Critique of an STD/HIV Prevention Intervention: Safe in the City – Kristin B.
Sexually transmitted diseases (STDs), including Human Immunodeficiency Virus (HIV), are one of the biggest public health issues facing the United States today. Left untreated, STDs can pose serious and oftentimes irreversible health threats, and in the case of HIV, can lead to death. A 2011 Centers for Disease Control and Prevention (CDC) report estimated that there are 19 million new STD infections in the U.S. annually, of which half are among young people (1). STDs cost the health care system over 17 billion dollars a year (1). In addition, a March 2012 CDC report estimated that 1.2 million people in the U.S. are living with HIV and there are 50,000 new infections annually (2). Among these new infections, African American and Latinos are disproportionately affected (2). The same report also determined that one in five HIV-infected individuals is unaware of their status (2). Because STDs and HIV are transmitted overwhelming through sexual contact, getting tested and knowing one's status is imperative in reducing the number of new STD/HIV infections. Research shows that knowledge of one’s status increases the likelihood that infected individuals will decrease risky sexual behaviors (3).
Abstaining from oral, vaginal, and anal sex, practicing monogamy with uninfected partners, reducing one’s number of sex partners, and using condoms correctly for every sexual encounter can reduce one’s risk of contracting STDs/HIV (4). Because using latex condoms is the most efficient way to reduce the risk of contracting an STD/HIV among those who do not abstain from sexual activity (5), many STD/HIV infection reduction interventions focus on giving people the knowledge and skills to use condoms effectively. Risk factors for not having protected sex include a lack of knowledge and perception of STD/HIV risk, negative attitudes about using condoms, a lack of knowledge about using condoms correctly, a lack of intentions to use condoms, a lack of self-efficacy and skills to get tested, and a lack of self-efficacy and skills for practicing safer sex, including acquiring condoms and negotiating their use. A majority of STD/HIV prevention interventions target these risk factors.
Overview of Safe in the City
Safe in the City is a 23 minute video designed to reduce HIV and other STD infections by increasing condom use. The video is shown in public STD clinic waiting rooms and has no staff involvement and does not require any counseling or group facilitation – the video is simply shown on loop to those in the waiting room. The video’s goals are to increase STD/HIV knowledge, increase the perception of risk of getting HIV or another STD, promote knowledge of correct condom use and positive attitudes toward condom use, increase intentions to use condoms, build self-efficacy and skills for getting tested and facilitating partner testing, and build self-efficacy and skills for acquiring condoms, negotiating the use of condoms with their partner, and increase actual condom use (6). After watching the video, clients of the STD clinic are expected to use condoms correctly and consistently.
The video is made up of five parts: three vignettes about negotiating condom use in various relationships and two animated portions about different types of condoms available and proper condom usage. As the video begins, the following words appear on the screen: “Remember, not having sex is the most reliable way to prevent getting an STD. Please talk to your healthcare provider for more information or if you have any questions.” The first story begins with Paul pressuring Jasmine to have sex without a condom, but Jasmine insists on using one. Later, Paul hooks up with an ex-girlfriend, Theresa, but only uses a condom for the end of the sexual encounter. Theresa calls Paul to tell him that she went to a clinic and was diagnosed with an STD and encourages Paul to get tested. Paul gets tested and decides to hold off on any further sex until his test results are back (7). An animated portion about properly putting on and removing a condom follows the story and emphasizes the fact that condoms should be used consistently and correctly for them to be effective (8). The next story shows Luis and Theresa beginning to get intimate and Theresa asking Luis if he has a condom, which he does not. He gets offended and Theresa explains that pulling out is not always effective and doesn’t protect against STDs, and that condoms make her feel safe and free. The scene ends with Luis running to a convenience store and returning to his apartment with a condom (9). The following animated segment is about different types of condoms and emphasizes the idea that there is a condom just right for everyone's needs (10). The final story picks up after Ruben has sex with Tim, who notes afterward that he had a condom with him but they got carried away and ended up not using it. Ruben later has sex with Christina and she finds out that he gave her an STD. The video ends with them going to the clinic together to get treatment for their STD (11).
Flaws of the Intervention
Findings from the CDC's 2008 evaluation of Safe in the City show that the intervention did indeed significantly reduce new STD infections by 10% among patients attending the clinics where the intervention was provided (12). However, this reduction was seen only in males. Among females who viewed the video, there was neither a beneficial nor harmful outcome found which indicates that the intervention was ineffective among this population. Safe in the City, as the current intervention now stands, is not only flawed for the purpose of increasing condom use and reducing STD infections among females, but is also flawed as a standalone intervention that does not fully take into account social and behavioral science principles, theories, and research.
Critique #1 – Lack of Group-Level Component
Safe in the City is an individual-level intervention that requires no contact or discussion with healthcare providers. The video is played in STD clinic waiting rooms where patients may choose to actively watch the video or not. In addition, the video is just over 20 minutes long, so the viewer might not have the chance to see the entire video or may only see the end of it. The viewer knows that the people in the video are actors and what is happening on the screen is not real even though it may depict real events. There is no opportunity for discussion or questions, though the video passively lets the viewer know that they should ask their healthcare provider if they have any questions. A short video cannot possibly cover all scenarios that are likely to come up, and because it is scripted, does not allow for spontaneous questions to lead to discussion. Most importantly, the video does not allow the viewer to practice the skills depicted.
Simply watching a video intended to change behavior without being given the opportunity to practice the skills demonstrated or even discuss what was viewed is deemed less effective than pairing the video with another component (13, 14). In a study that examined the effectiveness of video-based patient education interventions on promoting condom use among men and women in public STD clinics in New York City, researchers looked at results from a control group, a group that only viewed the video, and a group that viewed the video and then participated in an interactive group session led by a trained facilitator (13). Subjects who participated in the interactive group session showed increased STD/HIV risk perceptions, greater self-efficacy, and higher rates of condom acquisition than the control group or the video-only group, however those in the video-only group demonstrated greater STD and condom knowledge and more positive attitudes about condom use (13). Another study, also conducted in public STD clinics in New York City, looked at the impact of a video-based educational intervention on condom acquisition among African American and Hispanic men and women (14). Findings show that compared to the control group and video-only group, subjects who experienced the video in conjunction with a group discussion were significantly more likely to acquire condoms (14).
An important aspect of social cognitive theory, one of the theories Safe in the City is based on, is observational learning or modeling. Observational learning/modeling is the theory that people do what they see others do, not what people tell them to do (15). However, observational learning/modeling is not complete with just behavior imitation, it must also involve learning skills and retaining those learned skills for future use (16). This connection is made through aspects of the theory known as behavioral capability and self-efficacy, which emphasize the execution of observed skills and address performance and confidence barriers. Without also incorporating these other aspects, the social cognitive theory will come up short when put into practical use. While the stories portrayed in Safe in the City successfully show modeling by depicting bad outcomes occurring when one or one's partner does not wear a condom, the individual-level intervention does not take into account the importance of developing skills and collaborating on strategies for safer sex behaviors, which a group-level component could provide.
Critique #2 – Theoretical Basis in Rationality
Safe in the City is theoretically based in the Information-Motivation-Behavioral Skills (IMB) Model, Social Cognitive Theory, and the Theory of Planned Behavior. The IMB Model holds that there are three fundamental determinants of risk reduction: information, motivation, and behavioral skills. Information, including facts about STD/HIV transmission and information regarding specific methods to prevention, is seen as the precursor to risk reduction behavior, then comes motivation to reduce risk, which entails attitudes toward prevention, social norms, and intentions to practice preventive behaviors, and finally behavioral skills are seen as needed in order to perform specific preventive acts (17). However, because this particular intervention does not develop behavioral skills, it is only based in the informational and motivational aspects of the model.
Social Cognitive Theory is built on the understanding that behavior change is based on self-efficacy, goals, and outcome expectancies. It involves reciprocal determinism (the interaction between the individual, the behavior, and the environment), behavioral capability (the knowledge and skills to perform a behavior), expectations (anticipated outcomes of a particular behavior), self-efficacy (confidence in one's ability to take action), observational learning or modeling (deciding to perform a behavior based on watching someone else perform that behavior and seeing the outcome), and reinforcements (responses to the behavior that increase or decrease the likelihood of reoccurrence) (18).
The Theory of Planned Behavior states that a person's attitude toward a specific behavior and that person's perception of the subjective norms (whether or not the behavior is likely to be approved or disapproved by one's social groups) associated with that specific behavior come together in an intention to perform a behavior (18). This behavioral intention is based on one's perceived behavioral control, which is made up of a person's self efficacy, or a belief in the ability to actually perform a behavior and a belief in the amount of power they have in actually performing the behavior (18).
The assumption behind Social Cognitive Theory and the Theory of Planned Behavior is that people are rational decision-makers. However, these theories are flawed in that they overlook emotional variables, particularly those associated with sex, which tend to make individuals' behavior especially irrational. In Dan Ariely's book Predictably Irrational: The Hidden Forces That Shape Our Decisions, he discusses an experiment he conducted to demonstrate the influence of arousal. Male heterosexual participants in his study were asked to respond to questions while imagining how they would respond while sexually aroused. The first set of questions revolved around sexual preferences, the second revolved around the likelihood of engaging in sexually immoral behaviors, and the third set revolved around the likelihood of engaging in unprotected sex. Later on in the experiment, the participants were instructed to view arousing pictures and to masturbate while answering the same sets of questions as were originally asked. One of the findings of the study was that individuals were 25% more likely to predict that they would not use a condom in the aroused state than in the unaroused state (19).
The theoretical basis of Safe in the City assumes that knowledge influences attitudes and that attitudes then influence behavior, yet this is not how actual behavior change seems to work. After watching Safe in the City, individuals may be of the mindset that they will always use a condom, but passion in the heat of the moment has been shown to say otherwise, particularly if one does not have the communication skills necessary for negotiation. While the IMB Model, Social Cognitive Theory, and the Theory of Planned Behavior may work well as a foundation for public health interventions that train in these types of skills, they do not sufficiently address how one can be expected to negotiate behavior, such as condom use, in an irrational or emotional state without training in a specific set of skills.
Critique #3 – Optimism Bias, Illusion of Control, and Stigma Theory Left Unaddressed Because of the stigmatized nature of an STD/ HIV diagnosis, all public health interventions that aim to reduce new infections will have some of the same fundamental barriers. These barriers stem from Optimism Bias, the Illusion of Control, and the Stigma Theories.
Optimism Bias is a bias that causes a person to believe that they are less likely to experience a negative event compared to others, yet more likely to experience a positive event (20). In fact, people who regard a disease as extremely serious are most likely to think that their likelihood of contracting that disease is less than average (21). Optimism Bias is the belief that contracting an STD/HIV could “never happen to me”, which leads people to engage in risky behaviors like having unprotected sex. Safe in the City does not address Optimism Bias, so even if an individual views the video, they may not think that the information pertains to them.
The Illusion of Control is the tendency for people to overestimate their ability to control events, for instance to feel that they control outcomes that they actually have no influence over (22). Realistic control would be the use of condoms, because using a condom does provide actual protection, whereas illusory control would be asking about a partner's sexual history, where this does not provide actual protection, particularly if one's partner has never actually been tested (23). The Illusion of Control can be reinforced every time an individual has unprotected sex but does not get an STD, leading that individual to continue with that risky behavior (23). While realistic control is addressed in Safe in the City through the promotion of consistent condom use, all partners getting tested, and the omission of illusionary control, this may not transfer to the viewer in the clinic who has avoided STDs despite inconsistent protection. In addition, while the video does stress the importance of using a condom every time, Safe in the City does not stress the need to get tested after each unprotected sexual encounter and after each change in partner, particularly if there is not an understanding of mutual monogamy. Instead, the video assumes the viewer will never make a mistake and does not include this possibility in the scenarios.
Stigma Theory is when an individual has an attribute and society discredits and rejects the individual because of that attribute (24). STDs, particularly HIV, are attributes affected by Stigma Theory and result in an individual being ostracized, rejected, avoided, and discriminated against by families, healthcare professionals, communities, and governments; violence against one who is perceived to have AIDS/HIV or who belongs to a high-risk group also occurs (25). Because Safe in the City is currently only implemented in public STD clinic waiting rooms, it does not address Stigma Theory adequately. The venue should not be exclusive and instead should reach those who are afraid of getting tested for fear of getting a positive result. In addition to Stigma Theory related to testing, some people may fear that using condoms, whether or not one is infected or not, may bring partner rejection (25). Safe in the City does not address how to proceed in a scenario in which one person attempts to negotiate condom use but has a partner that is resistant.
Safe in the City, along with many other STD/HIV prevention interventions, does not provide ways to combat Optimism Bias, Illusion of Control, and Stigma Theory. A video may not be the best way to address these barriers since interaction with the individual is needed in order to determine their exact level of risk. The intervention’s venue is also problematic since those who are most at-risk for infection may not be successfully reached.
Safe in the City is not an entirely failed intervention. In fact, it is listed in the CDC's Compendium of Evidence-Based HIV Behavioral Interventions and is classified as a best-practice intervention due to positive evaluation findings (26). As a brief, video-based, individual-level intervention, Safe in the City is effective among males. As an intervention that is easy and inexpensive to implement and that can reach large numbers of STD clinic patients of different races/ethnicities and of different sexual orientations, it can be considered a success. For clinics that want to provide a STD/HIV prevention component but do not have the resources or funding for individual counseling or a group-level program, Safe in the City might even be the best option to make a meaningful impact. Moreover, research does show that implementing a lone video in a clinic is better than solely implementing standard clinic procedures (13, 14).
A number of aspects of the intervention are good and should be incorporated into the modified intervention. Psychological reactance is the theory that when an individual is told that they cannot have something, there is more of a desire to get that particular something (27). While oftentimes public health interventions tell people what to do or not to do, Safe in the City instead empowers people by giving them choices while still insisting on condom use. There is an entire section of the video devoted to different styles of condoms that one can choose from, even ultra-sensitive ones for those who complain that they do not like the feeling of condoms. Communications theory and modeling call for a likeable, familiar, and similar person to deliver the message. Safe in the City successfully accomplishes this by using a young and racially/ethnically and sexually diverse cast of characters. Reciprocity is the idea that if someone does something for you, you feel like you want to do something for them (28). In the case of Safe in the City, the video drills into one's head that STD clinics have free condoms for the taking. Research has shown that when free condoms are visibly provided, about 80% of people take them, and of those that take them, almost 75% of people report using them (29). Finally, the video shows different reasons for using condoms including STD/HIV prevention, pregnancy prevention, and avoidance of long-term effects of STDs such as infertility, and the importance of using a condom for an entire sexual encounter from start to finish, waiting to know your status and your partner's status before having sex, standing your ground on using a condom even in the heat of the moment, and getting yourself and your partners tested (7, 9, 11).
The proposed intervention will still involve the Safe in the City video in its full format, but it will also contain a group-level component led by a trained facilitator. This new component will involve group discussion, a skills-building session, STD/HIV and condom use information, and the distribution of free condoms. The following proposed modifications to the intervention will address the critiques detailed in the previous section in the hopes that with the new group-level component, Safe in the City could be an even more effective intervention in reducing rates of new STD/HIV infections.
Modification #1 – Addition of a Small Group Component
The largest proposed modification to the Safe in the City intervention entails structural change. Instead of an entirely individually-based intervention, the proposed intervention would be a single session, small group-level intervention. This modification directly addresses the issue regarding the lack of opportunity for developing and practicing skill building. Specific aspects are pulled in part from a variety of similar video-based interventions that have an added counseling or group-level component, including RESPECT, Sisters Informing Sisters on Topics about AIDS (SISTA), and Video Opportunities for Innovative Condom Education & Safer Sex (VOICES/VOCES) (30, 31, 32, 33). To begin, small groups of about 4 to 8 individuals would be convened by gender and race/ethnicity, led by a trained facilitator of the same gender and race/ethnicity as the makeup of the group. The session would start with a viewing of the Safe in the City video in its entirety. Once the video was complete, the facilitator would begin the discussion by asking questions about the situations and characters in the video and encouraging participants to relate them to their own lives. The goal of this portion of the session is to increase the perception of personal risk of STD/HIV infection among the participants. Rather than providing general knowledge about STD/HIV, the discussion would focus on the behaviors that put people at risk for infection. The facilitator would also correct any misinformation about STD/HIV and condom use that is discussed.
Following this discussion would be a skills-building session to work on developing and practicing skills needed for overcoming barriers to condom use. After the skills-building session, the facilitator would educate participants about the different types of condoms available for use. Before the group disbands, the facilitator would actively distribute, rather than passively provide, different types of condoms to participants based on what the participant identifies as needing. Throughout the intervention the facilitator would be available for questions and at the end would let participants know how to contact them if questions or concerns should arise after the session. It should be noted that depending on the needs of a particular group due to gender or culture, aspects of the session could be altered.
An added group-level component allows participants to learn something through group interaction that they cannot learn from a video alone. Groups accomplish this by sharing common experiences, exposing one another to positive peer influence, increasing motivation to change, and providing support (34). The CenteringPregnancy program exemplifies this in another area of public health, prenatal care. While prenatal care is traditionally delivered individually, the CenteringPregnancy model is based on the theory that groups are effective in providing support and helping people reach goals and so is instead delivered in a group format by a healthcare provider to women in similar stages of pregnancy (34, 35). Evaluations of Centering Pregnancy show that compared to a one-on-one interaction, the group-level program increases social support, perceived empowerment, and exposure to useful skills and information (35). Adding this type of group-level component to Safe in the City will allow participants to learn from one another through discussion, social modeling and the aspects needed for modeling to be successful, behavioral capability and self efficacy, and will thus strengthen the existing intervention.
Modification #2 – Skills Building with Motivational Enhancement and Theory of Gender and Power
The second modification addresses the flaw in basing a risk reduction intervention on theories that assume behaviors are rational, like Social Cognitive Theory and the Theory of Planned Behavior, while the original intervention is not built to give people the tools to make positive decisions in irrational states. The incorporation of a skills-building session however, complete with group practice and facilitator and group feedback on performance, allows a participant of the new intervention the ability and confidence to negotiate condom use even in an emotional state.
Under the guidance of the facilitator, participants of the new intervention would role-play, practice, and discuss communication skills like sexual assertiveness, which includes refusal skills, or the ability to refuse unwanted sexual contact, and condom negotiation. Training in these types of skills is effective in increasing the frequency of condom-protected sexual activity (36, 37). The skills would first be modeled by the facilitator and then practiced and discussed. The group would discuss problems they have encountered in trying to adopt safer-sex behaviors and develop and practice strategies for overcoming these problems. The IMB Model would now be used in full as a theoretical basis. This skills-building component is also founded in Motivational Enhancement, which promotes positive outcomes by actively involving participants in the behavior change process and in developing risk-reduction strategies that are suited to their own situations (38).
While this sexual assertiveness skills-building aspect of the modified intervention would ideally address the fact that the original intervention is ineffective in increasing condom use among females, the group sessions would also have a component based on the Theory of Gender and Power. The Theory of Gender and Power is a social structure theory that posits that there is a sexual division of power that characterizes the gendered relationship of males and females, and that this division of power may explain non-condom use among women (39, 40). The modified intervention would address this power imbalance by correcting the misconception that a female asking her partner to use a condom use may imply infidelity or may compromise the relationship. SISTA, a peer-led HIV prevention program for African American women founded in the Theory of Gender and Power, has been shown effective in increasing consistent condom use, sexual behavior, self-control, sexual communication, and sexual assertiveness skills and in increasing partner adoption and support of consistent condom use (31). Borrowing from SISTA, facilitators of the new intervention for women would also use cultural- and gender-appropriate materials to encourage pride and enhance self-worth and teach verbal and nonverbal communication skills intended to reach partners hesitant to use condoms consistently or at all (31).
Finally, by actively distributing condoms to the program participants and making sure they are aware that condoms are always available for free at the clinic, the message sent is that there is no reason to ever be without one. Because people have a tendency to forgo condoms in the heat of the moment if they are not readily available, making sure that condoms are indeed always available is a good step towards combating people's would-be irrational behavior.
Modification #3 – Personal Risk Assessments, Teachable Moments, Alternate Venues
The modified intervention would address Optimism Bias through the personal risk assessments that occur after the viewing of the Safe in the City video. Relating the scenarios displayed in the video to ones in the participants' own lives, will make it clear that anyone can get an STD/HIV from unprotected sex, not just those who are stereotyped as “dirty”. This message will increase perception of risk of unprotected sex and reinforce the need for all individuals to use condoms (41). For participants who appear to underestimate their personal health risks, individual intensive counseling may be necessary to overcome Optimism Bias.
The group-level component would also be able to address participants experiencing illusory control through teachable moments brought about by the personal risk assessment discussion. Teachable moments are situations that create an opportunity to influence behavior change (30). One way of accomplishing this is following the format used in a research study that used failure experiences as a way to undermine perceived invulnerability to HIV and reduce Optimism Bias, resulting in increased perceptions of personal risk for HIV and intentions to use condoms (42). In the study, the facilitator asked participants to write about a time when they had sex without a condom followed by a group discussion about why condoms are a necessity, an exercise which forced participants to remind themselves of a past failure while also simultaneously reminding themselves that condoms are essential in protecting oneself (42). Participants then individually judged whether individuals were HIV-positive or negative based on pictures and brief biographical and sexual experience information. The majority of participants performed at or below chance levels (42), also demonstrating failure.
The sexual assertiveness skills-building portion of the group session and the component where the facilitator corrects misconceptions about what it means when one partner asks their partner to use a condom is intended to address the Stigma Theory critique. An additional way of addressing Stigma Theory is to hold the intervention in venues other than public STD clinics where other at-risk individuals can be found. These could include venues such as family planning centers, community health centers, schools, businesses, churches, drug rehabilitation clinics, and correctional facilities.
Safe in the City is an individual-level, brief, single-session, video-based intervention designed to prevent new STD/HIV infections by encouraging increased condom use among clients in STD clinic waiting rooms. Because clients simply view the video, there is no development of skills necessary to successfully negotiate condom use with sexual partners and no discussion of common barriers to condom use or strategies to overcome these barriers. By encompassing the video within a small group component, the modified intervention would include gender- and culturally- appropriate segments on personal risk assessment, sexual assertiveness skills-building, overcoming barriers to condom use, accurate condom information, and condom distribution. These added segments aim to address issues related to the theoretical foundation of the original intervention, behavioral irrationality, Optimism Bias, the Illusion of Control, and Stigma Theory in the hopes that such modifications would transform the original intervention into a more effective intervention for increasing condom use and reducing rates of new STD/HIV infections.
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