Nature, decay, and spiraling of the effects of fear-inducing arguments and HIV counseling and testing: a meta-analysis of the short- and long-term outcomes of HIV-prevention interventions.

Much past research has tested the effectiveness of intervention programs targeting a reduction of HIV/AIDS risk and an increase in HIV/AIDS-related knowledge among various populations (for reviews, see Albarracin et al., 2003, 2005; B. T. Johnson, Carey, Marsh, Levin, & Scott-Sheldon, 2003; W. D. Johnson et al., 2002). Of the various ways of achieving these objectives, appeals to increase perceptions of risk and the administration of an HIV test have enjoyed considerable popularity for a number of years (see Albarracin et al., 2003; Albarracin, Kumkale, & Johnson, 2004; Fisher & Fisher, 1992). Fear appeals usually describe the threat of HIV as significant, or even imminent, given the stated audience's risk for contracting the disease (Fisher, Fisher, Bryan, & Misovich, 2002; Kelly, St. Lawrence, Hood, & Brasfield, 1989). Ideally, because fear is arousing, these strategies should facilitate learning and, eventually, behavior change. Two prior meta-analyses of HIV-prevention interventions, however, have indicated that fear-inducing arguments do not produce increases in behavior change (Albarracin et al., 2005; Durantini, Albarracin, Mitchell, Earl, & Gillette, 2006). This finding is consistent with a potential side effect of fear appeals. If recipients attempt to control their fear by not paying attention to the intervention content (McGuire, 1968; see also Williams, Mark, Mathews, & MacLeod, 1996, for a review of the “emotional Stroop effect”), then fear appeals should deter from gains in both HIV knowledge and condom use. However, the potential effects of fear-inducing arguments on knowledge gains, or, for that matter, on risk perceptions themselves, were never explored in those prior reviews. Another finding from the Albarracin et al. (2005) meta-analysis is that HIV counseling and testing successfully increase condom use. It is important, however, to note that no direct comparison between the effects of fear-inducing arguments and HIV counseling and testing was provided. This omission is important because such comparisons are meaningful to understand the effects of risk perceptions in behavior change. In particular, all clients who freely seek an HIV test must have concluded that they may be infected, even when approximately 98% of U.S. individuals undergoing testing will find out that they are actually HIV negative (Centers for Disease Control and Prevention [CDC], 2001a). In other words, the initial risk sensitization followed by the favorable resolution of the fear may be pleasantly surprising to many of the individuals who seek testing. Thus, whereas the initial fear may motivate individuals to avoid the experience of fear in the future, the resolution of the fear may free up cognitive resources for the processing of the recommendations the counselor delivers. If this is the case, HIV counseling and testing should be much more successful at increasing knowledge and changing behavior than the presentation of fear-inducing arguments. This advantage should be present even after controlling for various differences in the techniques used in these two strategies. In this article, we provide a detailed examination of the efficacy of fear-inducing arguments and HIV counseling and testing over a period of time. Specifically, we synthesized the impact of these strategies on (a) perceived risk of contracting HIV, (b) knowledge about HIV transmission and prevention, and (c) actual condom use. This detailed approach consisted of examining various shapes of the influence of fear-inducing arguments, including direct and reverse linear relations, as well as curvilinear and moderated patterns. With respect to the time span we considered, the effects of any intervention can require time to manifest themselves. Thus, we analyzed change at the time of an immediate follow-up and also a delayed follow-up. In this regard, the negative or positive effects of an intervention on behavior could spiral, becoming more pronounced later rather than earlier in the change process (for a meta-analysis of sleeper effects in the experimental persuasion literature, see Kumkale & Albarracin, 2004). To our knowledge, however, such hypothetical patterns have never been studied in a meta-analysis of behavior change, which led us to synthesize studies of HIV-prevention outcomes reporting data from two measures following the intervention. We used the data set analyzed by Albarracin et al. (2005), except that effect sizes were calculated for two follow-ups instead of one and studies were added because of a later cutoff date in the bibliographic search.