uni versity sample. In a second study, the 1MB model was applied to explain HIV preventive behavior in a community sample of adult homosexual men (J. Fisher et al., 1994). Again using structural equation modelling to provide a multivariate test of the model, it was found t h a t HIV pre vention information and HIV prevention motivation were independent factors, information a n d motivation were associated with preventive behavior skills, and preventive behavior skills were associated with pre v e n t i v e b e h a v i o r per se, a s p r e d i c t e d by t h e model. A direct link between HIV prevention motivation and HIV preventive behavior was also observed, again as predicted by the model. In an additional, finergrain, prospective test of the 1MB model, J. Fisher, Bryan, and Fisher (1998a) applied the model to predict inner-city minority high school stu dents' HIV preventive behavior. Results showed t h a t HIV prevention information a n d HIV prevention motivation were i n d e p e n d e n t con structs; t h a t information and motivation were associated with preven tion behavioral skills; t h a t prevention behavioral skills were associated with enactment of a preparatory HIV preventive behavior (discussing condom use with a partner); and t h a t enactment of preparatory HIV preventive behavior was associated with HIV preventive behavior per se (condom use). Additional confirmations of the 1MB model have been reported in the context of research on HIV preventive behavior among



59

inner-city m i n o r i t y y o u t h (W. F i s h e r e t al., in p r e s s ) , low-income African-American women (Anderson et al., 1998), a d u l t homosexual men in the Netherlands (deVroom, deWit, Sandfort, & Strobe, 1996), and urban intravenous drug users (J. Fisher, Byran, & Fisher, 1998a). Across tests of the 1MB model, HIV prevention information, motivation, and behavioral skills have accounted for an average of 45% of the vari ance in HIV preventive behavior (J. Fisher & Fisher, in press). Direct multivariate confirmation of the 1MB model is also available in research concerning breast self-examination behavior. In research on this topic, Misovich, Martinez, et al. (1998) examined t h e theorized association of breast self-examination information, motivation, behav ioral skills, and behavior in a sample of adult employed women. Struc t u r a l equation modelling confirmed t h a t (a) b r e a s t self-examination information and motivation were independent constructs, (b) informa tion and motivation were each associated with breast self-examination behavioral skills, and (c) breast self-examination behavioral skills were reliably associated with b r e a s t self-examination behavior per se. A direct association of breast self-examination motivation and breast selfexamination behavior was observed as well. These findings consistently confirmed the relationships proposed by the 1MB model and accounted for 36% of the variance in breast self-examination behavior. The relationships of information, motivation, behavioral skills, and behavior hypothesized by t h e 1MB model h a v e received c o n s i s t e n t empirical support across a variety of sexual and reproductive h e a l t h behaviors and populations of interest. We t u r n now to discussion of the application of the 1MB model to promotion of sexual and reproductive health behavior. Promoting Sexual and Reproductive Health Behavior: A n Information-Motivation-Behavioral Skills A p p r o a c h The 1MB approach to promoting sexual a n d r e p r o d u c t i v e h e a l t h behavior specifies a set of generalizable operations for constructing, implementing, and evaluating health promotion interventions for par ticular target behaviors a n d populations of interest (J. Fisher & Fisher, 1 9 9 2 a , 1996; W. F i s h e r & F i s h e r , 1 9 9 3 ) . A c c o r d i n g to t h e 1MB approach, the first step in promoting sexual and reproductive h e a l t h behavior involves conducting elicitation research with a subsample of a target population to empirically identify t h a t population's deficits, and assets, in information, motivation, behavioral skills, and behavior in relation to a sexual and reproductive h e a l t h practice or practices of


60


i n t e r e s t . T h e 1MB model e m p h a s i z e s u s e of o p e n - e n d e d r e s e a r c h methodologies, such as open-ended q u e s t i o n n a i r e s a n d focus group techniques (e.g., W. Fisher & Fisher, 1993; H a m m e r et al., 1996; Offir et al., 1993; Williams et al., 1992), in addition to close-ended method ologies (e.g., Ajzen & Fishbein, 1980; Misovich, Fisher, & Fisher, 1998), in order to elicit accessible, unprompted, "top-of-the-head" content con cerning sexual and reproductive health information, motivation, behavioral skills, and behaviors. The second step in the 1MB approach to promoting sexual a n d reproductive h e a l t h involves creation and implementation of conceptually based, empirically targeted, populationspecific interventions, constructed on the basis of elicitation research findings. Such interventions address empirically identified deficits in sexual a n d reproductive h e a l t h promotion information, motivation, behavioral skills, and behavior, and capitalize on assets in these areas, t h a t a r e identified in elicitation r e s e a r c h concerning a p a r t i c u l a r behavior a n d population of i n t e r e s t . The t h i r d step in t h i s process involves conducting methodologically rigorous evaluation research to determine w h e t h e r t h e intervention h a s h a d intended effects on the theorized d e t e r m i n a n t s of sexual a n d reproductive h e a l t h behavior, and on sexual a n d reproductive h e a l t h behavior per se, across time. The 1MB approach advocates u s e of multiple convergent sources of evaluation research data, including data t h a t are relatively nonreactive and t h a t are collected in a fashion perceived by participants to be unrelated to the intervention itself (J. Fisher & Fisher, 1992a, 1996; J. Fisher et al., 1996; W. Fisher & J. Fisher, 1993). Finally, it should be noted t h a t these elicitation, intervention, and evaluation research pro cedures can be used to construct theoretically based, empirically tar g e t e d i n t e r v e n t i o n s d i r e c t e d a t v a r i o u s p o p u l a t i o n s a t r i s k (e.g., adolescents, men and women over age 40, etc.) and at the sexual and reproductive h e a l t h professionals responsible for serving these individ uals. The 1MB model approach to sexual and reproductive health pro motion is outlined in Table 6. Changing Information Behavior

and Promoting Sexual and Reproductive

Health

On the basis of the 1MB model's analysis of sexual and reproductive h e a l t h information a n d behavior, interventions for t h e promotion of such behavior should convey a very specific type of information. First, sexual and reproductive health intervention information m u s t be easily understood and easily translated into the personal practice of sexual

SEXUAL AND REPRODUCTIVE HEALTH BEHAVIOR Table 6 The 1MB Model Approach to Promoting Sexual and Reproductive

Health

61

Behavior


ELICITATION Elicitation of Existing Levels of Sexual and Reproductive Health Information, Motivation, Behavioral Skills, and Behavior

INTERVENTION Design and Implementation of Targeted Population-Spe cific Intervention to Modify Sexual and Reproductive Health Information, Motivation, Behavioral Skills, and Behavior

EVALUATION Evaluation of Intervention Impact on Sexual and Repro ductive Health Information, Motivation, Behavioral Skills, and Behavior

and reproductive h e a l t h behavior by those in t h e t a r g e t population (Byrne et al., 1993; W. Fisher & Fisher, 1993). Second, sexual and repro ductive health information should arouse no more t h a n moderate levels of fear and should be yoked to easy-to-implement and fear-reducing pre vention recommendations (W. Fisher, 1990a; Leventhal, 1970). The pit falls of sexism and heterosexism t h a t reinforce stereotypical b u t not necessarily adaptive behavior patterns or t h a t prove offensive should be avoided (e.g., W. Fisher, 1990a; Rindskopf, 1981). Finally, sexual and reproductive health intervention information should be carefully engi neered to e n s u r e t h a t it does not u n i n t e n t i o n a l l y promote r i s k (W. Fisher, 1990a; MacDonald et al., 1990; Misovich et al., 1996). As noted above, sexual and reproductive health intervention informa tion can be directed to a variety of target populations (e.g., adolescents, aging men and women) and to professionals who are responsible for serving the sexual and reproductive health needs of these populations. Thus, interventions may target sexual and reproductive health profes-


62


sionals—whether psychologists, family doctors, gynaecologists, or oth ers—and inform them about the sexual and reproductive health threats t h a t their clients routinely face (e.g., contraceptive neglect, STD/HIV risk, sexual function difficulties) and about how to disseminate easy-totranslate-into-behavior information for assisting their clients to practice sexual and reproductive health behaviors on a continuing basis (e.g., J. Fisher, Fisher, & Friedland, 1998). Elicitation research has been uti lized as a basis for constructing a variety of methods for communicating behaviorally relevant sexual and reproductive health information t h a t addresses population-specific deficits, including slide shows and videos targeting population-specific information deficits concerning HIV pre ventive behavior for university s t u d e n t s (J. Fisher et al., 1996) and inner-city minority youth (W. F i s h e r & Fisher, 1997), and scriptlike print presentations of behaviorally relevant contraceptive information for young adults (W. Fisher, 1990b). Changing Motivation Behavior

and Promoting Sexual and Reproductive

Health

According to the 1MB model, efforts to promote sexual and reproduc tive health m u s t involve efforts to change attitudes, social norms, and emotional responses to the personal practice of such behavior. The 1MB approach to changing attitudes and social norms concerning sexual and reproductive health behaviors is based, in part, on the con cepts and operations of the Theory of Reasoned Action (Ajzen & Fishbein, 1980; Fishbein & Ajzen, 1975). The Theory of Reasoned Action asserts t h a t beliefs about the consequences of sexual and reproductive health behaviors and perceptions of social support for performing such behaviors are fundamental psychological underpinnings of attitudes and social norms regarding performance of these actions. Systematic identifi cation of modal beliefs about the consequences of sexual and reproduc tive health behaviors and modal referents who support or oppose sexual and reproductive health behaviors can be accomplished in the context of elicitation research within a population of interest. Based upon this information, empirically targeted interventions can be crafted to change attitudes and social norms by strengthening favorable beliefs and per ceptions of referent support and weakening or offsetting unfavorable beliefs and perceptions of referent support concerning the performance of specific sexual and reproductive health behaviors (see Ajzen & Fishbein, 1980, Fishbein & Middlestadt, 1989, & W. Fisher et al., 1995, for discus sion of this approach to attitude and normative change).



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In addition to rhetoric and information-based attempts to strengthen favorable attitudes and norms, direct attempts to change attitudes con cerning sexual and reproductive health behavior can involve the condi tioning of positive affect to such behaviors or the conditioning of negative affect to the failure to engage in such behaviors (see W. Fisher et al., 1983, Tanner & Pollack, 1988, & Kyes, 1990, for discussions of classical conditioning of positive affect to contraceptive and safer sexual behav ior). For example, interventions might seek to condition sexual arousal to the practice of safer sexual behaviors (Kyes, 1990; Tanner & Pollack, 1988) and to condition anxiety to the practice of risky behaviors (e.g., W. F i s h e r & Fisher, 1993; J e m m o t t , J e m m o t t , & F o n g , 1992). D i r e c t attempts to change perceived normative support have also been devel oped, involving the use of natural opinion leaders (Kelly, St. Lawrence, Brasfield, Stevenson, & Haugh, 1991) who have been trained to articu late social support for HIV preventive behaviors in interactions with intervention participants. Direct attempts to alter attitudes and social norms concerning performance of sexual and reproductive health behav iors have also involved development of documentary communications showing similar others (Festinger, 1954) who have experienced calami tous sexual and reproductive h e a l t h outcomes and who spell out and strongly endorse easy-to-accomplish sexual and reproductive health pro motion behavioral remedies (J. Fisher & Fisher, 1992b). The 1MB approach to changing emotional responses to sexual and reproductive health behavior as a means of motivating such behavior is based on systematic desensitization principles (Wolpe, 1958) and on t h e counterconditioning of positive affect to sexual stimuli (Byrne, 1977; W. Fisher, Byrne, et al., 1988; W. Fisher et al., 1983). In this approach, sexual a n d reproductive h e a l t h promotion i n t e r v e n t i o n s expose individuals to the sequence of health promotion acts discussed earlier in this article in a hierarchical, inexplicit-to-explicit fashion. Discussion a n d vicarious experience of each step in t h e sexual a n d reproductive health behavior sequence may be followed by role-playing and then actual experience with these behaviors. Thus, intervention p a r t i c i p a n t s may discuss each e l e m e n t of a contraceptive behavior sequence (e.g., t h i n k i n g about one's sexual future a n d p l a n n i n g for one's contraceptive protection, imagining a pre-sex discussion with a p a r t n e r about t h i s topic, envisioning t h e p u r c h a s e of condoms in a pharmacy or a visit to a physician, etc.), and t h e n may role-play ele m e n t s of t h i s sequence of behaviors (e.g., role-played discussions of contraception with a p a r t n e r ) a n d actually engage in elements of it


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(e.g, visiting a p h a r m a c y or a clinic and talking with a pharmacist, nurse practitioner, or physician about acquiring contraception). Inter vention strategies can also emphasize anxiety reducing outcomes of sexual and reproductive h e a l t h behaviors, teach strategies for self- and partner-reinforcement, and seek to condition positive affect to the prac tice of sexual a n d reproductive h e a l t h behavior (W. Fisher, 1990a, 1990b; W. Fisher & Fisher, 1993; Kyes, 1990; Tanner & Pollock, 1988). In this fashion 1MB model-based interventions seek to reduce negative emotional responses and to increase positive emotional responses to t h e individual's practice of t h e sequence of sexual and reproductive h e a l t h promotion behaviors involved in initiation and maintenance of sexual and reproductive health practices over time. It is again i m p o r t a n t to stress t h a t interventions seeking to alter attitudes, norms, and emotional responses to sexual and reproductive health behaviors can be directed not only to specific target populations at risk but also to the sexual and reproductive health professionals who care for them. Thus, psychologists, family doctors, gynaecologists, urolo gists, and others, m u s t develop positive attitudes and expectations for peer support, a n d positive emotional responses, with respect to rou tinely assessing patients' sexual and reproductive health needs ("Part of my responsibility involves helping my patients look after their sexual and reproductive health. Are you sexually active? What are you doing to prevent pregnancy? W h a t are you doing to prevent STD/HIV?"), and t o w a r d identifying t h e m s e l v e s as approachable a n d knowledgeable addresses for sexual and reproductive health care ("You can always ask me" cf. Epstein et al., 1998; Health Canada, 1998). Changing Behavioral Health Behavior

Skills and Promoting Sexual and

Reproductive

According to the 1MB model, efforts to promote sexual and reproduc tive health behavior should involve efforts to teach the set of behavioral skills t h a t is required for the initiation and maintenance of such behav ior. A variety of techniques may be used to model, rehearse, and refine specific behavioral skills required for the practice of sexual and repro ductive health behavior. Observation of similar others (Bandura, 1989, 1997) performing the scriptlike sequence of acts involved in the initia tion and maintenance of sexual and reproductive health practices (e.g., self-acceptance of sexuality and reproductive potential, establishing a sexual and reproductive health agenda, negotiating prevention with a partner, engaging in public preventive acts, self-reinforcement, planfully



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shifting preventive scripts) is one method which has been used to facili tate the learning and performance of such acts in the areas of adolescent contraception (W. Fisher, 1990b) and adolescent (J. Fisher & Fisher, 1997) and young adult (J. Fisher & Fisher, 1992b; J. Fisher et al., 1996) HIV prevention. Role playing this sequence of behaviors and refining performance in response to constructive feedback, and assignment of homework involving performance of components of these behaviors in the individual's social ecology, comprise additional, direct techniques for acquiring and improving skills for enacting sexual a n d reproductive health promotion behaviors. Such techniques have been used to teach behavioral skills for adolescent contraception (e.g., Schinke, 1984), HIV prevention (e.g., Kelly & St. Lawrence, 1988), and breast self-examina tion (e.g., Champion, 1995; Orbell, Hodgkins, & Sheeran, 1997), among other sexual and reproductive health behaviors. It is noted t h a t many of the same tactics—observation of models, role plays, behavioral home work assignments—can be used to simultaneously teach sexual a n d reproductive health behavioral skills and relax emotional inhibitions about engaging in such behaviors, providing t h a t the approach to inter vention is hierarchical a n d does not itself elicit negative emotional responses to these behaviors (W. Fisher et al., 1983; Wolpe, 1958). Finally, it is once again worth noting that behavioral skills interven tion techniques can be employed to improve professionals' often limited ability to detect and address sexual and reproductive health concerns (e.g., Epstein et al., 1998; W. Fisher, Grenier, et al., 1988; Health Canada, 1998). For example, clinicians may be trained to establish environmental cues in the practice setting (e.g., sexual and reproductive health posters) to c o m m u n i c a t e t h a t t h e y a r e knowledgeable a n d n o n j u d g e m e n t a l addresses for client's or patient's questions about sexual and reproductive health. Clinicians can also learn via observation of models a n d roleplayed rehearsal to communicate verbally with clients or patients in a fashion t h a t will assist them in detecting and addressing reproductive health risks and prevention in areas such as adolescent pregnancy pre vention and primary and secondary prevention of STD and HIV infection (J. Fisher, Fisher, & Friedland, 1998; Health Canada, 1998). Empirical Support for the 1MB Approach to Promoting Sexual Reproductive Health Behavior

and

Direct empirical support for the 1MB approach to promoting sexual and reproductive health behavior comes from HIV prevention interven tion r e s e a r c h (Carey, Maisto, et al., 1997; J. F i s h e r et al., 1996, J .


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Fisher, Fisher, Misovich, & Byran, 1998). Support for the 1MB approach also is adduced in interventions which have heavily emphasized infor mation, motivation, and behavioral skills content, and which have suc cessfully promoted contraceptive behavior in adolescents (e.g., Kirby et al., 1991) and young adults (e.g., W. Fisher, 1990b). With respect to the promotion of HIV preventive behavior, experi mental research has demonstrated t h a t 1MB model-based interventions may result in significant and sustained improvements in HIV preven tion information, motivation, behavioral skills, and behavior. For exam ple, J. Fisher et al. (1996) conducted elicitation research with samples of heterosexual university students and systematically identified com mon information, motivation, and behavioral skills deficits with respect to t h i s group's m o s t common a r e a s of HIV r i s k exposure. An 1MB model-based, empirically targeted intervention was created on the basis of these elicitation research findings to address the information gaps, motivational obstacles, a n d behavioral skills deficits associated with HIV risk exposure in this population. The intervention comprised a field experiment in which male and female dormitory floors were paired and received a 3-session HIV prevention intervention addressing identi fied information, motivation, and behavioral skills deficits with slide shows, motivational videos, observational learning of behavioral skills, and peer educator endorsement of change or were assigned to a not r e a t m e n t control condition. E v a l u a t i o n research findings indicated t h a t the 1MB model-based intervention had significant effects on multi ple m e a s u r e s of HIV prevention information, motivation, and behav ioral skills 1 m o n t h following the i n t e r v e n t i o n . Significant improvements in discussing condom use with sexual partners, keeping condoms accessible, and using condoms during intercourse were also observed at this juncture. Results of a follow-up evaluation indicated t h a t the intervention had sustained effects on condom accessibility and on condom use during intercourse, as well as a significant effect on HIV antibody testing, 2 to 4 months following the end of the intervention. In r e l a t e d r e s e a r c h , Carey, Maisto, et al. (1997) applied t h e 1MB model to conduct elicitation, intervention, and evaluation studies of HIV prevention with very low income, primarily African-American, urban women. The 1MB model-based intervention, delivered in the context of four 90-minute sessions, emphasized acquisition of information about HIV prevention, changing motivation to practice HIV prevention, and development of behavioral skills for HIV prevention. Results showed t h a t the 1MB model-based intervention had a significant effect on HIV



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prevention information, motivation, behavioral skills, and behavior, with intervention participants significantly less likely t h a n controls to engage in unprotected vaginal intercourse at a 3-week follow up. Most of the effects of the intervention were sustained at a 12-week follow up. In further 1MB model based research, J. Fisher, Fisher, Misovich, & Bryan (1998), conducted elicitation, intervention, and evaluation stud ies of HIV prevention among inner-city minority youth in high school settings. Results showed t h a t a theoretically based, empirically targeted 1MB intervention, delivered in the classroom and via n a t u r a l opinion leaders, led to sustained increases in HIV prevention information, moti vation, behavioral skills, and behavior (condom use during intercourse) over a significant follow-up interval. With respect to c o n t r a c e p t i v e behavior, r e s u l t s of i n t e r v e n t i o n s emphasizing contraceptive information, motivation, a n d behavioral skills content (e.g., W. Fisher, 1990b; Kirby et al., 1991) lend further support to the 1MB approach to sexual and reproductive health promo tion. For example, W. Fisher (1990b) reported results of a campus-wide contraception promotion intervention which emphasized dissemination of information, motivation, and behavioral skills communications specif ically relevant to acquiring, discussing, and using contraception in the campus environment. The contraception promotion intervention included a dormitory-based lecture a n d group discussion which w a s approximately IV2 h o u r s in length. The dormitory session conveyed information about availability of contraceptive services on campus and included a videotape which walked a campus couple through a preg nancy scare and then through each of the steps involved in acquiring and using contraception as a m e a n s of avoiding a future pregnancy scare. Approximately one third of all incoming students participated in the dormitory sessions and saw the videotape during t h e course of the intervention. A print booklet providing the same scriptlike information about the actual behaviors involved in acquiring and using contracep tion on campus, and details concerning how to acquire and how to use each method of contraception, was distributed to each incoming student as well. Evaluation research focused on a criterion outcome measure of number of positive pregnancy tests recorded at the student health ser vice d u r i n g t h e y e a r s before a n d after t h e contraceptive promotion intervention. Results showed a relatively stable r a t e of positive preg nancy tests at the student health service for the 5 years prior to the contraceptive promotion intervention; an immediate drop of 28% in pos itive pregnancy t e s t s t h e y e a r t h e dormitory contraception lectures


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e m p h a s i z i n g i n f o r m a t i o n , m o t i v a t i o n , a n d b e h a v i o r a l skills w e r e phased in; an additional drop of 11% in positive pregnancy tests the fol lowing y e a r w h e n t h e p r i n t booklet e m p h a s i z i n g t h i s content w a s phased in; and sustained and stable lowered rates of positive pregnancy tests for the following 3 years during which the contraceptive interven tion was in place. As a n additional comparison, r a t e s of therapeutic abortion among Canadian young women of university age were exam ined for the years prior to and during the contraception intervention, and these rates remained stable both prior to and during the time of the intervention. Thus, a contraception intervention emphasizing informa tion, motivation, and behavioral skills content showed a sustained effect on rates of positive pregnancy tests which was distinctive over time in pre- to postintervention comparisons and in comparison with the gen eral untreated population of same-age females. Understanding and Promoting Sexual and Reproductive Health B e h a v i o r : C o n c l u s i o n s a n d S u g g e s t i o n s for F u t u r e R e s e a r c h In this article we have conceptualized sexual and reproductive health promotion acts as a unified behavioral category on the basis of the fact t h a t such acts represent sexualized behaviors, with common determi n a n t s , reciprocal effects, and common pathways for intervention. A the oretical model for understanding psychological factors governing sexual and reproductive health behavior h a s been advanced, and an associated methodology for t r a n s l a t i n g this conceptualization into theoretically based, empirically targeted interventions for the promotion of sexual and reproductive health behaviors was provided. Direct evidence sup porting the 1MB approach to understanding and promoting sexual and reproductive h e a l t h h a s been p u t forward, as well as supportive evi dence from related research areas. Directions for future research on the 1MB approach to understanding and promoting sexual and reproductive h e a l t h behavior clearly m u s t involve prediction a n d intervention studies focusing on an expanded range of sexual and reproductive health behaviors. At present, evidence most directly supports the utility of the 1MB model for understanding and promoting HIV prevention and contraceptive behavior across a number of populations of interest. Future efforts should focus on empirically testing the strength and integrity of the 1MB model's relationships in the context of predicting and promoting a range of sexual and reproductive health promotion behaviors, such as reproductive cancer screening and sexual function promotion, and should focus on both members of the defined pop-


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ulations a t risk and members of professions whose responsibility it is to address sexual and reproductive health concerns of these populations.


Acknowledgements Work on this manuscript was supported by a research grant from the National Institute of Mental Health (MH 54378) to the first and second a u t h o r s a n d by r e s e a r c h scientist a w a r d s from H e a l t h C a n a d a a n d Janssen-Ortho Pharmaceutical to the first author. References ALLGEIER, A. R. (1983). Information barriers to contraception. I n D. Byrne & W. A. Fisher (Eds.), Adolescents, sex, and contraception (pp. 143-169). Hillsdale, NJ: Erlbaum. AJZEN, I. (1985). From intentions to actions: A theory of planned behavior. In J . Kuhl & J. Beckman (Eds.), Action control from cognition to behavior (pp. 11-39). York: SpringerVerlag. AJZEN, I. (1991). The theory of planned behavior. Organizational Behavior and Human Decision Processes, 50, 179-211. AJZEN, I., & FISHBEIN, M. (1980). Understanding attitudes and predicting social behavior. Englewood Cliffs, NJ: Prentice-Hall. ALBARRACIN, D., JOHNSON, B. T., FISHBEIN, M., & MUELLERLEILE, P. A. (1998).

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