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Sexually
Transmitted Diseases > Program Guidelines > Community and Individual
Behavior Change Interventions
Sections on this page:
TYPES OF INTERVENTIONSIndividual-Focused Interventions Interventions at the individual level help people to change by providing knowledge or by attempting to alter beliefs, attitudes, perceived norms, motivation, skills, or biological states related to high-risk activities. Examples include skills-building workshops, multi-session behavior change groups, and individual counseling (NIH, 1997). These types of interventions usually incorporate the social learning theory and the stages of change model (See Appendix BC-B). Examples of individual-focused interventions include:
Project Respect - Public STD clinic patients who underwent a series of counseling sessions based on the Health Belief Model or Theory of Reasoned Action (Appendix BC-B) were significantly more likely to adopt protective behaviors and were less likely to acquire new STDs at six months of follow-up compared with those who received only informational messages (Kamb, 1996; IOM, 1997). Women in Group Support (WINGS) - Community women at high risk for STD who improved condom use and communication skills through a small group intervention also increased protected sex at three months of follow-up compared to control women (Greenberg, 2000). AIDS Evaluation of Street Outreach Projects (AESOP) - For injecting drug users and youth in high risk situations, contact with street outreach programs was a consistent predictor of having a condom at post-enhancement interviews, and having a condom at these interviews was a strong predictor of condom use with steady and casual partners (Anderson, 1998). For adolescents, interventions to reduce risk-associated behavior face several formidable challenges. Adolescents often feel invulnerable and do not perceive themselves to be at risk. It may be difficult to persuade some adolescents to remain abstinent or to use condoms if they are sexually active. Adolescents may hold negative beliefs about safer sex practices, including the belief that condoms adversely affect sexual enjoyment. They may lack the skills to negotiate safer sex. Even if an intervention successfully surmounts those obstacles, it may not have detectable effects on sexual behavior if that behavior is sporadic, which is often true of adolescents (NIH, 1997). Several well controlled studies documented significant intervention effects on adolescent HIV risk-associated behavior, including condom acquisition, condom use, unprotected sexual intercourse, frequency of sexual intercourse, and number of partners. A specific example of a tested intervention was a study addressing the risk of sexually transmitted HIV infection in 246 low-income African American adolescents at a comprehensive health center (St. Lawrence, 1995). The adolescents were randomly assigned to a single session HIV education program or an 8-week HIV cognitive-behavioral intervention that combined information with instruction and practice on correct condom use, sexual assertion, refusal, self-management, problem-solving, and risk recognition. (IOM, 1997). Significant post-intervention effects were found on HIV knowledge, response efficacy, and perceived self-efficacy; HIV risk-associated behavior was also affected. The participants reported a reduced number of instances of unprotected intercourse, and the percentage of adolescents who initiated sexual intercourse was significantly lower for those in the 8-week intervention. The effects on behavior were sustained through a 12- month follow-up. This study demonstrated that behavioral skills were acquired and that the intervention did not encourage sexual intercourse, but delayed it. Community-Focused Interventions Interventions at the group and community levels attempt to modify social norms and to influence social networking, resources and opportunities, and barriers to preventive practices in the community. Community-focused approaches to behavior change address the behavioral risk of individuals in the context of their personal networks and social environment (NIH, 1997). This type of community building can be done through empowerment, capacity building, community organizations, and community mobilization approaches. Provider behavior with clients at risk provides interventions such as risk reduction, condom use, screening exams, and sexual risk factor history. Social-level approaches include diffusion theory (idea or practice passed from person to person), leadership models (natural leaders within a group can be encouraged to exhibit or communicate innovation to those people they influence), community mobilization (how a culture's institutions, experiences, and characteristics can be changed by social movements initiated by members of that culture), and social network theory (focus on relationships and interactions between two or more people or on the linkages between people in a given group). Examples of change strategies include peer outreach, mass media, and condom social marketing (AED, 1997). Examples of community-focused interventions include:
A community risk-reduction intervention directed at young homosexual men in two west coast cities was shown to be successful (Kegeles, 1996). In that project, key opinion leaders were identified in each city's population of young homosexual men, and these key leaders delivered HIV prevention endorsement messages to their friends. In addition, risk-reduction workshops, social events that included HIV prevention messages, and printed and graphic HIV information materials were disseminated in venues frequented by young homosexual men in each city (NIH, 1997). The AIDS Community Demonstration Projects were another community-level HIV intervention program targeting high-risk, hard-to-reach populations in five U.S. cities. Mass media interventions were developed for IDUs recruited off the streets, for female sex partners of male IDUs, for women who trade sex for money and drugs, for men who have sex with men but who do not identify themselves as homosexual, for street youths, and for residents in areas with high rates of STD and injecting drug users. Each intervention site distributed printed HIV prevention materials, condoms, and bleach kits. Findings indicate positive changes in consistent condom use with a main partner and with other partners and consistent condom use for anal intercourse with other partners (IOM, 1997). In a nationwide program in Thailand (Rojanapithayakorn & Hanenberg, 1996), a "100% Condom Program" was implemented. This included a mass media condom-promotion campaign and wide distribution of condoms to prevent the spread of HIV by sex workers. The program enforced universal use of condoms by sex workers through the use of sanctions where condoms were not being consistently used. This resulted in a six-fold increase in the percentage of sex acts in which a condom was used, in an 85% decrease in STD cases in men, and a decline in HIV prevalence in pregnant women and miliary conscripts (NIH, 1997). The Gonorrhea Community Action Project (GCAP) is evaluating a provider intervention to see if skills building training will increase providers' taking of sexual histories or screening among adolescents. The skills building is provided in three formats: small group, large group, and office visit. Health Communication Interventions Health communication interventions require special emphasis, although there is some cross-over with individual, community, and policy-focused interventions. The Centers for Disease Control and Prevention (CDC) defines health communication as the crafting and delivery of messages and strategies, based on consumer research, to promote the health of individuals and communities (Healthy People 2010, 1998). Although it can be an effective tool to help shape individuals' perceptions regarding a health issue, and can influence their behavior in many areas of their lives, health communication should not be considered an automatic solution to complex health problems. It should be used in combination with other approaches. Health communication is a process that is enhanced by other disciplines. The behavioral sciences are particularly useful for understanding human behavior. For example, anthropology and ethnology provide an understanding of the social and cultural context within which certain behaviors occur. Other disciplines, such as communications and marketing, provide insight into the best ways to develop and deliver health messages that can influence health behaviors. Most public health campaigns strive for lasting behavior change and a sustained public health impact. However, lasting behavior change is a result of voluntary behavior change at the individual level. To facilitate voluntary behavior change, a campaign must appeal to the values and cost-benefit evaluation of each different audience group targeted, emphasizing the near-term salient benefits rather than the long-term, abstract collective benefits. Likewise, the health messages must be customized in such a way that they are interesting, relevant, and captivating to the audience(s). Messages should be clear, easy-to-understand, and easy to act on. Unless it's easy for people to remember how, when, and what to do, it's unlikely that a health communication campaign will be successful. Social marketing techniques applied to health communication campaigns have been shown to be effective in crafting health messages that "speak" to target audiences. Successful health communication campaigns are based on systematic planning efforts and on communication objectives that are attainable, measurable, clear, and time-bound. Successful campaigns develop and deliver health messages that are tailored to specific target audiences. Disseminating generic health messages widely and increasing knowledge about certain health issues and healthy behaviors have been shown to be less effective than more targeted efforts. Audience-centered health communication efforts with a "consumer-perspective" are much more effective in motivating target audiences to change their behavior. This requires designing and delivering messages that are adapted to the needs, perceptions, preferences, and situations of the intended audiences, rather than the needs and goals of the message designers or institutions. Therefore, health communicators in public health practice need to know as much as possible about their target audience(s) in order to stimulate voluntary behavior change. The most successful health communication campaigns involve a "systems approach" that combines multiple mass media approaches (TV, radio, print, etc.), community partnerships, training efforts, and activities by grass roots organizations that have credibility with the target audience(s). These efforts, blended together in an effective and coordinated manner, can attract more attention, reach more people in the community, and can create a perception that the campaign is exceptionally vigorous. The key is using multiple communication formats and changing messages to match changing needs and interests of different target audiences. For example, print materials serve best as tools for raising awareness, reinforcing a certain behavior, or as a reminder, while radio and television can reach millions of people simultaneously to disseminate information quickly. Interpersonal communication among peers may be key to persuading target audiences to try new products, services, or behaviors. Radio and TV announcements, peer education groups at street corners, poster contests, separate training videotapes, and brochure distribution can all take place simultaneously. Health communication may take many formats as described below.
Health communication activities that engage target audiences can be powerful tools to facilitate grass-roots involvement. For example, contests for materials to be published in print format or to be broadcasted via radio or television bring people together to work on the same cause. Effective relationships and partnerships with community leaders, policymakers, and other key individuals can strengthen health communication campaigns. Those who have influence in the community can be critical in establishing an environment receptive to STD prevention programs and to securing additional resources to support those programs. Many times partners can reach audiences who are inaccessible to health departments. Partners can be critical vehicles for funneling information, giving a new voice to messages, and for establishing community-level, grass-roots support for STD prevention. Some interventions attempt to influence laws, policies, and cultural norms. Legislative and policy changes are at the heart of such interventions. Examples from other fields of disease prevention include access to clean needles for HIV prevention, outlawing smoking in workplaces, fluoridating water to reduce cavities in teeth, and increasing the penalties for driving under the influence of alcohol. All of these interventions have had an important effect on risk behaviors and disease prevention (NIH, 1997). Examples of policy-focused interventions include:
Condom availability programs in schools in Massachusetts, New York City, and Philadelphia have been challenged in the courts (Mahler, 1996). Program opponents have generally argued that such programs violate parents' rights and religious sensibilities. In January 1996, however, the U.S. Supreme Court declined to review the Massachusetts case that upheld the school district's program that allowed students in grades 7-12 access to condoms on request without a procedure for parents to refuse participation on behalf of their children (IOM, 1997). Twenty three studies of school-based sex and AIDS/STD education programs that were published in peer-reviewed journals were reviewed and evaluated for their effect on sexual behavior. The authors found that some but not all programs were effective and that programs having the following six characteristics had a clear effect on behavior: (1) narrowly focused on reducing sexual risk-taking behaviors that can lead to STDs, HIV, or unintentional pregnancies; (2) utilized social learning theories as a foundation for development; (3) provided basic, accurate information about the risks of unprotected intercourse and methods for avoiding unprotected intercourse through experiential activities designed to personalize this information; (4) included activities that address social or media influences on sexual behaviors; (5) reinforced clear and appropriate values to strengthen individual values and group norms against unprotected sex; and (6) provided modeling and practice in communication and negotiating skills (Kirby, 1994). A significant barrier to implementation of effective school-based interventions is inadequate support for dissemination of such programs. To address this issue, the "Research to Classroom Project," supported by the Centers for Disease Control and Prevention, is the largest federal program to disseminate school-based curricula for reducing sexual risk behaviors. Under this program, CDC identifies curricula that have been evaluated and shown effective in reducing specific, risky behaviors and that meet other selection criteria, and then provides resources, including training and technical assistance, to ensure that such curricula are disseminated nationally.
Page last modified: August 16, 2007 Page last reviewed: August 16, 2007 Historical Document Content Source: Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention |
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Program Operations Guidelines for STD Prevention
