Interactive video behavioral intervention to reduce adolescent females’ STD risk: a randomized controlled trial
Introduction
Sexually transmitted diseases (STDs) are prevalent in the United States (Centers for Disease Control and Prevention [CDC], 2002; Eng & Butler, 1997) especially among low-income urban populations (Mehta, Rothman, Kelen, Quinn, & Zenilman, 2001) and adolescents (Burstein et al., 1998). STDs such as Neisseria gonorrhea and Chlamydia trachomatis (Ct), often progressing to pelvic inflammatory disease (PID), cause increased morbidity, including chronic pelvic pain, ectopic pregnancy, and infertility (Cates & Wasserheit, 1991; Weström, 1996; World Health Organization, 1995). Genital infections increase the risk of contracting and transmitting human immunodeficiency virus (HIV) (CDC, 1998; Wasserheit, 1992). Both human papilloma virus (genital warts) and Ct are risk factors for cervical cancer (Bosch et al., 1995; Koskela et al., 2000; Londesborough et al., 1996).
Adolescent females face special risk factors for STD acquisition (Conard & Blythe, 2003), including age-related physiological vulnerability (Critchlow et al., 1995), limited disease knowledge (Dell, Chen, Ahmad, & Stewart, 2000), and frequent condom failures (Crosby, Sanders, Yarber, & Graham, 2003; Macaluso et al., 1999). Furthermore, young women often feel little control over sexual situations, thereby limiting their ability to act on their knowledge (Amaro, 1995; Gutierrez, Oh, & Gillmore, 2000). They may be unduly influenced by older sexual partners (Kaestle, Morisky, & Wiley, 2002) who put them at greater risk for infection (Begley, Crosby, DiClemente, Wingood, & Rose, 2003), or by sexual partners with whom communication is poor (Crosby, DiClemente, Wingood, Rose, & Lang, 2003). Younger adolescents are more likely to engage in “serial monogamy” (Norris & Ford, 1999), putting them at greater risk for infection (Kelley, Borawski, Flocke, & Keen, 2003). African American adolescent females are at particularly high risk for HIV (Ickovics et al., 2002) and bacterial STDs, even controlling for differences in attributes of their sexual partners (Harawa, Greenland, Cochran, Cunningham, & Visscher, 2003).
STD prevention requires behavior change, including limiting the number and overlap of sexual partners, reducing risky behaviors, improving condom use, and seeking disease screening and early treatment (Johnson, Carey, Marsh, Levin, & Scott-Sheldon, 2003; Pinkerton, Layde, DiFranceisco, & Chesson, 2003; Roper, Peterson, & Curran, 1993). Numerous interventions have sought to reduce sexual risk behavior and STD acquisition using various approaches (for reviews, see Auerbach & Coates, 2000; Fisher & Fisher, 1992; Horowitz, 2003; Johnson et al., 2003). To date, no theoretical approach has demonstrated superiority, in part because few interventions have been subjected to randomized controlled trials. Among those that have, some have shown promise in changing behavioral intentions (Jemmott, Jemmott, Spears, Hewitt, & Cruz-Collins, 1992), self-reported behaviors (DiClemente & Wingood, 1995; Fisher, Fisher, Bryan, & Misovich, 2002; Jemmott, Jemmott, & Fong, 1998; Patterson, Shaw, & Semple, 2003; St. Lawrence, Crosby, Brasfield, & O’Bannon, 2002; Shrier et al., 2001), and clinical outcomes (Baker et al., 2003; Kamb et al., 1998a; Shain et al., 1999).
Programs demonstrating successful outcomes, such as CDC-identified “Programs That Work” (Collins et al., 2002), typically involve costly facilitator-led group sessions or individual counseling, requiring extensively trained personnel to ensure consistent delivery in face-to-face intervention. Group programs involve notoriously difficult scheduling and quality control assurance. Not all educators and health professionals are comfortable discussing sex-related decisions with teens, nor are all teens comfortable with such interactions. Perhaps as a result of this complexity, elaborate interventions have not had a good record of translation from controlled trials into community settings without losing fidelity in content or administration (Maher, Peterman, Osewe, Odusanya, & Scerba, 2003; Robinson et al., 2002; Valdiserri, Ogden, & McCray, 2003).
With the advent of high-quality and user-friendly media technology, it has become possible to create stand-alone interactive media interventions capable of being consistently and widely used. Such programs would eliminate the constraints of the facilitator-led group setting, enabling easier community implementation, reduced costs, and improved fidelity. An early review found effects of video interventions mostly limited to knowledge and attitudes (Healton & Messeri, 1993), but more recent studies have shown broader promise. Dramatized video, usually incorporated into facilitator-led group discussions, has improved psychosocial outcomes such as perceived vulnerability, condom attitudes, and self-efficacy (Robinson et al., 2002), behavioral intentions (Zimmers, Privette, Lowe, & Chappa, 1999), proximal behaviors such as condom coupon redemption and HIV testing (O’Donnell, San Doval, Duran, & O’Donnell, 1995; Rothman, Kelly, Weinstein, & O’Leary, 1999; Solomon & DeJong, 1989), longer-term behaviors including self-reported condom use several months following initial intervention (Kalichman, Cherry, & Browne-Sperling, 1999), and clinical outcomes (O’Donnell, O’Donnell, San Doval, Duran, & Labes, 1998).
Of particular interest is the O’Donnell, O’Donnell, San Doval, Duran, & Labes (1998), O’Donnell, San Doval, Duran, & O’Donnell (1995) evaluation of an intervention using culturally appropriate videos for high-risk populations. They found a reduction in STD acquisition (assessed through health records), with differences between video and control groups diverging over time and attaining significance 2 years after administration of the intervention. Although the effect was very small, the cost-effectiveness of preventing HIV infection is sufficient to warrant the use of this intervention in STD clinics (Sweat, O’Donnell, & O’Donnell, 2001). Given their efficiency, such interventions could be worth administering, even with modest effect sizes.
We sought to address this need with the mental models approach, which is theoretically grounded in behavioral decision research and methodologically grounded in qualitative research (Morgan, Fischhoff, Bostrom, & Atman, 2001). It has been shown to help people acquire and apply knowledge about many risks, including domestic radon, paint stripper, mammography, electromagnetic fields, HIV, Cryptosporidium, and breast implants (Byram, Fischhoff, Embrey, & Bruine de Bruin, 2001; Fischhoff, 1999; Fischhoff & Downs (1997a), Fischhoff & Downs (1998); Morgan et al., 2001; Riley, Fischhoff, Small, & Fischbeck, 2001; Silverman et al., 2001).
Social cognitive models of behavior change, such as the health belief model (Becker & Rosenstock, 1987) and the theory of planned behavior (Ajzen, 1991), have conceptually compelling formulations. However, by their very nature such general models have limited ability to guide the detailed design of problem-specific interventions, or to generate topic-specific hypotheses that can be tested (Ogden, 2003). In effect, the mental models approach picks up where general decision-making models leave off. It identifies context-specific aspects of behavior that are most relevant to the decisions of the target population and most in need of intervention. Iterative versions of intervention materials are extensively piloted with their intended audience to ensure that they address realistic, culturally appropriate, relevant, and useful information to help people make more informed decisions and better negotiate and implement related risk-reduction strategies (Fischhoff & Downs, 1997b; Morgan et al., 2001).
The formative research that guided the development of the intervention evaluated here started with an expert model of STD risks, informed by a panel of experts in public health, adolescent medicine, nursing, and psychology. That model summarized their knowledge regarding disease processes and behavior change (see Fischhoff, Downs, & Bruine de Bruin, 1998, for an in-depth presentation and explanation of this model). In 48 semi-structured interviews, adolescent females responded to open-ended questions regarding the main topics of this model (see Table 1). Specific prompts encouraged them to talk more about those topics they had brought up (e.g., “can you tell me more about how that happens?”). As opposed to closed-ended response modes, these open-ended questions allow people to reveal their full range of beliefs and misconceptions, in their own words, and without literacy barriers (Bruine de Bruin & Fischhoff, 2000).
The contrast between our expert model and the target audience's “mental model”, as revealed in the interviews, focused the intervention content. Topics that are present in the expert model, but absent from interviewees’ mental model, represent information gaps. Topics that are mentioned by interviewees, but missing from the expert model, often represent misconceptions. The overall structure of the audience's mental models suggests how the intervention can integrate new information with existing beliefs, filling in gaps and correcting misconceptions.
In addition to many specific beliefs, the mental models revealed in the interview study reflected four general trends, addressed in the intervention: (a) Respondents seldom described explicit decision-making regarding sexual behavior. Rather, they saw those behaviors as arising from situational influences, often beyond their control. Some explicitly said that sex could only be avoided by steering clear of all situations potentially triggering sex scripts (e.g., parties). (b) Many did not appreciate relative risk reduction, sometimes dismissing condoms because they were “not 100% effective”. (c) They knew little about reproductive health, sometimes expressing ignorance, sometimes using terms (e.g., safe sex) without revealing a clear understanding of what they might mean. (d) They knew little about STDs other than HIV/AIDS, many believing that a routine pap smear tests for all STDs.
Based on the mental models revealed in the interview study, we designed an interactive video intervention aimed at increasing young women's ability to make less risky sexual health decisions, addressing the gaps and misconceptions identified in the interviews, and two high-quality control interventions, each of which is described in detail below. A longitudinal randomized design compared the interventions’ impact on sexual behavior and STD acquisition over 6 months. Consistent with recent NIH guidance, we collected both behavioral and biological measures, recognizing that self-reported behavioral change need not ensure biological outcomes, and successful clinical outcomes may occur without presumed behavioral changes (Pequegnat et al., 2000; Peterman et al., 2000).
We anticipated that all three interventions would improve basic knowledge, reflecting the quality of the materials and teens’ ability to learn from them. However, for the more critical outcomes of risky behavior and disease acquisition, we expected the interactive video intervention to be superior to controls, given a design based on the mental models interviews, the engaging nature of the video, and its interactivity. This study was designed as a preliminary evaluation with a moderate sample size, to determine whether the video intervention warrants further study with a larger sample and more extensive biological measures.
Section snippets
Participants
We recruited 300 females from four urban Pittsburgh-area healthcare sites: a children's hospital's adolescent medicine clinic (57%), two community health centers (24%), and a women's teaching hospital (19%). Young women were asked whether they would like to participate in one of several studies; those indicating interest in this study were eligible if they were aged 14–18 and reported heterosexual vaginal sexual activity in the previous 6 months. At the two hospital sites, approximately 50% of
Baseline data
Participants scored 65.5% correct on the test of general STD knowledge and 67.7% on the test of STD-specific knowledge, where chance performance for both was 50%. Participants had to have been sexually active in the 6 months prior to recruitment to be eligible for the study, but 7.7% of participants reported having been abstinent in the 3 months prior to baseline. On average participants who were not abstinent reported using condoms more than half the time (4.26 on the 1–6 scale), and those who
Discussion
This preliminary evaluation suggests that our stand-alone interactive video intervention administered over a 6-month period shows promise in reducing risky behavior and STD acquisition, compared to two stringent controls. The control conditions were purposefully designed to be high quality, controlling not just for time invested, but also for specific information exposure. Performance on knowledge tests improved similarly in all conditions, reflecting the high quality of the materials in all
Acknowledgements
This research was supported by grant number IU19 AI 38513 from the National Institute of Allergies and Infectious Diseases (NIAID). Some of the data reported in this article were presented at the annual meeting of the National STD Prevention Conference, Milwaukee, WI, December 2000. The authors gratefully acknowledge the assistance of Susan Barr, Tara Duffey and Kimberly Daye for their help in data collection, and King Holmes, Bill Klein, Peggy Stubbs and two anonymous reviewers for comments on
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