JOURNAL OF SEX RESEARCH, 52(1), 3042, 2015

Copyright # The Society for the Scientic Study of Sexuality

ISSN: 0022-4499 print=1559-8519 online
DOI: 10.1080/00224499.2013.806647

Simple But Powerful Health Messages for Increasing

Condom Use in Young Adults
Rocio Garcia-Retamero
Department of Experimental Psychology, University of Granada; and Max Planck Institute
for Human Development, Center for Adaptive Behavior and Cognition

Edward T. Cokely
Department of Cognitive and Learning Sciences, Michigan Technological University; and
Max Planck Institute for Human Development, Center for Adaptive Behavior and Cognition
In a large longitudinal study involving young adults, we conducted an eight-hour STD
educational intervention and examined the impact of the intervention on the efcacy of a
message for promoting condom use. The message was framed in positive or negative terms
and was presented visually or in numbers (percentages or frequencies). Results indicated that
the numerical positive-framed message increased condom use among young adults who did not
receive the intervention, whereas the numerical negative-framed message did not. Attitudes
toward condom use along with changes in intentions to use condoms mediated this framing
effect. In contrast, the positive-framed and negative-framed messages were equally and highly
effective for promoting condom use when the messages were presented visually or when young
adults received the STD educational intervention before reading the message, suggesting
that the simple brochures featuring visual aids were as effective in changing attitudes and
behavioral intentions as the extensive intervention. These ndings add to a growing body of
evidence detailing the mechanisms that allow well-constructed visual aids to be among the
most effective, transparent, memorable, and ethically desirable means of risk communication.
Clinical and public health implications are discussed.

In the past decades, rates of sexually transmitted diseases

(STDs), including exposure to the human immunodeciency virus (HIV), have increased sharply in young
adults (Centers for Disease Control and Prevention
[CDC], 2012). One response to these increasing rates
has been an emphasis on education. Effective interventions for reducing STDs focused on changing attitudes
about condom use and skill development (e.g., training
in assertive communication), in addition to providing
information about STDs (Kirby, 2008; Kirby & Laris,
2009; Kirby, Laris, & Rolleri, 2007; see also Bruine de
Bruin, Downs, Fischhoff, & Palmgren, 2007). The rst
aim of the current research was investigating whether
an extensive educational risk awareness intervention
about STDs boosts the efcacy of health messages
This research is part of the projects How to Improve Understanding of Risks About Health (PSI2008-02019), funded by the Ministerio
de Ciencia e Innovacion (Spain), and Helping Doctors and Their
Patients Make Decisions About Health (PSI2011-22954), funded by
the Ministerio de Economa y Competitividad (Spain).
Correspondence should be addressed to Rocio Garcia-Retamero,
Department of Experimental Psychology, Universidad de Granada,
Campus Universitario de Cartuja s=n, 18071 Granada, Spain. E-mail:
rretamer@ugr.es

promoting condom use. We also aimed at assessing the

effect of the content and structure of such messages
and the psychological mechanisms mediating their effect.
The target of our intervention was a large sample of
sexually active young adultsthe age group most at risk
for infection with STDs (CDC, 2012).
Framed messages are often used for promoting
prevention of STDs (for reviews, see Devos-Comby &
Salovey, 2002; Garcia-Retamero & Cokely, 2012). To
illustrate, a message promoting condom use can be
framed in terms of its success rate (e.g., there is a 95%
chance that condoms prevent exposure to the virus that
causes acquired immunodeciency syndrome [AIDS])
or its failure rate (e.g., there is a 5% chance that condoms
do not prevent exposure to the virus that causes AIDS).
Linville, Fischer, and Fischhoff (1993) investigated the
impact of positive-framed and negative-framed messages
about condom effectiveness on young adults intentions
to use condoms. When condoms were described as
95% effective in preventing AIDS (the positive-framed
message), young adults reported stronger intentions to
use them than when they were described as having a
5% failure rate (the negative-framed message). Although
the authors did not include a report of actual safer-sex

POWERFUL HEALTH MESSAGES

practices, these results are consistent with the notion

that positive frames are more effective than negative
frames in fostering intentions to perform a prevention
behavior.
Recently, several authors (e.g., Edwards, Elwyn,
Covey, Matthews, & Pill, 2001; Edwards, Elwyn, &
Mulley, 2002; Gigerenzer, 2003) have argued that using
framing to enhance the effects of health messages is not
consistent with truly informed decision making as it can
bias patients toward certain behaviors. Rather than
using these framed appeals, these authors recommended
making efforts to create health messages that help all
patients understand risks so that they can make their
own informed decisions (Gigerenzer & Gray, 2011;
Garcia-Retamero & Galesic, 2013). Other authors have
suggested that encouraging patients to become aware of
framing effects, rather than trying to eliminate them,
might lead to sustained improvements in patient care
(Redelmeier, 2005).
Relatively few empirical studies have evaluated
methods of overcoming the inuence of message framing.
Two prominent methods involve stating the rationale for
a choice (e.g., Kim, Goldstein, Hasher, & Zacks, 2005;
Miller & Fagley, 1991; Sieck & Yates, 1997) and describing the decision situation to another person before
making the choice (Simon, Fagley, & Halleran, 2004),
both of which promote a more careful consideration of
the decision options. In addition, asking decision makers
to provide a rationale for the option they plan to choose
or listing the advantages and disadvantages of the
decision options are also known to attenuate framing
effects and generally improve performance (e.g.,
Almashat, Ayotte, Edelstein, & Margrett, 2008; see also
Fox, Ericsson, & Best, 2011).
In the current research, we examined the effect of two
potential methods for eliminating the effect of framed
messages for promoting safe-sex practices. In particular,
we investigated whether increasing knowledge and
STD-relevant skillsvia an extensive STD educational
interventionreduces the effect of message framing on
condom use. Recent research showed that people
with relatively limited cognitive abilities, language prociency, and numerical skills were likely to be inuenced
by framed messages, whereas those who have higher
levels of cognitive abilities, language prociency, and
numeracy tended to show weaker framing effects
(Cokely & Kelley, 2009; Cokely, Galesic, Schulz, Ghazal,
& Garcia-Retamero, 2012; Garcia-Retamero & Dhami,
2011; Garcia-Retamero & Galesic, 2010; Peters et al.,
2006). Drawing on this literature, we hypothesized that
young adults receiving the educational intervention
might have more knowledge and better skills and therefore would be less inuenced by framed messages than
young adults who did not receive the intervention
(hypothesis 1). This hypothesis is also in line with
previous research suggesting that skilled decision makers
show less biases and errors than novices (Ericsson &

Lehmann, 1996; Ericsson, Prietula, & Cokely, 2007;

Shanteau, 1992; but see Reyna, 2012).
We also investigated the advantage of using visual
aids for eliminating the effect of framed messages and
whether their effect interacts with that of an educational
intervention. Recent research by Garcia-Retamero and
Cokely (2011) showed that visual aids boost the efcacy
of framed messages for promoting prevention and
detection of STDs. In particular, the authors showed
that positive-framed and negative-framed messages
became equally and highly effective in promoting condom use and screening for STDs if the messages were
accompanied with a visual aid presenting representative
numerical information about the behaviors. In contrast,
in the absence of visual aids, positive-framed messages
induced greater adherence for the prevention behavior,
whereas negative-framed messages were more effective
in promoting the detection behavior (see GarciaRetamero & Cokely, in press-b). This research suggests
that visual aids can be simple but powerful tools for
improving risk communication. Recent research further
indicates that visual aids confer additional benets in
that they are fast, simple, and memorable ways of promoting informed decision making (Lipkus, 2007; Paling,
2003; see Garcia-Retamero & Cokely, in press-a, for a
review).
In the current research, we compared the efcacy of
framed messages including visual aids depicting information about condom effectiveness to other framed messages reporting the same information but using simple,
numerical formats (i.e., percentages or frequencies). To
the extent that visual aids represent the health information in a more transparent and accessible way, they
should be more effective in promoting prevention of
STDs as compared to presenting the same information
in percentages or frequencies (hypoyhesis 2). Moreover,
the format manipulation would ultimately allow the rst
controlled comparison of the relative efcacy of the
simple visual aids to that of an evidence-based extensive
educational intervention about STDs. In other words,
the current research provides a direct comparison of
two interventions: an extensive training versus simple
visual aids. Given the previously observed powerful
inuence of visual aids on condom use, we hypothesized
that these simple tools would be highly effective, providing benets similar to those caused by the extensive STD
intervention (hypothesis 3).
The underlying psychological mechanisms by which
health messages affect sexual behavior are not currently
well understood (Devos-Comby & Salovey, 2002).
Rothman and Salovey (1997) developed a conceptual
framework that suggests risk perceptions along with cognitive and affective processes can mediate the inuence of
framed messages on behavior (see also Apanovitch,
McCarthy, & Salovey, 2003; Rothman, Martino, Bedell,
Detweiler, & Salovey, 1999). With results supporting this
framework, Garcia-Retamero and Cokely (2011) showed
31

GARCIA-RETAMERO AND COKELY

that the inuence of framed messages on condom use can

be mediated by changes in attitudes toward the behavior,
along with changes in behavioral intentions. These results
are consistent with the theory of planned behavior
(Ajzen, 2005; Ajzen & Fishbein, 2005; Ajzen & Manstead,
2007), which suggests that behavior can often be accurately predicted from intentions to perform the behavior
and attitudes toward the behavior. Accordingly, the nal
aim of the current research was to map the relations
among (a) attitudes toward condom use, (b) risk perceptions of contracting HIV, (c) affective reactions to the
framed message, (d) intentions to perform such behavior,
and (e) the likelihood of performing the behavior. Drawing on the extant literature, we hypothesized that attitudes and behavioral intentions would play a key role
in explaining the effect of framed messages on condom
use (hypothesis 4); we also hypothesized that the relations
between these variables would be inuenced by the
extensive educational intervention as well as the message
format (percentages, frequencies, or visual aids)
(hypothesis 5).

Current Study
Method
Participants. Participants were 1,168 nevermarried, sexually active young adults (average age of
20 years, range 18 to 22 years; 43% males). All participants were recruited from the Universities of Granada
and Jaen (Spain) and received course credit for participating in the study. To be eligible for recruitment, participants had to report that (a) they had at least one sexual
encounter involving sexual intercourse during the three
months prior to the study, (b) they had never been
married, and (c) they were heterosexual (as was the case
for 88% of all individuals assessed for eligibility; see
Figure 1). Individuals reporting sexual orientation other
than heterosexual were excluded because the educational
intervention did not address same-sex behavior. Participants were randomly assigned to the groups. Participants
in all groups had similar demographic characteristics.
Stimuli and design. We manipulated three betweengroups variables, including intervention (intervention
versus control group), message frame (positive versus
negative), and message format (percentages versus
frequencies versus visual aids). Participants in the intervention group received an STD educational program presented in two 4-hour group sessions. The program was
designed for sexually active young adults and was based
on the evidence-based recommendations of Kirby and
colleagues (see Kirby, 2008; Kirby & Laris, 2009; Kirby
et al., 2007). The intervention included (a) an interactive
educational component focused on increasing knowledge
and reducing misconceptions about STDs as well as
32

effective ways to prevent these diseases and (b) a skill

training component focused on enhancing young adults
skills related to safe sex (i.e., training in correct condom
application, assertive communication, and partner
negotiation). The program incorporated representative,
timely information about STDs from several sources
(see CDC, 2012; Dehne & Riedner, 2005; Holmes,
Levine, & Weaver, 2004; Wald et al., 2005; Winer et al.,
2006). The program also included different interactive
activities (e.g., games and role-playing exercises) designed
to involve young adults. The control group received two
4-hour group sessions of an educational intervention
on a topic not related to sexual behavior (i.e., healthy
nutrition).
After the intervention, all participants received a
message reporting statistical information about condom
effectiveness for preventing heterosexual HIV transmission. The information accurately reected current
statistics (see Weller & Davis-Beaty, 2002; see also Davis
& Weller, 1999).1 Half of the participants in each group
received the message in positive terms, while the other
half received the message in negative terms. In addition,
one-third of the participants in each group and framing
condition received the information in percentages;
another third received the same information in frequencies; the rest of the participants received the information
visually.
Following Linville and colleagues (1993), participants
received the following information when condom effectiveness was expressed in positive terms and percentages:
Recent research on condom effectiveness in reducing
heterosexual HIV transmission showed that condoms
have an 80% success rate. That is, if a person has a sexual
encounter involving sexual intercourse with someone
who has the virus that causes AIDS, there is an 80%
chance that condoms will prevent this person from being
exposed to the virus.

When condom effectiveness was expressed in positive

terms and frequencies, participants were told:
Recent research on condom effectiveness in reducing heterosexual HIV transmission showed that condoms have a
success rate of 80 in 100. That is, if 100 people have a sexual encounter involving sexual intercourse with someone
who has the virus that causes AIDS, condoms will prevent 80 of these people from being exposed to the virus.

Finally, participants who received the visual aid representing condom effectiveness in positive terms were told
that the success rate of condoms according to recent
research was represented in the picture that appeared
on the same page. The number of people in 100 for whom
1
We ensured that the experts who administered the program did
not report the information about condom effectiveness during the
intervention.

POWERFUL HEALTH MESSAGES

Figure 1. Flowchart of participants progress through the phases of the study.

condoms would prevent from being exposed to the virus

that causes AIDS was represented using an icon array, as
shown in Figure 2(a). When condom effectiveness was
reported in negative terms, participants received equivalent information expressed as the failure rate of condoms
(i.e., there is a 20% chance that condoms will not prevent
a person from being exposed to the virus that causes
AIDS; or condoms will not prevent exposure to the virus
that causes AIDS in 20 out of 100 people). Similarly,
participants who received the visual aid representing

condom effectiveness in negative terms received an icon

array representing the number of people in 100 for whom
condoms would not prevent from being exposed to the
virus that causes AIDS, as shown in Figure 2(b).
Measures
Demographics. Participants reported their age,
gender, educational level, ethnic background, and
marital status. They also reported whether they were
33

GARCIA-RETAMERO AND COKELY

Figure 2.

Icon array representing condom effectiveness in positive (a) and negative (b) terms.

heterosexual, had received formal sex education, had a

history of previous STDs, and had at least one sexual
encounter involving sexual intercourse in the three
months prior to the rst phase of the study.
Measurement of knowledge about STDs. We selected a pool of 55 items drawn from existing questionnaires and knowledge measures from clinical literature
(see Kelly, St. Lawrence, Hood, & Braseld, 1989; Morrison, Baker, & Gillmore, 1994; Polacek et al., 2008) or
adapted from the Youth Risk Behavior Surveillance
System (YRBSS) developed by the U.S. Department
of Health and Human Services, Centers for Disease
Control and Prevention (2002a, 2002b). The entire pool
of items was administered to a group of 50 young adults
from the University of Granada. From these items, we
selected 16 items of varying levels of difculty with the
aim of developing a short, psychometrically sensitive
and sound instrument that measured (a) relevant knowledge about STDs (e.g., knowledge about transmission
routes and screening, high-risk sexual practices, and
risk-reduction steps); (b) knowledge with implications
for condom use; and (c) misconceptions regarding STDs
and AIDS. We omitted items that tapped less behaviorally relevant information, such as whether AIDS is
caused by a virus or a bacteria. A true=false format
was used for ease of administration and because such
items can be completed relatively quickly. Highly technical terminology was avoided, and items were phrased in
language that would be easily understandable. The
16-item scale was pretested on another group of 50
young adults from the University of Granada and was
presented to a focus group for discussion. Subsequently,
necessary modications were made to improve question
comprehension. Table 1 shows the text of the 16 items.
The coefcient alpha for the scale was .75, indicating
desirable levels of internal consistency. Additional
analyses that separated the items into subscales of items
covering knowledge about STDs and condom use versus
34

misconceptions about STDS yielded highly correlated

scales with lower reliability. These and other unreported
analyses indicate that the scores on our new instrument
are best interpreted as reecting a single underlying sexual health knowledge factor.
Attitudes toward condom use. On 9-point scales
ranging from 1 (Not at all) to 9 (Very much), participants evaluated (a) the effectiveness of using condoms,
(b) how benecial it was to perform the behavior, and
(c) how favorable they felt toward engaging in the
behavior. Answers to these questions were combined
into a single index (Cronbachs a .84).
Risk perceptions. On a 9-point scale ranging from 1
(Very unlikely) to 9 (Very likely), participants estimated
how likely they were to contract HIV if they continued
behaving as they had in the past.
Affective reactions to the health message. Participants indicated how they felt while they were reading
the message. On 9-point scales ranging from 1 (Not at
all) to 9 (Very much), participants indicated the extent
to which they felt assured, calm, cheerful, happy, hopeful, relaxed, and relieved (positive adjectives). On 9-point
scales ranging from 1 (Not at all) to 9 (Very much),
participants also indicated the extent to which they felt
anxious, afraid, discouraged, disturbed, sad, troubled,
and worried (negative adjectives). Scores in negative
adjectives were reversed and combined with positive
adjectives into a single composite score showing high
internal consistency (Cronbachs a .90).
Evaluation of the health message. On a 9-point scale
ranging from 1 (Not at all) to 9 (Very much), participants
evaluated how interesting the health message was. On a
9-point scale ranging from 4 (Mostly negative) to 4
(Mostly positive), participants also evaluated the tone
of the information in the health message.

POWERFUL HEALTH MESSAGES

Table 1. Text of the 16 Questions Included in the Knowledge Scale Along with the Percentage of Participants Who Answered Each
Item Correctly in the Intervention and Control Group
Item
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.

AIDS is less contagious than the common cold. [T]

If you have unprotected sex (sex without a condom) with someone who has an STD you will catch it for sure. [F]
If you get an STD, you probably got it from the last person you had sex with. [F]
A person can be infected with the virus that causes AIDS and not have the disease AIDS. [T]
A woman can only get AIDS from a man if she has anal (rectal) sex with him. [F]
A negative result on the HIV antibody test can occur even for people who carry the virus. [T]
AIDS can reduce the bodys natural protection against disease. [T]
You wont catch the virus that causes AIDS by donating blood. [T]
Only people who have lots of sex partners get STDs. [F]
Oral intercourse carries risk for transmission of the virus that causes AIDS. [T]
It is unwise to touch a person with AIDS. [F]
The virus that causes AIDS does not penetrate unbroken skin. [T]
Pre-ejaculatory uids carry the virus that causes AIDS. [T]
Withdrawal immediately before orgasm makes intercourse safe. [F]
A positive result on the HIV antibody test can occur even for people who do not carry the virus. [T]
The virus that causes AIDS can be transmitted by mosquitoes or cockroaches. [F]

Total

Control
Group

Intervention
Group

11.9
14.9
20.4
50.2
89.9
20.6
59.8
46.2
80.3
34.8
36.4
19.9
75.9
36.7
33.3
36.2

27.9
74.3
39.8
85.8
95
32.2
91.2
53.6
96.6
78.9
95
70.9
93.5
98.1
46
72

39.8

71.9

Note. [T] and [F] indicate the correct answer for each question.

Intentions to use condoms. On a 9-point scale ranging from 1 (I have no intention of doing this) to 9 (I am
certain that I will do this), participants indicated how
likely it was that they would use condoms in future
sexual encounters.
Condom use. Participants indicated whether they
used condoms in their most recent sexual encounter
involving sexual intercourse in the previous three weeks.
Possible answers were Yes, No, and Not sure.
Procedure
The study had three phases. In the rst phase,
participants completed a questionnaire measuring
demographic information and indicated whether they
used condoms in their most recent sexual encounter
involving sexual intercourse in the previous three weeks
(i.e., a measure of condom use at baseline). In addition,
participants received an educational intervention, which
consisted of two 4-hour group sessions conducted one
week apart. After the second group session, participants
completed the scale measuring knowledge about STDs.
In the second phase of the study, conducted two days
after the second group session, participants read a message reporting information about condom effectiveness
for preventing HIV transmission. They also indicated
(a) their attitudes toward condom use, (b) their perceptions of the risk of contracting HIV, (c) their affective
reactions to the message, and (d) their intention to use
condoms in future sexual encounters. Finally, participants evaluated the health message. In the third phase
of the studyconducted three weeks after the second
phaseparticipants reported whether they used condoms in their most recent sexual encounter during

this period (i.e., a measure of condom use after the

intervention) and were debriefed. All participants signed
an informed consent form at the beginning of the study.
Participant responses were self-reported in a response
booklet that allowed responses to remain condential.
The Ethics Committee of the University of Granada
approved the methodology of the study.
Data Analyses
First, we tested whether our manipulations were
effective. In particular, we examined whether (a) the
STD educational intervention successfully increased
knowledge about STDs and (b) perceptions of the health
message reliably differed as a function of how the information was framed. Second, we tested our hypotheses
about the effect of the intervention, the message frame,
and the message format on condom use. In particular,
we examined whether framed messages primarily
affected young adults who did not receive the STD
intervention (hypothesis 1). We also examined whether
framed messages, including visual aids, were more effective for promoting condom use than messages reporting
the same information in numbers (hypothesis 2). Finally,
we assessed the relative efcacy of the visual aids as compared to the extensive STD intervention (hypothesis 3).
Third, we conducted multiple mediational analyses to
investigate whether the effect of intervention, message
frame, and message format on condom use was mediated
by knowledge about STDs, attitudes toward the behavior, perceptions of the risk of contracting HIV, affective
reactions to the health message, and behavioral intentions (hypothesis 4 and hypothesis 5). In the interests
of space and clarity, only signicant or predicted nonsignicant effects are reported.
35

GARCIA-RETAMERO AND COKELY

Results
Effectiveness of the STD Intervention
The frequency distribution of total test scores (Figure 3)
shows a large effect of the intervention wherein young
adults in the intervention group answered more HIV
knowledge items correctly than those in the control group
(M 71.9%, SEM 1.4 versus M 39.8%, SEM 1.5,
t1166 41.96, p .0001, d 2.84). This result suggests
that the intervention successfully and dramatically
increased knowledge about STDs (see also Table 1).
Evaluation of the Health Message
An analysis of variance (ANOVA) revealed a moderate effect of message frame on tone of the information,
F1,1156 162.46, p .0001, g2 .12. Young adults who
read the information about condom effectiveness framed
in positive terms evaluated the message as more positive
than those who read the information framed in negative
terms (M 1.83, SEM .08 versus M .39, SEM .08,
respectively). In contrast, young adults estimates of the
quality of the message were not inuenced by message
frame, message format, or intervention (the average
score was 6.39, SEM .05; F < 1). Overall, versions of
the message providing information in percentages or
frequencies were judged as equally interesting compared
to those providing the information visually.
Condom Use
A log linear analysis on the percentage of participants
who used condoms in their most recent sexual encounter
showed a main effect of message frame, Wald1 12.51,
p .0004, which was qualied by an interaction between
intervention, message frame, and format, Wald2 6.24,
p .044.
In support of hypothesis 1, more participants in the
control group reported using condoms when they read
the positive-framed rather than the negative-framed
message in either numerical format (i.e., percentages or

Figure 3. Frequency distribution of total scores in the knowledge

scale in the intervention and control groups.

36

frequencies), X2(1) 30.14, p .0001 (OR 2.91, 95%

CI 1.984.28; see Figure 4). The percentage of participants who reported using condoms after reading the
positive-framed message was considerably larger as
compared to the percentage reporting condom use at
baseline, X2(1) 26.34, p .0001 (OR 2.66, 95% CI
1.823.87). In contrast, the percentages of participants
reporting condom use at baseline and after reading the
negative-framed message were similar, X2(1) .04,
p .842 (OR 1.04, 95% CI 0.701.54).
In support of hypotheses 2 and 3, when participants
received the intervention and=or the visual information
about condom effectiveness, both the positive-framed
and the negative-framed messages had similar effects,
X2(1) 1.87, p .171 (OR 1.23, 95% CI 0.921.65),
signicantly increasing reported condom use. That is,
many participants in these conditions reported using
condoms regardless of whether the message was presented in positive or negative terms. Results in the intervention group were consistent regardless of whether the
information was reported in percentages, frequencies,
or visually. The percentage of participants who reported
using condoms after reading the positive-framed or
the negative-framed message in these conditions was
larger as compared to that percentage at baseline,
X2(1) 25.14, p .0001 (OR 2.11, 95% CI 1.572.84)
and X2(1) 19.07; p .0001 (OR 1.94, 95% CI 1.44
2.62), respectively.
Mediational Analyses
In the following section, we rst report results in the
control group when the framed message was provided
in numbers. We collapsed results in the percentage and
frequency conditions because the two conditions showed
similar ndings (i.e., differences were not signicant). We
then describe the results in the control group when the
message was provided visually. Finally, we report results
in the intervention group when the framed message was
provided in percentages, frequencies, or visually. Again,

Figure 4. Percentage of participants who reported using condoms in

their more recent sexual encounters involving sexual intercourse during
the past three weeks, as a function of intervention, message frame,
and message format. Percentage at baseline is also included for
comparison. Error bars indicate one standard error.

POWERFUL HEALTH MESSAGES

we collapsed results in the three format conditions

because they showed similar results.
Results in the control group when the framed message
was provided in numbers. In line with the ndings
reported, message frame strongly inuenced condom
use, b .27, t400 5.88, p .001, with more young adults
using condoms when they read the positive-framed than
the negative-framed message, as illustrated in Figure 5a.
Message frame also inuenced attitudes toward the
behavior, b .50, t400 12.06, p .001, and behavioral
intentions, b .52, t400 12.64, p .001, with young
adults showing more favorable attitudes toward using
condoms and stronger intentions to use condoms when
they read the positive-framed than the negative-framed
message. Similarly, attitudes strongly inuenced behavioral intentions, b .69, t400 20.16, p .001, and
actual behavior, b .29, t400 6.37, p .001. More
positive attitudes toward using condoms were related
to intentions to perform the behavior and the likelihood
of performing the behavior. Risk perceptions also inuenced intentions to use condoms, b .12, t400 3.55,
p .001, with young adults showing stronger intentions
to perform the behavior when they perceived themselves
at higher risk. Behavioral intentions were related to
actual behavior, b .36, t400 8.12, p .01, with more
young adults using condoms when they previously had
stronger intentions to do so. Finally, neither knowledge
about STDs nor affective reactions to the health message
inuenced behavioral intentions or the likelihood of
performing the behavior.
When attitudes were included in the regression analysis, the effect of message frame on behavioral intentions
was signicantly reduced, b .22, t400 5.96, p .01.
The result of the Sobel test2 indicated that attitudes
toward condom use mediated the inuence of message
frame on intentions to use condoms, z 10.42,
p .001. Similarly, when behavioral intentions were
included in the regression analysis, the effect of attitudes
on condom use was signicantly reduced and was no
longer reliable, b .08, t400 1.26, p .212. The result
of the Sobel test indicated that behavioral intentions fully
mediated the inuence of attitudes on condom use,
z 7.55, p .001. Importantly, when attitudes and behavioral intentions were included in the regression analysis
the effect of message frame on condom use was no longer
reliable, b .10, t400 1.80, p .10, suggesting that
message frame affected behavior only indirectly via its
inuence on attitudes and behavioral intentions.
Results in the control group when the framed message
was provided visually. When participants did not
receive the STD educational intervention but received
the information about condom effectiveness visually,
2

The Sobel test (see Sobel, 1982) indicates whether the indirect effect
of the independent variable through the mediator variable is signicant.

Figure 5. Path analysis of the effect of message frame and knowledge

about STDs on behavior and the mediational effect of attitudes, risk
perceptions, affective reactions, and behavioral intentions. (a) Results
in the control group when information was provided in percentages or
frequencies. (b) Results in the control group when information was
provided visually. (c) Results in the intervention group when
information was provided in percentages, frequencies, or visually.
Standardized coefcients are shown.  p < .05.

message frame did not inuence attitudes toward using

condoms, intentions to use condoms, or condom use;
see Figure 5b. Attitudes again inuenced behavioral
intentions, b .57, t193 9.91, p .001, and actual
37

GARCIA-RETAMERO AND COKELY

behavior, b .26, t193 3.76, p .001. In addition, risk

perceptions inuenced behavioral intentions, b .17,
t193 3.02, p .003, and behavioral intentions affected
actual behavior, b .27, t193 4.04, p .001. When
behavioral intentions were included in the regression
analysis, the effect of attitudes on actual behavior was
again signicantly reduced and no longer reliable,
b .15, t193 1.80, p .10. The result of the Sobel test
indicated that behavioral intentions fully mediated the
inuence of attitudes on condom use, z 3.74, p .001.
Finally, neither knowledge about STDs nor affective
reactions to the health message inuenced behavioral
intentions or the likelihood of performing the behavior.
Results in the intervention group when the framed
message was provided in numbers or visually. In alignment with previous results, when participants received
the intervention, message frame did not affect attitudes
toward using condoms, intentions to use condoms, or
condom use; see Figure 5c. In contrast to the previous
ndings, however, knowledge about STDs substantially
inuenced attitudes toward condom use, b .51, t591
13.64, p .001, behavioral intentions, b .31, t591
7.37, p .001, and actual behavior, b .11, t591 2.48,
p .02. Young adults with relatively high knowledge
about STDs after the intervention showed more favorable attitudes toward using condoms and stronger
intentions to use condoms than those with relatively
low knowledge. More young adults also used condoms
when they had relatively high knowledge after the
intervention. Again, attitudes inuenced behavioral
intentions, b .68, t591 17.62, p .001, and actual
behavior, b .26, t591 5.21, p .001. Risk perceptions
also inuenced behavioral intentions, b .19, t591 4.58,
p .001. Finally, behavioral intentions affected actual
behavior, b .38, t591 6.89, p .001.
When attitudes were included in the regression analysis, the effect of knowledge on behavioral intentions
was signicantly reduced and was no longer reliable,
b .03, t591 .52, p .60. The result of the Sobel test
indicated that attitudes fully mediated the inuence of
knowledge on intentions to use condoms, z 10.80,
p .001. Similarly, when behavioral intentions were
included in the regression analysis, the effect of attitudes
on actual behavior was signicantly reduced and eliminated, b .01, t591 .01, p .98. The result of the Sobel
test indicated that behavioral intentions fully mediated
the inuence of attitudes on condom use, z 6.42,
p .001. In addition, the inclusion of attitudes and behavioral intentions in the regression analysis eliminated
the effect of knowledge on actual behavior, b .01,
t591 .19, p .85, suggesting that knowledge affected
behavior indirectly via its inuence on attitudes and
behavioral intentions.
In summary, results of the mediational analyses
suggest that message frame affected attitudes toward
condom use only when the information about condom
38

effectiveness was provided in numbers (either percentages

or frequencies) and participants did not receive the STD
educational intervention; see Figure 5a. In contrast, when
the information was provided visually or when participants received the STD intervention, message frame
did not affect attitudes; see Figures 5b and 5c. Instead,
attitudesand perceptions of risk of contracting
HIVaffected intentions to use condoms. Ultimately,
these intentions inuenced reported levels of condom
use. In addition, knowledge about STDs inuenced attitudes toward condom use only when participants
received the STD intervention. This result appeared
consistently when the information about condom use
was provided both in numbers and visually; see Figure 5c.

Discussion
In a large longitudinal study, we investigated whether
an extensive STD educational intervention affected the
efcacy of framed messages promoting condom use.
We also compared the efcacy of framed messages
including visual aids to other framed messages reporting
the same information but using simple, numerical formats (i.e., percentages or frequencies). Moreover, we
compared the relative efcacy of the simple visual aids
to that of the more extensive educational intervention
about STDs. Finally, we investigated the psychological
mechanisms mediating reported condom use.
In support of hypothesis 1, when the information
about condom effectiveness was provided in numbers,
the positive-framed message was more effective than
the negative-framed message among less knowledgeable
young adults (i.e., those in the control group, who did
not receive the STD educational intervention). In support of hypotheses 2 and 3, when the information about
condom effectiveness was reported visually and=or when
young adults received the extensive STD educational
intervention, both the positive-framed and the negative-framed messages were equally and highly effective
for promoting reported condom use. Finally, consistent
with hypotheses 4 and 5, attitudes toward condom use
along with changes in intentions to use condoms tended
to fully mediate the effect of the framed message on
condom use. These attitudes in turn were inuenced
by knowledge about STDs only when young adults
received the STD educational intervention, likely reecting the fact that the majority of young adults had very
low levels of HIV knowledge unless they participated
in the intervention. Several clinical and public health
implications follow from these ndings.
Effective Messages for Improving Risk
Communication
There is a growing body of research suggesting that
visual aids are effective means of risk communication

POWERFUL HEALTH MESSAGES

when they are transparentthat is, when their elements

are well dened and they accurately and clearly represent the relevant risk information (Garcia-Retamero
& Cokely, in press-a; Garcia-Retamero & Galesic,
2013). For example, appropriately designed visual aids
improve comprehension of risks associated with different medical treatments, screenings, and lifestyles
(Lipkus, 2007; Lipkus & Peters, 2009; Paling, 2003),
promoting consideration of benecial treatments despite
side effects (Waters, Weinstein, Colditz, & Emmons,
2007; Zikmund-Fisher, Fagerlin, & Ubel, 2008). Risk
information presented visually improves Bayesian inferences in doctors and their patients (Garcia-Retamero &
Hoffrage, 2013), increases benecial risk avoidance,
promotes healthy behaviors, and reduces errors induced
by anecdotal narratives (Cox, Cox, Sturm, & Zimet,
2010; Fagerlin, Wang, & Ubel, 2005; Schirillo & Stone,
2005) and other biases (e.g., denominator neglect;
Garcia-Retamero & Galesic, 2009). Risk information
presented visually is also judged as easier to understand
and recall, and requires less viewing time than the same
information presented numerically (Feldman-Stewart,
Brundage, & Zotov, 2007; Gaissmaier et al., 2012;
Goodyear-Smith et al., 2008).
Our research adds to the literature on the efcacy of
visual aids for improving risk communication in three
noteworthy ways. First, it shows that visual aids can
eliminate the effect of framed messages. Therefore, it
provides evidence on the validity of a potentially effective method for communicating health information in
a way that is consistent with informed decision making:
Messages about prevention of STDs can be framed in
positive or negative terms as long as visual aids representing the risk information are also provided.
In addition, our results illustrate that not everyone
benets equally from visual aids: Visual aids offer a
promising method for efciently communicating health
information to individuals with relatively low knowledge (i.e., young adults who did not receive the STD
intervention). People with high knowledge, in contrast,
tend to understand the implications of the health information even if visual aids are not provided. Thus,
well-designed visual aids are especially useful for communicating with groups of people who are disadvantaged by their lack of knowledge. These individuals
otherwise have problems understanding numerical and
risk-related health information. Similar ndings were
documented in other vulnerable populations such as
people with low numeracy, older adults, and immigrant
populations with limited language prociency (Galesic,
Garcia-Retamero, & Gigerenzer, 2009; GarciaRetamero & Cokely, in press-b; Garcia-Retamero &
Dhami, 2011; Peters, 2012; Reyna, Nelson, Han, &
Dieckmann, 2009).
Finally, our study provides some of the rst experimental evidence indicating that simple visual aids can
in some regards be as effective for promoting prevention

of STDs as an extensive STD educational intervention.

In other words, the percentage of young adults who
reported using condoms during sexual intercourse when
they received eight hours of evidence-based educational
intervention was similar to that of untrained participants
who received only a simple brochure with visual aids.
Results indicate that in 1=50th of the time, visual aids
can have the same kind of impact on some targeted
behaviors as an extensive educational program (i.e., 5
to 10 minutes versus 8 hours).
Our results also converge to suggest that changing
attitudes and behavioral intentions is the key to the
effect of the visual aids: Visual aids are as effective in
changing attitudes and behavioral intentions toward
the prevention behavior as the extensive STD educational intervention, whereas framed messages in percentages of frequencies were not. Compared to the
framed message in percentages or frequencies, the visual
message might represent health information in a more
transparent, accessible, and memorable way. In fact, visual aids may have increased the likelihood of better or
more elaborative encoding of the relevant information
relating to the prevention of STDs (Garcia-Retamero
& Cokely, 2011; see also Cokely & Kelley, 2009; Cokely,
Kelley, & Gilchrist, 2006). This assumption is consistent
with current research indicating that visual aids improve
reasoning by making part-to-whole relations in the data
visually available, helping people understand and represent superordinate classes (e.g., the overall number
of people having a sexual encounter with someone with
AIDS, see Figure 2; Ancker, Senathirajah, Kukafka, &
Starren, 2006; Reyna & Brainerd, 2008). Ongoing
research is currently using cognitive process tracing
techniques (e.g., eye tracking, memory assessments,
reaction time analyses, and protocol analyses; see
Woller-Carter, Okan, Cokely, & Garcia-Retamero,
2012) to assess the validity of this conclusion in comparisons with alternative theoretical accounts. Preliminary
data indicate that when participants understand
their risks better, they have more trust in the available
information, which in turn can change their attitude
toward health related behaviors (e.g., engaging in shared
decision making).
Implications for Medical Practice and Public Policy
Health repercussions of STDs, particularly undiagnosed infections, can be serious and include death
(Chesson, Blandford, Gift, Tao, & Irwin, 2004;
Weinstock, Berman, & Cates, 2004). The risk is particularly pronounced among young adults (CDC, 2012).
As several authors have pointed out (e.g., Medley,
Kennedy, OReilly, & Sweat, 2009; Merakou &
Kremastinou, 2006; Picot et al., 2012), some educational
programs for promoting prevention of STDs reduce
sexual risk taking by only a modest amount
(Medley, Kennedy, OReilly, & Sweat, 2009; Merakou
39

GARCIA-RETAMERO AND COKELY

& Kremastinou, 2006; Picot et al., 2012). The specic

factors responsible for the success of effective interventions remain somewhat unclear (Albarracn, Johnson,
Fishbein, & Muellerleile, 2001; Yankah & Aggleton,
2008). The current research indicates that implementing
a risk-awareness educational intervention based on the
recommendations of Kirby and colleagues (see Kirby,
2008; Kirby & Laris, 2009; Kirby et al., 2007) resulted
in large improvements in knowledge about STDs and a
commensurate, large increase in reported condom use
among sexually active young adults. Our research also
indicates that the increase in knowledge about STDs
inuenced condom use by positively affecting attitudes
toward the behavior, which in turn modied behavioral
intentions and subsequent behavior. If attitudes toward
condom use do not become favorable, providing
information about STDs alone does not consistently
increase the likelihood of performing the prevention
behavior (see Morrison et al., 1994, for similar results).
While knowledge alone is not sufcient to produce behavior change, prevention efforts might not be successful
unless people at high risk for STDs accurately understand what aspects of their behavior contribute to risk
(Kelly et al., 1989).
Overall, our results suggest that a balanced approach
to STD awareness is likely most effective. While educational programs may be a key component in a larger
initiative for promoting prevention of STDs, other simpler and less time-intensive interventions are also likely
valuable, if not essential. To the extent that the current
research generalizes, such policies should include the
reporting of risk via simple, well-constructed (i.e.,
validated) visual aids. As is clear in the current research,
visual aids can be a very efcient and cost-effective
means of helping people develop positive health attitudes
and practices before they develop unhealthy health
habits. Given the extant literature, prevention is also
likely to be enhanced with the implementation of developmentally appropriate peer educational programs at
earlier ages. When implementing community-based and
school-based programs promoting prevention of STDs,
simple visual aids should be included as they make
information more transparent and memorable, and dramatically reduce risks at relatively low costs. Ongoing
investigations are examining the benets of Web-based,
customized, tailored risk communication for participants
of varying ages and demographics.
Limitations, Open Questions, and Conclusions
In this article, we provided more evidence that wellconstructed, simple visual aids can be highly effective,
transparent, fast, and ethically desirable means of risk
communication. Nevertheless, as with any research,
our study has some limitations and leaves open several
questions for future research. Specically, we measured
young adults reported behaviors and assumed that
40

these self-reports were largely accurate reections of

actual actions. We might be wrong. Published research,
however, has documented relatively high reliability of
properly assessed self-report data in relation to sexual
behavior by the use of interpartner reports (McLaws,
Oldenbrug, Ross, & Cooper, 1990) and by the study
of the association between self-reported condom use
and seroconversion (Winkelstein et al., 1987). In
addition, participants in our study should have had little
incentive to edit their answers because we used anonymous response booklets. Similarly, although it is possible, it seems unlikely that accuracy of self-reports
varies as a function of the experimental condition, as
all participants answered the same questions.
The current research assessed only relatively shortterm effects of the educational program (i.e., we measured condom use only in young adults most recent
sexual encounter involving sexual intercourse, which
took place within weeks of the intervention). A prospective study investigating the sustainability of the results
in the long run (e.g., months or years after the intervention), particularly when compared to the sustained
change in knowledge and associated attitudes, is needed.
Future research should also investigate whether providing health information via visual aids can be as effective
as the extensive intervention for promoting other important behaviors and outcomes related to prevention of
STDs, such as increasing abstinence, delaying initiation
of sex, decreasing the number of sexual partners, or
reducing pregnancy and STDs rates. Future research
should also examine whether visual aids confer similar
results when promoting detection (e.g., screening) or
treatment of STDs. Recent research indicates that
knowledge about STDs plays a crucial role in all these
behaviors (Ebrahim, Anderson, Weidle, & Purcell,
2004).
An inspection of the distribution of scores in our
sexual-health knowledge scale revealed that most young
adults in our study tended to lack some basic
information about STDs despite having a great deal of
sexual experience. Young adults knowledge of AIDS,
STDs, and condom use varies widely and is changing
rapidly, and levels of knowledge may differ in other
populations and in other countries. Future research
should investigate the extent to which the current ndings generalize to other populations, including young
adults in developing countries, who may be be especially
disadvantaged by their lack of knowledge about STDs
and their limited access to resources. We predict that
simple, well-designed visual aids are likely to show
substantial benets, even among these less knowledgeable populations. In summary, the current research converges with a growing body of data indicating that
health messages presented via simple visual aids cause
large and meaningful changes in sexual health attitudes
and intentions, which are associated with health behaviors that prevent STDs.

POWERFUL HEALTH MESSAGES

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