Sexually Transmitted Diseases  >  Program Guidelines  >  Community and Individual Behavior Change Interventions

Program Operations Guidelines for STD Prevention
Community and Individual Behavior Change Interventions

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Sections on this page:

• Community Needs Assessment
• Behaviors That Influence Risk
• Factors That Influence Risk
• The Contexts of Risk

IDENTIFICATION OF BEHAVIORS & CONTEXTS THAT PLACE INDIVIDUALS AND COMMUNITIES AT RISK

Community Needs Assessment

The Community Identification process (CID) was developed in 1989 by LTG Associates in collaboration with DSTD and HIV. This process used qualitative and ethnographic methods to gain information about values, beliefs, lifestyles, needs, and facilitators and barriers to health care services from the perspectives of target populations and from the perspectives of those persons who have substantial contact with the target populations. The process used semi-structured interviews with members of the target populations, their gatekeepers, relevant interactors, and formal service providers.

The 1995 "Innovations in Syphilis Prevention in the United States: Reconsidering the Epidemiology and Involving Communities" projects (ISP) adapted the CID process in five communities in the southern United States, using the same methods and processes as the CID. These projects were aimed at improving partnerships with communities affected by syphilis, as well as with other health and social service providers. They also sought to identify social and behavioral factors associated with syphilis transmission and treatment.

The Rapid Ethnographic Community Assessment Process (RECAP) was developed out of the ISP initiative. Initially, a modified version of the ISP was conducted in Guilford County, North Carolina in 1998. The goals of the assessment were to determine points of access for persons at behavioral risk for syphilis, ascertain culturally appropriate and acceptable syphilis prevention messages and strategies, and to tailor outreach and syphilis screening efforts. This process was further refined in 1999 and became known as RECAP.

The decision to undertake RECAP demands sustained support before, during, and after the assessment is launched. If programs have questions about RECAP or need assistance in deciding if it is appropriate for their area, they can call the Division of STD Prevention at CDC. It is essential that the local program take and lead the initiative. The site should discuss with their CDC program consultant and local partners why RECAP makes sense in their area and how RECAP will facilitate later interventions. Potential RECAP sites should identify local staff from the health department as well as community based organizations and other community groups that will participate in RECAP. The site must also be willing to commit sufficient resources such as staff, supplies, and office space to RECAP.

Once a site has been selected, a pre-assessment meeting is held in the area. Some topics that should be discussed at this meeting include:

• How does RECAP fit into the project area's objective?
• In what areas will RECAP take place?
• What local staff will participate in the assessment?
• What local resources will the project area commit for RECAP?
• How will the survey instruments need to be modified to meet local needs?

Data analysis and the writing of the final report should be done by those with appropriate expertise. Such expertise is available at CDC, local universities, and PTCs. Once data analysis has been completed and a draft copy of the written report is available, a meeting is established between STD program staff, those involved in the analysis, and partners to present and discuss the report. This meeting should include as many key players as possible. The objective of this meeting is to orally present the report and to discuss post-RECAP recommendations. The written report is finalized one to two weeks after this meeting and includes recommendations and discussions from the meeting.

 

Behaviors That Influence Risk

Researchers have conducted surveys to assess the prevalence of behaviors in various populations. National probability surveys also have been conducted, providing periodic snapshots of risk in the general population (NIH, 1997).

Research to date identified the key risk behaviors as unprotected anal and vaginal intercourse in HIV transmission, with oral-genital sexual contact considered somewhat less risky. Although there are some documented cases of transmission through oral-genital sexual contact, methodological issues make it difficult to precisely determine the primary route of transmission. At present, oral-genital sexual contact is considered somewhat less risky than anal or vaginal intercourse for transmission of HIV. For other STDs the degree of risk is not well established and may vary by STD. Other factors are important as well because they impact the probability of exposure, facilitate transmission, or provide a context that may act as a trigger for risk (or protective) behaviors. Examples of such factors include multiple sex partners, early initiation of sexual behavior, and the excessive use of alcohol and substances that impair judgment (NIH, 1997). Other factors may include partners with multiple partners or sex for money.

It is important for program planners to have a better understanding of the risk behaviors of the populations they serve before developing and implementing intervention programs. For example, youth in school are reporting an increase in condom use at last sexual contact, but they report a trend for decreased condom use as they get older. Women, particularly women of color, have recently increased drastically as a risk group in the United States. Much of the growth in their risk is caused by sexual contact with partners whose sexual or drug use behavior puts the women at risk (NIH, 1997). In both instances, risk reduction efforts should include strategies for addressing gender, age, and relationship issues.

Quantitative and qualitative assessments can assist in determining the scope of risk behaviors and other factors that influence risk. An assessment (qualitative or quantitative) can also be used to determine the need for developing and implementing an intervention.

 

Factors That Influence Risk

A program planner should consider the risk behaviors as well as the context in which that behavior occurs. Factors influencing behavior are more numerous and more difficult to measure than biomedical factors. Four categories of factors that influence STD risk are behavioral, demographic, psychosocial, and contextual. Behavioral factors are specific actions that increase risk such as sex without condoms, sex with multiple partners, or substance use. Demographic factors are those that enable you to describe individual characteristics such as age, sex, ethnicity, marital/relationship status, education, or income. Psychosocial factors are those that assist in the understanding of why individuals may engage in risk behavior. Some examples of psychosocial factors include self esteem, self efficacy, perceptions of personal risk, future orientation, or hopelessness. Contextual factors, the broadest and probably the hardest to impact, are those that are considered characteristics of the situation(s) in which risk behaviors may occur. Specific types of contextual factors include interpersonal factors such as sex with partners of unknown status, safer sex negotiation, or domestic violence; sociocultural factors such as social norms, religious beliefs, gender role norms, or marginalization; as well as political, economic, health policy, and legal factors such as unemployment, poverty, sexism, racism, homophobia, and the availability of basic public health care tools for protective behaviors.

 

The Contexts of Risk

Although behavioral, demographic, and psychosocial factors are often used in prevention research and programming, the scope, and utility of contextual factors as a means of understanding and impacting risk behaviors is a more recent phenomenon. The work on safer sex negotiation is an example of how interpersonal and sociocultural contextual factors can impact sexual risk behavior. Specifically, researchers have found that initiation of safer sex negotiation within heterosexual relationships is more difficult (or almost impossible) when a relationship is already established or when the partners are from sociocultures where women are disempowered (Wingood, 1993). However, in some cultures, such as the gay male community, safer sex is incorporated into the social norm, thus making the negotiation of safer sexual behaviors a less threatening process. An example of how economic or health policy contextual factors can influence STD risk, are the effects of poverty and the lack of universal health care on health care seeking behavior. In essence, people who are impoverished or who do not have access to adequate health care are less likely to seek preventive health services or treatment (Lynch, 1997).

One important contextual factor that agencies should always consider is the prevalence of disease in the local area or in populations that are at significant risk. Combined usage of behavioral, demographic, psychosocial, and contextual factors will enable managers to generate ideas as to how to describe, understand, and intervene on risk behaviors that lead to STDs on an individual and community level. However, the prevalence of disease in the local areas may play a larger role in the focus, scope, and intensity of primary or secondary prevention efforts.

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