Introduction
There
are an estimated 35.3 million people living with human immunodeficiency virus (HIV)
infection worldwide (1). Of these, 1.1 million are living in the United States
(2). Progress in treatment options and prevention strategies has led to a 33%
decline in the global incidence rate of HIV, since 2001 (1). Despite forward
progress, the rate of new infections has increased in some populations (1-2). In
the United States, there are approximately 50,000 new HIV infections every year
(2). From 2008 to 2010, the number of new infections per year among men who
have sex with men (MSM) increased from approximately 26,700 to 29,800, a 12% change
(2). MSM represent just 4% of the US population, but male to male sexual
contact was believed to be the mode of transmission for 63% of all new
infections in 2010 (2). There are a variety of factors believed to contribute
to the HIV epidemic among MSM, including unprotected anal intercourse (UAI),
concentration of the community viral load among MSM, and lack of awareness of
HIV status (3). Concurrent with the rise in HIV incidence rate among MSM are
more data that show increased UAI among MSM (3). From 2005 to 2011, the
percentage of MSM reporting UAI in the past 12 months rose from 48% to 57% (3).
Given
the decreased reliability of condoms as a realistic primary prevention
strategy, public health professionals have long searched for other solutions,
such as vaccines or the use of antiretrovirals for chemoprophylaxis (4). Chemoprophylaxis
of HIV has now been shown to be efficacious with two approaches. The first, known
as treatment as prevention, involves the early usage of antiretroviral drugs in
HIV-positive people, with the goal of achieving viral suppression and reducing
infectivity (5). The second approach, known as pre-exposure prophylaxis (PrEP),
is more controversial (6-8) and involves the usage of antiretroviral drugs in
HIV-uninfected, but high-risk persons, with the intention of preventing
infection (9). A 2010 randomized controlled trial of 2499 HIV-uninfected men or
transgender women who have sex with men showed that once-daily tenofovir
disoproxil fumarate (FTC-TDF; a combination of antiretroviral drugs used for
the treatment of HIV-infection) provided a 44% reduction (p=0.005) in
HIV-incidence, when compared to placebo. Among study subjects with a detectable
blood level of the study drug, there was a 92% reduction (p<0.001) in HIV incidence
(9). On July 16th, 2012, the Food and Drug Administration (FDA)
approved TruvadaTM, an antiretroviral manufactured by Gilead Sciences
for the treatment of HIV-infection (10), for use as PrEP (11). PrEP has been suggested
for use in multiple high risk populations (4), but this paper is limited to the
promotion of PrEP among MSM in the US.
Despite
the potential to greatly protect against HIV-infection, a limited number of MSM
know about PrEP and almost none are using it (12). The low immediate uptake of
PrEP has been discussed in a number of recent widely circulated editorials,
including one by Christopher Glazek in The
New Yorker (7). Glazek explores the tepid response to PrEP and points out a
number of concerns by healthcare professionals about PrEP efficacy and toxicity.
Advocates for HIV-infected persons, Glazek explains, are also concerned about
the availability of antiretrovirals in resource limited settings or the
emergence of viral resistance to TruvadaTM, which is a first line
drug to treat HIV. Other public health officials are worried about the
implications of suggesting that there is an alternative to condom usage. These
opponents have publicly argued against PrEP usage. A further setback to PrEP
implementation is the unprecedented decision by Gilead Sciences not to promote
or research TruvadaTM as PrEP. (7) In the absence of Gilead Sciences’
participation in the promotion of TruvadaTM as PrEP, public health
officials have failed to create campaigns that would adequately promote its
use. Perhaps, it was initially assumed that the benefits of PrEP alone would be
enough to promote its use. This “if you build it, they will come” approach to
intervention promotion did not work (7-8, 12). In response to low interest in
PrEP, advocates have started to make promotional materials. These materials have
not effectively increased interest in PrEP (7-8, 12). This paper will critique
three aspects of the campaign to promote PrEP that have contributed to its
ineffectiveness along with solutions to those challenges.
Critique
1: Reliance on the Health Belief Model
The
primary way that PrEP has been promoted is through the use of educational
campaigns, such as fact sheets and videos. These promotional materials have
emphasized the health benefits of PrEP (i.e. HIV risk reduction) and have
served as informative educational tools. These materials are essential
resources for people already interested in PrEP, but do little to actually
disseminate information and promote interest in the intervention. Using health
education as a way to promote an intervention is a common approach, which
relies on rational decision making. The model of behavior, known as the Health
Belief Model, assumes that people make rational choices about health by
weighing the risk for and severity of a disease, with the costs and benefits of
adopting a new behavior (13). In this logic structure, a public health official
would only need to educate and inform a person about a disease, while offering
education about interventions or alternative behaviors that prevent that
disease. The Health Belief Model can be an effective strategy for one time
interventions, like vaccines; unfortunately, the Health Belief Model is not a
very effective way to promote an intervention that may need sustained commitment
or a more complex decision calculus (14).
The
Health Belief Model is not an effective approach for the promotion of PrEP (14-15).
To understand why, it is helpful to analyze the assumptions that the Health
Belief Model uses. First, the Health Belief Model for PrEP requires that MSM accurately
perceive their own risk for HIV infection. Research has shown that while many MSM
are able to accurately define behaviors that are high risk for HIV, they
inaccurately use those criteria while assessing their own risk (16). As a
result, many men perceive their own personal risk for HIV to be lower than what
it actually is. Second, the Health Belief Model assumes that MSM perceive HIV/AIDS
to be severe. Advancements in treatment options, and the common belief that HIV
can be managed with “one pill, once a day,” may have decreased community
perception of HIV disease severity (17). Many MSM now perceive HIV to be an
inconvenient, but manageable disease. This reduction in the perception of
disease severity may partially explain the decrease in condom usage among MSM
(3, 17). Taken together, the miscalculation of HIV susceptibility and
diminishing perception of HIV severity are major barriers to individuals
self-necessitating PrEP (14-17). Third, the Health Belief Model requires an
individual to negotiate the perceived benefits of PrEP with the perceived
costs. While the educational materials that have been created could be used to
aid in this decisional analysis, it is unlikely that most MSM would take the
time to carefully assess each factor (14). Decisions about PrEP are more likely
to be made based on a quick assessment and emotional instinct. The second
problem with the implementation of PrEP are those emotional instincts, such as
reactance, that occur.
Critique
2: Activation of Psychological Reactance
The use of educational materials to promote PrEP may
create reactance and have opposite the intended effect. Psychological Reactance
Theory shows that people hold tightly to their beliefs and statements, even
when given logical reason to change position. This occurs because people take
ownership of their beliefs. Challenging someone’s behaviors or beliefs is to
take something away and violate their freedom. The natural response to having
something taken away is to hold tighter. (18)
Psychological
reactance occurs in health campaigns when people feel that someone else is
telling them how to live or behave. The implications of reactance and the
clinging to behaviors often results in increased frequency or magnitude of the
bad health behavior (18). Since sexual contact was first identified as a way to
transmit HIV, authoritative figures have been telling MSM how to have sex (19).
Compounded with decades of stigma against homosexuality and same-sex sexual
relationships, many MSM may be feeling attacked and defensive of the way they
have sex, establishing them as a high reactance group (19). As such, reactance
may be another contributing factor to why men are using condoms less. In that
context, it is difficult to continue telling men who to have sex with, how to
have sex, and how to manage HIV risk.
In the
case of PrEP promotion, the response by many MSM is likely aversion to being
told to adopt yet another strategy to avoid HIV. Many of the promotional
materials being presented are steeped in medical information and statistics, so
the message is received as a patronizing instruction (20). The underlying
message is: “you’re not being safe enough, so you need to take a pill now as
well.” With reactance, the introduction of PrEP is viewed as another way that
authoritative healthcare figures are exerting control over the sex lives of MSM
(18-20).
Psychological
reactance is also occurring in the resistance by medical professionals and HIV
advocates to shift away from a condoms-only approach to HIV prevention (21). For
almost three decades, public health professionals have asserted (and believed) that
condoms are the only way to practice safe penetrative anal sex among MSM (4). For
three decades, that was largely true. Accepting an HIV prevention strategy that
does not completely rely on that approach is a difficult change for many
advocates. The result is a backlash to PrEP that questions everything from
medication safety to efficacy. The reaction has been a well-articulated
campaign against PrEP. The framing of this rhetoric by both health care
professionals and patient advocates is the third problem with the campaign to
promote PrEP.
Critique
3: Ineffective Use of Framing Theory
The usage of PrEP is a controversial and new approach to
HIV prevention, with vocal opponents on either side of the debate (6-8).
Proponents of PrEP have been persistent in discussing the benefits of PrEP as a
tool to reduce risk for HIV acquisition and a pathway to maintain health. Opponents
of PrEP question the implications of PrEP on the individual level, as well as
on the community level. On the individual level, opponents look at the paradox
of using a drug in a person who is actually healthy and introducing the risk of
side effects and toxicities. The potential to increase sexual risk, along with
poor compliance to a daily regimen of medication, are factors often used as
evidence against PrEP efficacy. Other opponents worry about the community
implications of using TruvadaTM in HIV uninfected persons, including
the distribution of drugs in resource limited settings and the selection for
and dissemination of TruvadaTM resistant HIV in the community.
Finally, there has even been speculation of the validity of study data and ulterior
motivations of study investigators, the government, and Gilead Sciences. (7) The
collective opposition to PrEP is likely encouraging both MSM and the healthcare
providers who would prescribe PrEP to be skeptical and avoidant of use. The
reason opponents of PrEP have been more convincing is due to the way the discourse
has been presented (22-23). Framing Theory shows why the ideas opposing PrEP
resonate much stronger with MSM and healthcare professionals.
Framing
theory explains that an audience responds to discourse based more on an
emotional response and less on facts (22-23). As such, people are much more
likely to be convinced by an argument that speaks to their core values. To
capture this emotional response, a properly framed argument is constructed
surrounding a core value, which is supported by a core position, metaphors,
symbolism, and catch phrases. The core value should be universal and in the
subconscience of the target audience. Examples of strong core values are
freedom, security, and love. The core position is the actual argument being
communicated. The metaphors, catch phrases, and imagery are used during communication
of the core position, in order to associate the argument being stated with the
desired core value. (23)
Opponents
of PrEP rely heavily on core values like safety (PrEP is a dangerous medication
with toxicities), freedom (PrEP compromises a person’s freedom by requiring compliance
to a daily drug regimen; PrEP is a ploy by “Big Pharma” to sell drugs), and
tradition (medications should only be used in sick people). (7) These arguments
speak to the core values of MSM as well as healthcare providers. There are
clear images in these frames, such as doctors prescribing a pill that will make
people sick or predatory corporations trying to turn a profit at the expense of
the public. Comparatively, proponents of PrEP are much more likely to use
health as a way to frame PrEP. The flaw is that health is not a particularly strong
core value when used in a frame. This may be counter intuitive, but the
tangible value of health is difficult to conceptualize until it is lost (14). As
a result, people often don’t respond strongly to campaigns that use health as the
core value (23). The advocates for PrEP have failed to adequately frame the
intervention in a way that addresses the core values of high risk MSM.
Solution 1: Group Level Approaches to PrEP
Implementation
Advocates for PrEP can avoid the fallacies of the Health
Belief Model by shifting away from an intervention that focuses exclusively on
changing behavior on the individual level. One approach to influencing the
normative behaviors of a population is to use strategies employed in marketing
(24). Gilead Sciences is not promoting PrEP the way any other medication would be
(7), so it is the job of PrEP advocates to do the marketing. A marketing based
approach would follow a very careful campaign design strategy. Rather than
define the intervention and create a campaign based on selling the merits of
PrEP, advocates should first question what the needs and core values of its
target population are (25). By identifying these characteristics, a campaign
can be designed without any specific information about PrEP. Because PrEP is an
ideal intervention for sexually active MSM at high risk for HIV, the campaign
should include values important to that population. The common experience with
this group is sexual encounters without a condom. Therefore, the campaign
should incorporate messages that use sex as a primary core value. The core
position of this campaign would be: “PrEP keeps sex enjoyable by offering a
second line of defense when condoms are skipped.” The fear that this type of
message will cause men to have more unprotected sex does not acknowledge that
many MSM are already not using condoms (3). By adding PrEP, the risk for HIV
acquisition is dramatically decreased. A campaign based on sex acknowledges the
prevalence of UAI and invokes the core values desired by this population (19).
The campaign can take cues from some of the more effective condom and HIV
prevention campaigns that feature attractive men and employ sexual innuendo
(19, 25, 26).
The second component to the group level implementation of
PrEP is to analyze the Diffusion of Innovations Model (27-28). The Diffusion of
Innovations Model identifies an S-curve of innovation adoption, in which the
proportion of the population that adopts an innovation grows slowly, then
accelerates quickly, and finally tapering off. A small group of innovators are
the first people to adopt a new innovation. The innovators are followed by a
second, slightly larger group known as early adopters, who are followed by a
large early majority and then late majority. Once a product or innovation has
reached the early majority, its uptake accelerates dramatically as the
innovation becomes popular. This phenomena occurs due to the herd-mentality and
desire to participate in trends. Diffusion of Innovations is often a natural
process, but by taking advantage of how this pattern occurs, advocates for PrEP
can accelerate the process in the same way that marketers create demand for a
product. To do this, it is important to understand the transition from slow
early adoption to accelerated population adoption. Early adopters often begin
buying a new product because it is scarce and only the innovators have it. The
early and late majority will buy the product once social proof has developed
and the product is viewed as trendy. (28)
PrEP is
a new intervention and so far only a few innovators have started to use it (12).
The challenge now is to encourage early adopters to use PrEP by creating the
idea of scarcity. Instead of the product itself (PrEP) being promoted as
scarce, the benefit of PrEP (reduced risk for HIV) could be promoted as a scarce
(i.e. brand new and unique) opportunity to reduce HIV-risk. The message will
be: “This is a whole new way to protect against HIV and there is nothing else
like it.” The campaign will also attempt to create social proof by creating the
illusion that PrEP is already popular. To do this, the campaign should
incorporate testimonials and statements from men who are using PrEP, explaining
how it has improved their lives.
Solution
2: Understand The Role Of Reactance In Health Promotion Campaigns
The reactance created by PrEP promotion is avoidable, if
there is attention paid to this psychological reactance during the planning of
the campaign (18). As discussed previously, reactance can often occur if the
audience feels that an authoritative figure is commanding which behavior is
acceptable and which is not. A great way to avoid the reactance is to have the
message communicated from someone that the target audience identifies with (29).
This similarity will reduce the likelihood that the audience feels like it is
being told what to do. The messenger cannot be a scientist or healthcare
professional, because they are seen as authority figures (18-20, 29). Since
this particular campaign for PrEP is being targeted toward MSM, the messenger
should be a gay (appearing) man who is speaking as a peer (29-31). A great
approach would include real men discussing their real experiences with PrEP and
how it has impacted their life. If the messenger is seen as an equal or peer,
the reactance will be minimized (29).
To
avoid reactance in healthcare professionals, who are the gate-keepers for
prescribing and promoting PrEP, there needs to be well designed physician oriented
trainings. These trainings should focus on promoting PrEP as a single option to
reduce HIV risk in a provider’s practice (21). The goal would be to deemphasize
the failures of condom campaigns and safer-sex counseling and focus instead on
adding to the tools that a provider has available. In this way, it reduces the
possibility that a provider or public health advocate feels criticized for
using other strategies in the past.
A key
part of avoiding reactance is to actually do research (25). Before old strategies
are selected and the campaign is implemented, formative research should occur
to determine whether those strategies are effective or actually create
reactance. Focus groups can serve as a way to collect ideas from the target
audience. Qualitative interviews can discuss certain themes more in depth, if
needed. From focus group research the campaign can be proposed. Finally, before
launching the campaign, the idea should be presented to a sample from the
target population for quantitative assessment. Tools like the Therapeutic
Reactance Scale (32) and the Questionnaire for Measuring Psychological
Reactance (33) can be used or adapted to detect psychological reactance in the
sample based on the proposed PrEP advertisements. The sample should be surveyed
to determine what the emotional response to a particular advertisement is, if
it creates reactance or not, and if it effectively promotes any interest in
PrEP.
Another
factor to consider with psychological reactance is how it can be used to
intentionally create a desired emotional response. For example, part of the
campaign to promote PrEP can be messaging that directly draws attention to the
opponents of PrEP. The message in this part of the campaign will focus on the
doctors and pharmaceutical industry forces that are trying to keep PrEP away
from people. HIV-prevention strategies that do not rely on just condoms have
long been desired by MSM (4, 7-8, 17) and it would be a powerful statement to
point out that PrEP is being withheld. Counter-industry campaigns have been
effective in other public health campaigns, like the successful Truth Campaign
for smoking cessation (25). The take away feeling is a desire to have what is
being restricted.
Solution
3: Reframe the Rhetoric Using Strong Core Values
The final part of the campaign that needs to be
restructured is the framing of the debate over the effectiveness of PrEP as an
HIV prevention strategy and the appropriateness of using antiretroviral drugs
in HIV-uninfected persons. The proponents of PrEP are confident that the
primary research supports implementing PrEP as an effective way to reduce
HIV-risk. It is important to now communicate that confidence outside of the
context of data and scientific literature. It has not been effective to allow
the data to stand alone. Furthermore, it is not effective to just assert that
PrEP is useful for its potential to maintain health (i.e. HIV uninfected
status) (23). Instead, the defense and promotion of PrEP should be re-framed to
have stronger core values. The actual goal of the message does not need to be
different (PrEP is safe and effective) but the way in which the message is
communicated will need to change.
Successful core values will create an emotional response
in the target audience that will be more compelling than facts or statistics
alone (22-23). For many MSM, using condoms consistently is a challenge and
there is constant anxiety of HIV infection (17). PrEP can be a second line of
defense when passion precludes rational decision making and condoms are not
used. In this way, PrEP is a provision for security and not simply a tool for
health maintenance. Therefore, the promotion of PrEP should focus on security
as its core value instead of health. The core position of this message is that
“mistakes happen, but everyone deserves to be protected.” Catch phrases could
be created from the type of familiar messages used in insurance advertisements.
For example, phrases like “peace of mind” (Chubb Group of Insurance Company; 34);
“when accidents happen, [PrEP] is there” (State Farm®; 35); and
“responsibility, what’s your policy?” (Liberty Mutual Insurance; 36) are
effective ways to frame security. Additional analogy could be made with a
comparison to birth control medications, which similarly protects against a
potential consequence of sex without a condom. This core value can be used in
written media as well as promotional materials, like videos.
Conclusion
Advocates
for PrEP may be remembering the 1980s and 1990s, when fear of HIV fueled the
mobilization of community advocacy and quick uptake of new ways to fight AIDS. With
the advancements in HIV treatment, it is likely that community fear of HIV has
diminished and taken a back seat to other community aspirations, like marriage
equality and non-discrimination policies. Given this environment, it is unlikely
that fear will create excitement about PrEP. A well strategized marketing
campaign for PrEP can surpass community apathy and promote increased use of
PrEP among high risk MSM.
References
1.
Joint United Nations Programme on HIV/AIDS
(UNAIDS). Global Report: UNAIDS report on
the global AIDS epidemic 2013. Geneva, Switzerland: Joint United Nations
Programme on HIV/AIDS, 2013.
2.
Centers for Disease Control and Prevention. HIV In The United States: At A Glance.
Atlanta, Georgia: National Center for HIV/AIDS, Viral Hepatitis, STD, and TB
Prevention, Division of HIV/AIDS Prevention, 2013.
3.
Centers for Disease Control and Prevention. HIV Testing and Risk Behaviors Among Gay,
Bisexual, and Other Men Who Have Sex With Men – the United States. Atlanta,
Georgia. November 29th, 2013, Morbidity and Mortality Weekly Report,
2013.
4.
Mayer KH. Thinking About An AIDS End Game. Lancet, 2013; 382(9903): 1462-1464.
5.
Cohen MS., Chen YQ., McCauley M., et al.
Prevention of HIV-1 Infection with Early Antiretroviral Therapy. New England Journal of Medicine, 2011;
365(6): 493-505.
6.
Grady D. Prevention In A Pill Has Risks Of Its
Own (Section D5, May 15, 2012). In: The New
York Times. New York, NY: The New York Times Company, 2012.
7.
Glazek C. Why Is No One On The First Treatment
To Prevent H.I.V.? (October 1, 2013). In: The
New Yorker Online. New York, NY: Condé Nast, 2013. Accessed: December 8,
2013. http://www.newyorker.com/online/blogs/elements/2013/10/the-battle-over-truvada-and-the-first-treatment-to-prevent-hiv.html
8.
Murphy T. Is This The New Condom? (September 9,
2013). In: Out Magazine Online. Los
Angeles, CA: HereMedia Inc, 2013. Accessed: December 8, 2013. http://www.out.com/news-opinion/2013/09/09/hiv-prevention-new-condom-truvada-pill-prep
9.
Grant RM., Lama JR., Anderson PL., et al.
Preexposure Chemoprophylaxis for HIV Prevention in Men Who Have Sex With Men. New England Journal of Medicine, 2010;
363(27): 2587-2599.
11.
U.S. Food and Drug Administration. FDA approves first drug for reducing the
risk of sexually acquired HIV infection. FDA News Release, July 16, 2012.
12. Krakower
DS., Mimiaga MJ., Rosenberger JG, et al. Limited Awareness and Low Immediate
Uptake of Pre-Exposure Prophylaxis among Men Who Have Sex With Men Using an
Internet Social Networking Site. PLoS One,
2012; 7(3): e33119.
13. Janz
NK, and Becker MH. The health belief model: a decade later. Health Education Quarterly, 1984; 11(1): 1-47.
14. Ogden
J. Some problems with social cognition models: a pragmatic and conceptual
analysis. Health Psychology, 2003;
22(4): 424-428.
15. Kowalewski
MR, Henson KD, and Longshore D. Rethinking perceived risk and health behavior:
a critical review of HIV prevention research. Health Education & Behavior, 1997; 24(3): 313-325.
16. Klein
H, and Tilley DL. Perceptions of HIV risk among internet-using, HIV-negative
barebacking men. Am J Mens Health,
2012; 6(4): 280-293.
17. Balan
IC, Carballo-Dieguez A, Ventuneac A, et al. Are HIV-Negative men who have sex
with men and who bareback concerned about HIV infection? Implications for HIV
risk reduction interventions. Arch Sex
Behav, 2013; 42(2): 279-289.
18. Brehm
SS, and Brehm JW. Psychological reactance: A theory of freedom and control. New York: Academic Press, 1981.
19. Mason
TL. A test of psychological reactance theory and risk-related sexual behaviors
among HIV-positive men who have sex with men. Electronic thesis or
dissertation. Ohio State University,
2003. https://etd.ohiolink.edu/
20. Graybar
SR, Antonuccio DO, Boutilier LR. Psychological reactance as a factor affecting
patient compliance to physician advice. Scandinavian
Journal of Behaviour Therapy, 1989; 18(1): 43-51.
21. de
Almeida Neto AC, and Chen TF. When pharmacotherapeutic recommendations may lead
to the reverse effect on physician decision-making. Pharm World Sci, 2008; 30(1): 3-8.
22. Chapman
S, and Lupton D. The fight for public health: principles and practice of media
advocacy. London: BMJ Publishing Group,
1994.
23. Menashe
CL, and Siegel M. The power of a frame: An analysis of newspaper coverage of
tobacco issues- United States, 1985-1996. J
Health Commun, 1998; 3(4): 307-325.
24. Luca
NR, and Suggs LS. Theory and model use in social marketing health
interventions. J Health Commun 2013;
18(1): 20-40.
25. Hicks
JJ. The strategy behind Florida’s “truth” campaign. Tobacco control, 2001:
10: 3-5.
26. Svenkerud
PJ, and Singhai A. Enhancing the effectiveness of HIV/AIDS prevention programs
targeted to unique population groups in Thailand: lessons learned from applying
concepts of diffusion of innovation and social marketing. J Health Commun, 1998; 3(3): 193-216.
27. Gladwell
M. The Tipping Point: How little things can make a big difference.
Introduction. Boston, MA: Little, Brown
and Company, 2000: pp 3-14.
28. Dearing
JW. Applying diffusion of innovation theory to intervention development. Res Soc Work Pract, 2009; 19(5):
505-518.
29. Silvia
PJ. Deflecting reactance: the role of similarity in increasing compliance and
reducing resistance. Basic and Applied
Social Psychology, 2005; 27(3): 277-284.
30. Calloway
DS, Long-White DN, and Corbin DE. Reducing the Risk of HIV/AIDS in African
American College Students: An Exploratory Investigation of the Efficacy of a
Peer Educator Approach. Health Promot
Pract, 2013. [Epub Ahead of Print: October 13, 2013]
31. Roye
CF, and Hudson M. Developing a culturally appropriate video to promote
dual-method use by urban teens: rationale and methodology. AIDS Educ Prev, 2003; 15(2): 148-158.
32. Dowd
ET, Milne CR, Wise SL. The therapeutic reactance scale: a measure of
psychological reactance. Journal of
Counseling and Development, 1991; 69: 541-545.
33. Merz J.
Fragebogen zur Messung der psychologischen Reaktanze. [Questionnaire for
measuring psychological reactance]. Diagnostica,
1983; 29: 75-82.
34. Chubb
Group of Insurance Company, Chubb Corporation; http://www.chubb.com/
Accessed: December 12, 2013.
36. The
Responsibility Project, Liberty Mutual Insurance; http://responsibility-project.libertymutual.com/
Accessed: December 12, 2013.
No comments:
Post a Comment