STD Risk Reduction: One Size Doesn’t Fit All
April 15, 1999 5 minutes read
STD Risk Reduction: One Size Doesn’t Fit All
abstract & commentary
Synopsis: Behavioral intervention with high-risk populations of women of color, in which cultural and gender-specific issues were considered, proved to significantly decrease the rate of STD infection and/or reinfection by almost 40%.
Source: Shain RN, et al. A randomized, controlled trial of a behavioral intervention to prevent sexually transmitted disease among minority women. N Engl J Med 1999;340:93-100.
Growing numbers of african-american and latina patients are becoming infected with STDs such as chlamydia, gonorrhea, syphilis, trichomoniasis, and HIV. In an effort to reduce infection rates among high-risk populations of women of color, Shain and colleagues designed and implemented a behavioral intervention adapted from the AIDS Reduction Model. This model is based on the integration of several social and psychological theories (e.g., the Health Belief Model,1 self-efficacy theory,2 decision-making models,3 and diffusion theory4). For this study, the AIDS Reduction Model was further modified with extensive ethnographic data on the study’s target population—English-speaking, African-American, and Mexican-American females with a nonviral STD. Ethnographic data were collected over a period of approximately 18 months through 25 focus-group interviews and 102 in-depth interviews. Extensive observations of the communities were also conducted.
In all, 424 Mexican-American and 193 African-American female participants were enrolled in the study. Of the 617 participants, 304 women were randomly assigned to the control group and 313 women to the intervention group. Overall, 71% of the women were 24 years old or younger (range, 14-45 years of age) and most had low levels of formal education and income.
The women in the control group received standard individual counseling (a one-on-one counseling session usually lasting 15 minutes), with an invitation to participate in the group intervention at the completion of the study.
Women in the intervention group attended three group sessions that addressed recognition of their own risk, a commitment to change their behavior, and acquisition of new skills. The average group size was five or six women (range, 3-12) and they met once a week for three or four hours over a three-week period. Each group was led by a female facilitator. The facilitator and participants in each group were the same ethnicity.
Activities in the sessions consisted of group discussions, role playing, watching videos, and modeling changes in behavior. Each of these activities was further modified and enhanced by the ethnographic information that had been gathered, allowing the session leaders to include cultural- and gender-specific issues in the intervention. For example, in the groups for Mexican-American women, the concept of "machismo" was discussed, as was recognition that sexual enjoyment is appropriate for women. In the African-American groups, the belief that the HIV virus was purposefully introduced into the African-American community was discussed. And all of the groups discussed what women want from relationships, what they derive, and why they may tolerate poor behavior from their partners. Triggers for unsafe sex were identified and discussed. All participants were screened for chlamydia, gonorrhea, trichomoniasis, and syphilis at baseline and at 6 and 12 months, as well as in the event of any gynecological symptoms, to assess the success of the intervention. HIV testing was offered at each visit.
Retention rates in both the study group and the control group were high (more than 80%) at both the six-month and 12-month follow-up visits. The intervention ultimately proved to be effective and long lasting. At the six-month follow-up, the infection rate of the intervention group was 34% less than that of the control group (11.3% vs 17.2%; P = 0.05); at 12 months, it was 49% less (9.1% vs 17.7%; P = 0.008); and overall, the intervention group’s rate of infection was 38% less than that of the control group. Furthermore, women in the intervention group were less likely to have multiple sex partners and/or to engage in high-risk sex.
Comment by SAMANTHA BROUN, EdM
The findings of this study are important for a number of reasons. First, while changes in sexual behavior are imperative in reducing the rate of infection and reinfection, most behavioral interventions do little more than give participants concrete facts about risky behavior and possible alternatives. Information alone rarely results in changes in behavior. This intervention, however, provided participants with group support, opportunities to participate in discussions, and exercises that allowed them to practice newly gained skills. In addition, although the goal of this study was to reduce the risk of repeated STD infection, its results may provide insight into effective interventions for also reducing the risk of infection with HIV.
Secondly, surprisingly few behavioral studies incorporate clinical end points to assess their success in changing sexual behaviors. The effectiveness of this study was not only measured by reported changes in behavior, but by actual reduction in STDs. In this way, reported changes in behavior could be more accurately compared to actual clinical outcomes.
And third, this intervention is important for the mere fact that not only does it acknowledge the importance of what disease the patient is dealing with but also who the patient is. Ethnographic information increases the sense of understanding between practitioners and their patients and may provide practitioners insight into the specific cultural and social roots of certain behaviors. What may have previously been seen as an irrational risk-taking behavior may make more sense given its proper cultural context. And, by incorporating gender-specific and culturally relevant issues into interventions, participants may identify more closely with intervention curriculums and feel less resistant and more supported in making changes.
Hines and Caetano take this notion a step further. In their study on Latino men and women and the effects alcohol may have on risky sexual behavior, they suggest that perception of risk and engagement in risk-taking behavior are related to levels of acculturation5 (i.e., the varying degree of change in cultural orientation of Latinos as they adapt to American culture). Furthermore, levels of acculturation affect men and women differently. In some cases, greater levels of acculturation mean greater risk-taking behaviors. For example, research has shown that there is an increase in the number of sexual partners for both Latino men and women the more acculturated they are to U.S. culture. Therefore, Hines and Caetano suggest that the design and focus of intervention and prevention programs should vary according to the gender, ethnicity, and the level of acculturation of its participants.
The keys to the success of Shain and colleagues’ intervention were: 1) its format—group sessions with all the participants of the same gender and ethnic group; 2) repeated group session interventions over time; and, perhaps most importantly, 3) the intervention was based on specific qualitative and ethnographic data of the target population. Ultimately, using ethnographic data can only contribute to creating a more holistic, healthy, and responsive health care system. (Samantha Broun is Study Coordinator and Research Assistant, Positive PACE Clinic, Santa Clara Valley Medical Center, San Jose, CA.)
References
1. Becker MH, Joseph JG. AIDS and behavioral change to reduce risk: A review. Am J Public Health 1988; 78:394-410.
2. Bandura A. Self-efficacy: Toward a unifying theory of behavioral change. Psychol Rev 1977;84:191-215.
3. Fishbein M, Ajzen I. Belief, Attitude, Intention and Behavior: An Introduction to Theory and Research. Reading, MA: Addison-Wesley; 1975.
4. Rogers EM. Diffusion of Innovations. New York: Free Press; 1983.
5. Hines AM, Caetano R. Alcohol and AIDS-related sexual behavior among hispanics: Acculturation and gender differences. AIDS Educ Prev 1998;10(6):533-547.
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