The Importance of the Milieu
Those narrators who became sexually active before the advent of the AIDS epidemic practiced CLAI, because it was the peer norm in their milieu. Those who became sexually active after the advent of HIV/AIDS fell into two groups, determined by the peer norm of the milieu in which they started having sexual intercourse. Most narrators started their sex practice in a milieu in which safe sex was the peer norm. Some had learned about safe sex before they started having sexual intercourse. This learning came through promotional information, sex education in school, and/or through word-of-mouth. Others learned about safe sex from their early-and/or-initial sex partners. Others started their sexual experiences with CLAI. Soon afterwards, they sought information about safe sex, or others in their milieu told them about it. Once they learned about safe sex, they became safe sex loyals - adherent to a regimen of consistent condom use. On the other hand, two narrators consistently practiced CLAI for long periods of their lives. This was because the peer norm was CLAI in the milieux in which they started to have sexual intercourse.
External Interventions Can Change Loyalty
In addition to the learning processes described in the foregoing, external events caused some men to commit to safe sex. The first external event was the advent of AIDS, and the second were personal epiphanies that befell two narrators. In the period before the advent of HIV/AIDS, those narrators who were having sexual intercourse practiced CLAI, the norm at that time. After the advent of HIV/AIDS, their new fear of HIV infection, plus the new information about safe sex, caused these narrators to convert from CLAI to safe sexloyalty. Their community attachment and the effectiveness of the safe sex communications caused them to convert. For two narrators, personal epiphanies caused them to convert to safe sex.
The outcome for the narrators; one narrator became HIV positive very early in the epidemic. Safe sex had not been codified at the time of his infection. The 15 others were HIV negative at the start of the epidemic, or the start of their sexual activity, whichever came first. All but one remained HIV negative; he too would have remained HIV negative except for a flukish accident.
HIV testing did lead to changes in behavior in some narrators, and not in others. One felt unwell, and had an HIV test with a Positive result. He then changed his sexual practice to strategic positioning (36). At the advent of AIDS, another narrator had changed his sex practice on learning about safe sex. Some time later he had an HIV test. His negative result did not lead him to change away from safe sex, because in his view the risk of CLAI remained.
The narrators’ stories indicate the importance of integrated marketing communications campaigns and the need to make that message immediately relevant to the recipient in a way that they understand. Both technically (what do I need to do?) and as a high-risk threat to them personally (why does this apply specifically to me?...and why now?).
All narrators, positive and negative, single or partnered, retired or working, consider safe sex as the enabler of their happiness. They regarded safe sex as protecting themselves and their sex partners, loved ones and their self-evaluation. The narrators’ report more-rigorous adherence than the general population with regards to use of condoms outside of their steady relationship (35).
The Overall Themes of the Narrators’ Autobiographical Life Histories.
The overarching themes of the narrators’ autobiographical life histories regarding sex practice were fear and protection. All sixteen narrators cited self-protection as an important reason to adhere (be loyal) to safe sex. Several narrators, unsurprisingly, explicitly cited the fear of illness as a major driver. Several mentioned that their health was their own responsibility. Importantly, protection extended beyond the self. The protection of their long-term partners was, if anything, an even more important driver of the narrators’ adherence to safe sex than was self-protection. Of the 12 narrators with long-term partners, all mentioned the very high importance of protecting them.
Caring for others was also a prime driver of adherence for our narrators. Three narrators are carers for HIV positive people. One is a social worker, caring for abused men and boys (abused sexually and otherwise). Another brought up two young children on his own after his wife (their mother) left them. Another narrator was additionally motivated by his need to protect his mother’s feelings by not becoming HIV positive. Another saw adherence as a moral commitment. A professional sex worker was scrupulous in always using condoms with his clients. He also took the trouble to explain to them why consistent condom use was so important, and why relying on people telling you that they are HIV negative is neither reliable nor sensible. Caring for others was also demonstrated by initiating novice men into consistent condom use.
For all narrators, self-identity was closely aligned with their consistent adherence to safe sex and with protecting their HIV negative status (negative narrators), their general good health (positive narrators) and the protection of others. Seven narrators stated that their self-identity is closely entwined with their partner and the need to protect them.
And finally, the narrators all consider that what we termed their Quest for the Ideal Gay Life (however they defined it) was facilitated by their adherence to safe sex. All narrators articulated their life satisfaction and overall happiness with their present-day lives. Four were happy in their retirement. One, despite living in a nursing home, still finds sexual pleasure with one of the young care attendants. Another enjoys his part-time job while seven are enjoying their full time careers. Some are continuing their studies, and several have found fulfillment in their relationships.
The Theoretical Rationale for Caring
The narrators cared for others because they held a moral norm that obligated them to behave altruistically to achieve values important to them (17), namely, the protection of their sex partners and loved ones, self-protection (the protection of their HIV negative status), and the maintenance of their positive self-evaluation. Altruistic motivations are internal sources of motivation for helping (17). They are “intentions or purposes to benefit another acting as an expression of internal values, without regard for the network of social and material reinforcements.” (17 pg. 222). Schwartz therefore considered altruism to be distinct from social and material reinforcements.
Social norms act as external controllers on the individual's behavior, with various social sanctions attached should they be transgressed (17). In contrast, personal norms are anchored in the self and bring with them the individual’s self-evaluation (17). That is, the individual’s view of themselves and their expectations therefore of their own behavior. Because behavior is tied directly to the maintenance of the self-evaluation, the self-evaluation acts to support some behaviors and to sanction others (17). Conforming, or the anticipation of conforming, enhances positive self-evaluations such as pride, self-esteem and security (17). Violating the self-evaluation, or anticipation thereof, brings negative self-evaluations such as loss of self-esteem, guilt and self-criticism (17). In their meta-analysis, regarding the Theory of Planned Behavior (TPB), Conner and Armitage (37) found support for the inclusion of the moral norm in the TPB. Rivis, Sheeran and Armitage (38) found the moralnorm to be strongly associated with significant consequences for others. Conner and Armitage (37) concluded that strong self-identity would strengthen attitude through the mechanism of attitudinal consistency. The narrators' stories concur with these findings. The adherent narrators' narratives showed a consistent drive to maintain a favorable self-evaluation through their consistent execution of safe sex. Schwartz (17) summarized the drivers of this behavior in the foregoing explanation. The narrators therefore reinforce Schwartz’s observation that “internalized norms are standards for behavior which are self-reinforcing” and “represent ideals against which events are evaluated.” (17 pg. 231).
The Pre-Existing Content-Specific Norm
Schwartz (17) proposed a process for moral norm construction. He termed these “preexisting content-specific norms” (17 pg. 233). These norms were formed based on the individual’s past experiences, were then internalized, and would create self-expectations to be drawn-on in current situations (17). Therefore, the pre-existing context-specific norm obviates the need to construct a norm on every decision-making occasion. It therefore acts in a similar way to brand loyalty within the Framework of Customer Loyalty (FCL) (11). Loyalty to a particular brand removes the need for the individual to evaluate competing brands each time he needs to make a purchase (11). The addition of the moral norm and the pre-existing content-specific norm to the FCL is illustrated in Figure 1.
The adherent narrators possessed a pre-existing content-specific norm, their loyalty to safe sex, which they consistently practiced without undertaking a process of norm construction every time they contemplated undertaking sexual intercourse. In this regard, it is likely that the narrators’ consistent reporting of their adherent practice is akin to what Schwartz describes as “a well-practiced instrumental reaction [which] may be elicited directly by the appropriate stimulus without feelings of obligation (e.g. a medic treating a wounded soldier under fire).” (17 pg. 233).
Double Obligation and Double Motivation
The narrators went beyond invoking their pre-existing content-specific norm and adhering self-protectively to protect themselves. In addition they adhered altruistically to protect their sex partner and loved ones and to maintain their positive self-evaluation. This form of double obligation and double motivation explains the consistent and rigorous implementation of this norm by the adherent narrators. The narrations provide numerous examples of double motivation and double obligation whereby the narrators acted to protect themselves and others. Double obligation and double motivation concurs with studies which have identified both self-directed (egoistic) and altruistic motivators (39) and that individuals exhibit the highest motivation when they have both a high concern for self and for others (40). How double obligation and double motivation contributes to the creation of the pre-existing content-specific norm can be explained in detail by Schwartz’s Processual Model (17). It is an actionable model for the creation of a pre-existing content specific norm (such as consistent adherence to a Combination Prevention regimen) which then acts as an instrumental (automatic) reaction whenever the appropriate cue (that sexual intercourse is imminent) is provided to the actor (17).
Other authors have identified that caring for others is likely to create effective health promotion campaigns to further increase adherence (23, 41, 42, 43). Caring for others is a significant theme in this article.
Personal Norms as a Source of Sanctions
Schwartz (17) noted a study by Acock and DeFleur (44) which adds credence to the view that social norms do not have a strong influence on behavior. On the other hand, those persons who were a potential source of sanctions in the specific situation thereby influenced the behavior of the individual; “considering in particular, possible sanctions for acting one way or another; then he makes his action decision.” (44 pg. 725, emphasis in the original). This concurs with the narrators’ stories - because sexual intercourse is a private matter (and therefore, as in the Acock study, the social norm referents would be unlikely to find out about the behavior), it is the personal norms that determine behavior and not the social norms. However, as Schwartz (17) observes, social norms might well have been already built into the individual's personal norms. On the other hand, the sex partner is a potential source of sanctions. When confronted with requests for CLAI, the narrators imposed the social sanction of withholding sexual intercourse. Thereby the narrators demonstrate high Perceived Behavior Control (45). Examples of narrators imposing sanctions on sex partners include refusing CLAI, and in some cases ending the relationship if condom use was refused.
Exposure to a Direct Appeal Will Result in Safe Sex Practice.
The narrators' stories concur with Schwartz (17) that “A final basis for responsibility is exposure to a direct appeal.” (17 pg. 249). A direct appeal will focus responsibility very clearly from the person needing help to the person being addressed (17). Some narrators mentioned that their partner requested condom use, and of course, in other circumstances the narrator requested the use of condoms. Both forms of request constitute a direct appeal.
Direct Activation of Social Norms
Schwartz (17) concluded that social articulation of a norm (such as advertising to promote adherence) might block the activation of personal norms, leaving the individual to feel deprived of freedom of choice and therefore of responsibility and the self-satisfaction which could be achieved through satisfying their own personal norms. Consequently, social articulation of the norm might create “perception of social pressure to act which elicits reactance.” (17 pg. 269). The narrators did not support Schwartz on this point. They reported that social articulation of safe sex had acted to educate them.
Conclusions Regarding Normative Influences on Altruism
This enquiry enables understanding of attitude formation and evolution in a way that provides managerial direction for the creation of social marketing communications to promote adherence to Combination Prevention regimens. Most notably, the key role of the personal moral norm, altruistic behavior, double obligation and double motivation, pre-existing content specific norms and the nine step Processual Model. Finally, the use of the direct appeal to activate the personal moral norm. These findings inform the design of future Combination Prevention promotions.
Sadly, not all men possess a moral norm, and so not all men behave altruistically. In a Sydney court a man “pleaded guilty in March (2018) to recklessly causing grievous bodily harm to his former partner” by transmitting the HIV virus to him (46). His former partner said in court, "He made no reasonable effort to stop the prevention of a completely preventable disease. I never got an apology. I never got any sympathy from him for what he did to me. And for what he put me through, I will never be able to forgive him.” (46).
A Theoretical Framework Provides Managerial Direction for Health Promotions to Increase Adherence to Combination Prevention Regimens.
Effective implementation of the findings requires the identification of theories and frameworks. Campaigns/interventions are more likely to succeed when they are based on theories or frameworks (10, 7). Marketing loyalty frameworks have been shown to be effective in other contexts in recruiting and retaining ‘clients’ (7). And an extensive ‘toolbox’ exists to assist marketers in recruiting and retaining ‘clients’ (7). We selected Dick and Basu’s Framework for Customer Loyalty (FCL) (11) because it is a well-known marketing framework for managing customer loyalty. In addition, other researchers have referred to it as the classical model of loyalty in marketing (47). As Dick and Basu (11, pg. 99) explain in their introduction; “The objective of this article is to develop a new conceptual framework to understand more fully the cognitive, affective and conative antecedents of customer loyalty as well as its consequences.” Furthermore, others had researched it in an attempt to provide empirical evidence to demonstrate its predictive ability (48). Our analysis of the narrations demonstrate that firstly, the Framework for Customer Loyalty (FCL) (11), illustrated in Figure 1, provides an illuminating method by which to categorize and understand the narrators’ autobiographical life histories. Secondly, FCL provides a framework that enables understanding of each narrator’s process by which he developed and changed his attitude and behavior regarding adherence. That is, in terms of the FCL they exhibited consistent repeat-patronage of safe sex. This was because all narrators held strongly differentiated perceptions of safe sex compared with CLAI, and strong attitudes towards both. They lived in a milieu where safe sex was the social norm and situational influences (availability of safe sex materials and information) supported safe sexpractice. (During the period of their lives when two narrators were loyal to CLAI, they were attached to parts of the milieux where CLAI was the norm.) Therefore, findings support the predictive capabilities of the FCL; they either practiced CLAI consistently if they had a strong relative attitude in favor of CLAI, or they practiced safe sex consistently if they had a strong relative attitude in favor of safe sex.
We also found passages in the narrations that illustrate all the components of the FCL and explained the evolution of safe sex loyalty. We conclude therefore that the FCL framework provides managerial direction as to how to deploy the understanding (of formation and evolution of attitudes) into social marketing communications to create and maintain adherence to Combination Prevention regimens.
Garland and Gendall (48 pg. 81) conducted “a test of the predictive ability of Dick and Basu’s model in personal retail banking.” in New Zealand. Their findings concur with ours “both relative attitude and share loyalty are significant predictors of number of banks used.” (48 pg. 85). They concluded that the FCL might have validity in “subscription type markets” with a small number of brands and low customer churn rates (48 pg. 81). This concurs with our findings, in that it could be argued that the gay sex ‘market’ is similar to Garland and Gendall’s (48 pg. 81) “subscription type markets” in that there are a small number of brands (today there are three brands; abstinence, non-adherence and adherence) and low customer churn rates (most gay men remain loyal to one brand, most of the time). Our findings regarding the non-defection of safe sex loyals also concurs in that the most loyal customers have “the lowest probability of defection” (48 pg. 85).
The individual’s self-evaluation (17) and the individual’s drive to maintain it, shares characteristics with the cognitive antecedent of centrality (11). Centrality is the degree to which an attitude toward the brand relates to the value system of an individual (11). Attitudes that are central cause both the individual’s values and the likely outcomes of proposed actions to be considered in the decision-making process (11) Being central, they relate to knowledge held in memory, are distinct, cause affective emotional response when activated, and are frequently activated (11). Central attitudes are important, are stable over time, resistant to counter-persuasion and are strongly associated with behavior (11). On the other hand, attitudes not closely related to the individual’s values are more likely to be swayed by counter-persuasion, resulting in variable loyalty (11). From the narrations it is clear that safe sexloyals held safe sex as a central attitude which was closely related to behavior through its’ impact on accessibility (ease of retrieval) (11).
Moreover, the narrators were completely resistant to counter-persuasion (11). Dick and Basu (11) refer to a study by Sirgy and Samli (49) who found that congruity between store image and self-image is related to store loyalty. In our enquiry it was clear that the safe sex narrators strove to achieve congruity between their self-image (their self-evaluation) and their perceived image of safe sex.
Conclusions and Contributions to Knowledge Regarding Dick & Basu’s Framework for Customer Loyalty
- The FCL enables understanding of attitude formation and evolution in a way that provides managerial direction to the developer of social marketing communications to increase adherence to Combination Prevention.
- This enquiry’s finding supports the predictive capabilities of the model. This is broadly aligned with some previous studies (48).
- The findings suggest two additions to the FCL. These are the Feedback Loop and the additional consequence of Satisfaction (see Figure 1).
- Dick and Basu (11 pgs. 7 - 109) provide specific direction for managing loyalty. In addition, the FCL provides a linkage to the extensive body of marketing research that is available to the developer of social marketing communications to increase adherence to Combination Prevention.