Sexually Transmitted Infections Adopting a Sexual Health Paradigm (2021) / Chapter Skim
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8 Psychosocial and Behavioral Interventions
8 Psychosocial and Behavioral Interventions
Pages 399-462
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8 Psychosocial and Behavioral Interventions Chapter Contents Introduction Contributions of Psychosocial and Behavioral Interventions on STI Prevention and Control • Psychosocial and Behavioral Theories and Conceptual Models Psychosocial and Behavioral Interventions Individual-Level Interventions • Theoretical Basis and Content • Intervention Delivery Mechanisms • Population and Context-Specific Tailoring • Sexual Education Interpersonal-Level Interventions • Family-Level Interventions • Social Network Interventions Community-Level Interventions • Meta-Analytic and Systematic Reviews of Community Interventions for HIV/STIs • Promising Community-Based Strategies 399
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. These interventions' important contributions to promote sexual health and prevent and control STIs can be categorized as having three distinct types of influence: (1)
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Second, the chapter offers an overview of interventions at the individual, interpersonal, and community levels, with attention to various key groups. Consistent with the report's social ecological framework for sexual health promotion and STI prevention, the highlighted interventions target factors across all levels of the social ecology -- from individual to community and across the life span.
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CONTRIBUTIONS OF PSYCHOSOCIAL AND BEHAVIORAL INTERVENTIONS ON STI PREVENTION AND CONTROL Psychosocial and Behavioral Theories and Conceptual Models Psychosocial and behavioral theories and conceptual models of health and behavior change have guided the development of interventions to prevent STIs and reduce associated health risk behaviors. Below is a summary of commonly used theories and conceptual models.
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. Social Ecological Theory The social ecological theory describes the multiple and interrelated influences on STIs and associated behaviors (Bronfenbrenner, 1979, 1986)
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enacting change by seeking solutions and adopting behaviors that decrease STI risk. Individuals may progress through certain stages, regress to a previous stage, and move back and forth between stages before behavior change is sustained (Catania et al., 1990)
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increase their impact on preventing and reducing STIs and related outcomes, including condomless sex (DiClemente et al., 2008; Estrada et al., 2017; Guilamo-Ramos et al., 2020)
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. While these early sexual and reproductive health intervention programs were designed to promote behaviors associated with reduced STI risk among adolescents, such as delay of sexual debut, preventing sexual transmission of infection was not a primary target outcome.
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and dependent (e.g., sexually transmitted infection incidence) variables to further refine an understanding of the causal relationship.
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. Incorporating important shared principles and characteristics of these effective existing interventions into the development of future STI prevention programs represents a meaningful step toward strengthening sexual health promotion in the United States.
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. Yet, the importance of aligning intervention delivery mechanisms with theoretically identified mediators of intervention effects has been discussed (Guilamo-Ramos et al., 2019)
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. Incorporating lessons learned from decades of successful intervention science into the development of future STI prevention programs represents a meaningful step toward strengthening sexual health promotion in the United States and also can be leveraged to improve school-based sexual education (Rankin et al., 2016)
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. Comprehensive sexual education, also referred to as "abstinence plus" or "sexual risk reduction," promotes abstinence as the primary approach to prevent STIs but also encourages sexually active adolescents to use available barrier and contraceptive methods (Denford et al., 2017; Santelli et al., 2017)
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, yet they frequently identify their lack of sexual health expertise as the primary reason that schools need to provide comprehensive content and resources (Johnson-Motoyama et al., 2016)
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. In sum, school-based comprehensive sexual health education programs that seek to meaningfully involve parents are sorely needed.
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414 SEXUALLY TRANSMITTED INFECTIONS TABLE 8-2 Sex and HIV Education in Schools Sex and HIV Education Require Sex and When Provided, When Provided, Mandate Sex HIV Programs Sex Education HIV Education and/or HIV to Be Medically Must Include Must Include State Education Accurate Contraception Condoms U.S. Total 39 states and 17 states and 20 states and 19 states Washington, Washington, DC Washington, DC DC Alabama HIV X X Alaska Arizona HIV Arkansas HIV California Sex and HIV X X X Colorado X X Connecticut HIV X Delaware Sex and HIV X X DC Sex and HIV X Florida Sex and HIV Georgia Sex and HIV Hawaii Sex and HIV X X X Idaho Illinois HIV X X X Indiana HIV Iowa Sex and HIV X Kansas Sex Kentucky Sex and HIV Louisiana X Maine Sex and HIV X X X Maryland Sex and HIV X X Massachusetts Michigan HIV Minnesota Sex and HIV Mississippi a Sex Missouri HIV X Montana Sex and HIV Nebraska Nevada Sex and HIV
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b Sex education is required in a county if pregnancy rate is at least 19.5 or higher per 1,000 young women aged 15–17. c State also prohibits teachers from responding to students' spontaneous questions in ways that conflict with law's requirements, State Laws and Policies, Sex and HIV Education, as of June 1, 2020.
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Family-level interventions are informed by several models, including family systems theory and social ecological theory. For sexual health and preventing STIs, these interventions typically occur during adolescence, generally incorporate the adolescent and parent(s)
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In both studies, the intervention effects on the sexual health outcomes and/or STIs were mediated by improvements in parent–youth interactions (Caruthers et al., 2014; Spoth et al., 2014)
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, including sexual health outcomes (Guilamo-Ramos et al., 2020) and STI outcomes (Prado et al., 2007)
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Future research to address current gaps in family interventions to promote sexual health and to prevent STIs is sorely needed, with adequate resources for development, implementation, and long-term follow-up. Social Network Interventions Social networks have been demonstrated to be important in STI transmission (Ellen et al., 2006; Klovdahl et al., 1994; Wylie and Jolly, 2001)
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In a systematic review and meta-analysis (Hunter et al., 2019) , social network interventions showed a significant effect on sexual health outcomes that was consistent across a myriad of populations (e.g., ethnic minorities, MSM)
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Beyond the central social ecological perspective, there is no singular definition of community interventions related to STI prevention and control. Of more than three decades of interventions focused on sexual health, most were designed for HIV prevention, leading to a dearth of evidencebased interventions to reduce STI incidence.
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They aim to affect behavior change through community mobilization; they target specific communities disproportionally affected by HIV/STIs, including MSM; they are based on established behavior change theories; and, importantly, they use peer models as change agents in the community to affect behavioral outcomes. Furthermore, the initial studies that evaluated the interventions were controlled trials with intervention and control groups and, while they did not include HIV or STI incidence outcomes, they all showed efficacy in changing behaviors, including decreases in condomless sex.
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The findings indicated that no studies reported incident HIV, but community-based unlimited condom distributions modestly reduced condomless sex, while the condom distribution interventions along with other intervention activities significantly reduced multiple sexual partnerships. One coupon-based study, which was a not a randomized controlled trial (RCT)
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systematic review and meta-analysis of community empowerment interventions for HIV prevention among sex workers in low- and middle-income countries from 1990 to 2010 revealed a reduction in gonorrhea and chlamydia in a longitudinal study and a reduction gonorrhea in an observational study. For this group, community empowerment included the traditional core elements of peer education, condom distribution, and periodic STI screening, but also emphasized principles that support the perspective that "sex work is work and should be respected as such, that sex workers know best how to identify their priorities and areas of concern, and that meaningful and sustainable responses to these challenges should be led by sex workers" to reduce their risk for HIV and to improve their overall health and well-being (Kerrigan et al., 2013, p.
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Community stakeholders should be enlisted to serve in partnership to ensure that interventions are culturally tailored and community situated to build on strengths and address unique needs. Promising Community-Based Strategies Partnering with Faith Institutions to Build Capacity and Sustainability To address cultural and structural influences on HIV awareness, testing, risk-reduction behaviors, and stigma, community interventions have focused on forming collaborations with African American churches and other faith-based institutions (Abad et al., 2015; Derose et al., 2016; Griffith et al., 2010; Lightfoot et al., 2014)
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. Given barbershops' prominence in African American communities and the trust and rapport between barbers and their clients, "barbershops are potentially one venue that is culturally situated and contextually appropriate" to reach diverse groups of African American men to disseminate information about sexual health, wellness, and STI prevention (Brawner et al., 2013, p.
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, tailored to reach other groups of racial and ethnic men, and adapted to focus on sexual health, including STI prevention. Clearly, more rigorously designed trials using LHAs are needed to determine the long-term efficacy of this promising approach.
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Moreover, these lesser-known community approaches to sexual health promotion and STI prevention have shown the importance of community engagement and capacity building through deliberate and ongoing partnership with key community stakeholders, collaboration between public health researchers and key community members, and allocation of dedicated resources for formative work, intervention implementation, evaluation, replication, and scale-up. COST EFFECTIVENESS OF PSYCHOSOCIAL AND BEHAVIORAL INTERVENTIONS In addition to STI-preventive interventions being efficacious and effective, evidence indicates that they are cost effective.
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WSIPP's work has included a number of different areas, including criminal justice, education, child welfare, behavioral health, workforce development, public health, and prevention and thus interventions that target risk factors (e.g., alcohol use) for sexual health promotion and STI prevention and management.
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This requires extensive consideration of when, how, and why they should be incorporated into interventions. For example, in addition to acting as a delivery tool, technologies such as social media can influence people's perceptions of sexual health and related STI risk, moral and sexual-related judgments about themselves and their peer groups, and social normative behaviors around sex (Young and Jaganath, 2013; Young and Jordan, 2013)
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For example, participants who perceived a sexual health text message intervention as more interactive, regardless of actual differences in technological affordances, selfreported an increased likelihood to recommend the service to a friend and showed increased levels of repeat use (Willoughby and L'Engle, 2015)
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Specific to text messaging and sexual health, a meta-analysis of 35 studies examined intervention effects on prevention, detection, treatment, and knowledge of STIs and HIV (Taylor et al., 2019)
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2.0 intervention -- rooted in the IMB Skills model of HIV risk behavior change -- compared to those in a matched eHealth control group (with static text and content not tailored to young MSM) , had improved STI-related outcomes.
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The model is based on five overarching factors that are needed to develop sustainable technologybased interventions: (1) basic behavior change components; (2)
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FIGURE 8-1 Adaptive Behavioral Components (ABC) model for technology-based interventions.
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was impacted by these changes; analysis of the HOPE study found that intervention participants received fewer notifications about HIV prevention and testing compared with control (Facebook) group participants (Young, 2020)
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A review of how social marketing principles were applied in sexual health campaigns found that some elements were limited in campaign creation (Akbar et al., 2020)
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Box 8-2 outlines important considerations when developing interventions that use technology or adapting an offline intervention to be online. DISSEMINATION OF EVIDENCE-BASED BEHAVIORAL INTERVENTIONS Psychosocial and behavioral interventions with documented efficacy in preventing STIs have generally not been widely disseminated.
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Although these were not always implemented with high fidelity (Rotheram-Borus et al., 2009) , largely because community organizations adapted them for local use, CDC's effort was successful in reducing sexual risk behaviors and STIs (Dworkin et al., 2008)
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Models such as the ABC described earlier can also be used to sustain technology-based interventions. IMPLEMENTATION SCIENCE It is also important to turn to the field of implementation science for methods to facilitate the adoption and sustainment of evidence-based interventions to promote sexual health and STI prevention.
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To date, no intervention strategies have been evaluated to examine the adoption of evidence-based sexual health and STI behavioral interventions. The following section briefly reviews some implementation strategies and systems that have been found to be effective in integrating behavioral interventions, although not specific to sexual health and STIs.
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CDC's Community Approaches to Reducing Sexually Transmitted Diseases (CARS) program began in 2011 (CDC, 2020b)
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For example, Hybrid II effectiveness-implementation trials (Brown et al., 2009) that evaluate individual-level outcomes (e.g., STI incidence, condomless sex)
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CONCLUSIONS AND RECOMMENDATION Based on its review of the evidence, the committee provides the following conclusions, and Recommendation 8-1: Conclusion 8-1: Psychosocial and behavioral interventions, in conjunction with biomedical, structural, informatics/technological, and health service interventions, are integral to a comprehensive strategy for sexual health and STI prevention and control. Therefore, multidisciplinary investigative teams are needed when developing psychosocial and behavioral interventions.
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Political conflict over abstinence-only education, combined with pronounced conflict over addressing sexual orientation and gender identity diversity in schools, has meant that many young people do not receive sufficient instruction of guidance in these areas. School-based sexual health education programs across the United States are highly variable, with no nationwide policy regarding how sexual education is taught in schools.
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Divi sion of Adolescent and School Health should work in partner ship with parents and guardians, parent–teacher associations, states, districts, and local school boards to establish standard evidence-based guidelines for school-based comprehensive sexual health education that is grounded in psychosocial and behavioral theories and research. To ensure that each student receives medically accurate, age-appropriate, and culturally inclusive comprehensive sexual health education in elemen tary, middle, and high school, dedicated staff, including school based nurses and health educators, should be trained, provided adequate time, and given necessary resources.
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2007. One to one interventions to reduce sexually transmitted infections and under the age of 18 conceptions: A systematic review of the economic evaluations.
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2007. Youth united through health education: Community-level, peer-led outreach to increase awareness and im prove noninvasive sexually transmitted infection screening in urban African American youth.
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2012. The effectiveness of group-based comprehensive risk-reduction and abstinence educa tion interventions to prevent or reduce the risk of adolescent pregnancy, human im munodeficiency virus, and sexually transmitted infections: Two systematic reviews for the guide to community preventive services.
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2007. The efficacy of behavioral interventions in reducing HIV risk sex behaviors and incident sexually transmitted disease in black and Hispanic sexually transmitted dis ease clinic patients in the United States: A meta-analytic review.
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2006. Sex partner selection, social networks, and repeat sexually transmitted infections in young men: A preliminary report.
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Sexually Transmitted Diseases 43(2)
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2020. Behavioral counseling interventions to prevent sexually transmitted infections: Updated evidence report and systematic review for the U.S.
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1999. Reducing HIV risk associated sexual behavior among African American adolescents: Testing the generality of intervention effects.
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2016. Brief interventions to prevent sexually transmitted infections suitable for in-service use: A systematic review.
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2018. Interventions to reduce risk for sexually transmitted infections in adolescents: A meta analysis of trials, 2008-2016.
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2011. Structural and community-level interventions for increasing condom use to prevent HIV and other sexually transmitted infections.
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2007. A randomized controlled trial of a parent centered intervention in preventing substance use and HIV risk behaviors in Hispanic adolescents.
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Sexually Transmitted Infections 82(6)
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2019. Effectiveness of text messaging interventions on prevention, detection, treatment, and knowledge outcomes for sexually transmitted infections (STIs)
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2018. Technology based interventions to reduce sexually transmitted infections and unintended preg nancy among youth.
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2014. Project Hope: Online social network changes in an HIV prevention randomized controlled trial for African American and Latino men who have sex with men.
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