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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• THEORETICAL MODEL FOR BEHAVIORAL INTERVENTIONS
• PREVENTION INTERVENTION PLANNING
• Health Communications Planning
• Behavioral Surveillance Data Monitoring
• Outcome Measures

THEORETICAL MODEL FOR BEHAVIORAL INTERVENTIONS

The rate of spread of a communicable disease in a community is determined by three factors: (1) the rate of exposure of susceptible persons to infected persons; (2) the probability that an exposed, susceptible person will acquire the infection; and (3) the length of time that newly infected persons remain infectious (Anderson, 1988). To produce change in these parameters, theory-based interventions can be used to influence the rate of disease transmission. For example, transmissibility can be decreased by correct and consistent condom usage, by delaying the initiation of sexual activity, or by promoting increased usage of vaccines against STDs (e.g., hepatitis B). Duration of infectiousness can be reduced by promoting rapid health care seeking when symptoms are noticed or by screening asymptomatic populations. The interaction rate can be decreased by decreasing the rate of acquiring new partners or by maintaining mutual monogamy.

The program manager should routinely determine the distribution of available resources among the interventions which impact these three factors affecting transmission of disease. The program manager should determine if the resources that are available are appropriately used and if not, how they can be linked to other services and interventions.

Although it can be argued that every behavior has its own set of unique determinants, there is a consensus that a limited number of variables need to be considered to predict and understand any given behavior. (1) The person has a strong intention; (2) he or she has the skills and abilities required to perform the behavior; and (3) there are no environmental constraints to prevent the performance of the behavior. One implication for developing behavioral interventions is that very different types of interventions will be necessary depending on which of these variables reduces the likelihood a given behavior will be performed. The relative importance of these variables as determinants of intention and behavior depends on both the behavior and the population under consideration. Therefore, it is important to identify those factors that most strongly influence a given behavior in a given population and then to use that information to design and implement interventions (NIH, 1997). Models of behavior change that have formed the basis of much of the current STD/ HIV intervention research include social-cognitive theory and the information-motivation-behavior skills model. These models incorporate similar principles of accurate information, motivation, and behavior skills training. The principles of these behavioral theories have proven effective in changing high risk behavior for STD/HIV.

PREVENTION INTERVENTION PLANNING

Health Communications Planning

Program managers should develop a health communications plan to establish the steps to be taken to address program goals and objectives. In developing such a plan, the following steps should be taken:

• Among the program objectives, identify which might benefit from health communications. Based on these chosen program objectives, determine the health communication objectives. Note that all program objectives will not necessarily benefit from health communication strategies. It might be useful to think about these from the perspective of what a health department is best positioned to do, which would probably mean setting population-level rather than individual-level behavior change health communication objectives. For example, an appropriate objective might be to raise the level of awareness of the significance of the STD problem in an area among community leaders. A less appropriate objective might be to increase condom use by adolescents because informational approaches alone are less likely to be successful in achieving this goal.
• Identify the target audience for communication objectives. This step will probably take place most naturally in conjunction with the first step. While there may be more than one potential target audience, it may be important to prioritize audiences. (Examples of target audiences: policymakers, community leaders, non-STD public health leaders, nongovernmental organizations that serve at-risk populations, etc.)
• Identify strategies that will correspond to the communications objectives and reach the target audience. Example of a strategy: Influence key community leaders who have not paid attention to STDs to recognize why Medicaid managed care contracts must support STD prevention.
• Conduct a needs assessment. Determine which of these strategies are currently being addressed, what gaps there are in current efforts, and strategies that are not being addressed.
• Based on gaps, define key health communication strategies.
• Choose tools to carry out these strategies (see "Type of Interventions")
• Establish a system for evaluating the effect of health communications in meeting the defined objectives.

 

Behavioral Surveillance Data Monitoring

Collecting and analyzing behavioral surveillance data are necessary for developing effective interventions to prevent high-risk behaviors and to reduce neglect of or delay in treatment. STD behavioral surveillance will enable programs to anticipate emerging disease and to prevent disease occurrence. This could result in a level of undetectable prevalence of STDs many years sooner than if such a system were not in place, saving billions of dollars.

A behavioral surveillance network should be specifically designed to 1) estimate the size of populations at risk for sexually transmitted diseases; 2) monitor knowledge and attitudes about STDs and sexuality; 3) monitor recognition of symptoms and of the need for medical care; 4) monitor indicators of exposure to intervention; 5) monitor the patterns and prevalence of risk behaviors; 6) link behavioral and biomedical indicators of disease that will clarify the complex social and sexual networks underlying the STD epidemic; and 7) evaluate intervention and program effectiveness. Local areas must be able to incorporate local community values into the design of behavioral surveillance systems. In that respect, it becomes community- based surveillance, by which community is defined as an area or jurisdiction for which prevention planning is feasible.

Population-based surveys obtain information about the size of groups at risk for sexually transmitted diseases; rates of risk behaviors and prevention behaviors; level of awareness, knowledge, and misinformation about sexually transmitted diseases; social norms and structural factors related to behavioral risks for STDs; and decisions and actions about medical care and treatment. Population-based surveys strive to use sampling approaches for inclusion of hard-to-reach and vulnerable populations at special risk for STDs. Inclusion of specific "traditional" provider sites, such as public STD clinics, family planning clinics, and individual providers is important as are other non-traditional sites such as jails, detention centers, drug treatment facilities, schools, halfway houses, and other identifiable venues for monitoring behavior and disease in high-risk populations. Surveys of populations at the community level (e.g., high risk neighborhoods) is also of value but more resource intensive. This type of survey is capable of obtaining information from everyone in the community rather than only those who have accessed care or services at one of the above venues and this is more representative if the participation rate is high.

Community-based surveillance should focus on 1) local population and health service characteristics, 2) population-level health surveys, and 3) sentinel site surveillance monitoring. For instance, community-based surveillance should be able to profile the course of an epidemic by using data on behavior; by monitoring changes in behavior that may be the result of interventions or of media campaigns; by estimating relative coverage of STD diagnosis and treatment by public health clinics and private providers; by determining the extent to which private providers are involved in treatment, partner services, and risk- reduction counseling; and by tracking associations between prevention efforts and risk behaviors. It can also provide communities with an early warning of emerging risk behaviors. Community-based surveillance uses a mixture of data sources, including surveys (sampling and interviewing respondents), contextual data (e.g., census, labor, crime statistics, health care measures), and should be linked to biomedical indicators of disease (National and Community-Based Behavioral System for STDs, 1997). Community surveillance efforts may wish to consider user-friendly, analysis-friendly techniques such as custom developed scan forms to record data about behaviors.

 

Outcome Measures

A broad spectrum of sound outcome measures from self-reported behavior to disease incidence is essential in evaluating prevention programs and interventions. Self-reported behavior change can have solid properties (valid and reliable) if rigorous methods are employed. The consequences of prevention interventions and programs can be measured in a variety of ways; the choice of outcome measures should be driven by the type of evidence that is required to answer questions and determine the program's efficacy. The information needs of public health decision-makers who have the ultimate responsibility for managing and allocating resources for effective interventions and programs must also be considered (NIH, 1997).

Most research on the efficacy of prevention interventions has focused on self-reported behavioral outcomes; a small number have utilized STD and HIV infection as outcome measures. The selection of outcome measures depends on a range of issues, including the availability of valid and reliable behavioral assessments that are culture and gender appropriate; whether sufficient members of the at-risk population can be recruited and maintained in a longitudinal cohort; access to laboratory facilities; and available resources (NIH, 1997). Some examples of sexual behavior outcomes include 1) frequency of vaginal, anal, oral, or manual sex with, as well as without, internal or external condoms, latex gloves, dental dams, or other latex barriers during each sexual act; 2) number of sexual partners with which the person has had any kind of sexual activity; 3) number of sex workers including sex for drugs, money, a place to stay, or other favors; 4) number of sexual activities while using alcohol or illicit drugs; 5) risky behaviors of sex partner including interpersonal coercion or violence, multiple partners, alcohol use or abuse, drug use or abuse, or sex work; 6) frequency of refusals to engage in risky sexual behaviors; and 7) frequency of participation in behaviors such as assisted or mutual masturbation as an alternative sexual behavior when barrier methods were not available or possible to use. These types of outcome variables are also variables that can be part of a behavioral surveillance data system.

Although a minimum data set of behavioral variables has not been determined, it is strongly encouraged that program planners define outcome variables consistent with the interventions proposed. Thus, the information gathered over time can be used to measure the intervention's or program's effectiveness, or it can be used for quality assurance purposes and feedback to make mid-course corrections during the delivery of the intervention (NIH, 1997). Variables should also be incorporated in the behavioral surveillance data system so comparisons between populations can be made and trends evaluated over time in areas with and without targeted interventions and in areas after interventions have been completed.

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