DTIC ADA432133: Effectiveness of Two Versions of a STD/HIV Prevention Program

14 Pages·0.44 MB·English

by  Defense Technical Information Center

NAVAL HEALTH RESEARCH CENTER

EFFECTIVENESS OF TWO VERSIONS

OF A STD/HIV PREVENTION PROGRAM

S. Booth-Kewley
R. A. Shaffer
R. Y. Minagawa
S. K. Brodine

Report No. 01-01

Approved for public release; distribution unlimited.

NAVAL HEALTH RESEARCH CENTER
P. O. BOX 85122
SAN DIEGO, CA 92186-5122

BUREAU OF MEDICINE AND SURGERY (M2)
2300 E ST. NW
WASHINGTON, DC 20372-5300
EFFECTIVENESS OF TWO VERSIONS OF AN STD/HIV
PREVENTION PROGRAM

1NAVAL HEALTH RESEARCH CENTER
P.O. BOX 85122
San Diego, CA 92186-5122

Stephanie Booth-Kewley, PhD1, CDR Richard A. Shaffer, PhD, MSC, USN1, Rahn Y. Minagawa, PhD2,
CAPT Stephanie K. Brodine, MD, MSC, USN Ret3

2GEO-CENTERS INC., Rockville, MD 20852,
3GRADUATE SCHOOL OF PUBLIC HEALTH, San Diego State University, CA

Report No. 01-01, supported by 6816 research work unit. The views expressed in this article are those of the
authors and do not reflect the official policy or position of the Department of the Navy, Department of
Defense, or the U.S. Government. Approved for public release, distribution unlimited.
Human subjects participated in this study after giving their free and informed consent. This research has been
conducted in compliance with all applicable Federal Regulations governing the Protection of Human Subjects
in Research.

Address correspondence to: Stephanie Booth-Kewley, Operational Readiness Research, Naval Health
Research Center, P.O. Box 85122, San Diego, CA 92186-5122

Abstract
Little is known about the comparative effectiveness of HIV prevention interventions that differ in
duration but contain similar content. The objective of this study was to evaluate and compare the
effectiveness of two versions (6 hr vs. 3 hr) of a behavioral intervention called the STD/HIV Intervention
Program (SHIP) in a sample of Marines. Marines were exposed to either a 6 hr or a 3 hr version of SHIP.
Comparisons of pretest and posttest knowledge, attitude, and behavioral intention scores revealed similar
results for both versions. For both versions of the intervention, scores on STD/HIV knowledge were
significantly higher after the intervention. Both the 6 hr and the 3 hr versions of SHIP also led to
significant increases on scales measuring social norms and behavioral intentions. The two versions of
SHIP appeared to be of comparable effectiveness for producing short-term changes in knowledge,
attitudes, and behavioral intentions.

INTRODUCTION

Behavioral interventions to encourage behavioral interventions to reduce
safe sex practices have been shown to HIV/AIDS are effective and should be
reduce rates of unprotected sexual widely disseminated.11
intercourse in a variety of populations.1-6 A An important research question that has
growing body of scientific evidence received little attention to date is: “How
indicates that reductions in risky sexual long must an HIV intervention program be
behavior can occur as a result of well- in order to be effective?” The behavioral
designed interventions.7-9 A meta-analysis of interventions described in the research
cognitive-behavioral HIV interventions literature have varied widely in duration.
demonstrated a significant reduction in HIV Kelly et al.,2 for example, found a 16 hr
risk behaviors with small to moderate effect intervention to be effective for increasing
sizes.10 Moreover, a National Institutes of condom use in a sample of gay men, and St.
Health Consensus Panel concluded that Lawrence, Brasfield, Jefferson, and
2
O’Bannon6 found a 14-hr intervention to be A number of studies have compared
effective for increasing condom use among HIV interventions of the same duration with
African- American adolescents. At the other varying content,12,16,17 and several studies
extreme, some very brief HIV behavioral have compared HIV interventions that
interventions have also been shown to be varied in both duration and content.6,13,18
effective. Belcher et al.,12 for example, However, we were only able to find one
found a single-session, 2-hr intervention to study in which interventions of different
be effective for increasing condom use durations but very similar content were
among adult women. Similarly, Valdiserri systematically compared. 4 The
and colleagues13 found a single-session, effectiveness of a 3-session 9-hr HIV
140-minute program to be effective for prevention intervention was compared with
increasing condom use among homosexual that of a 1-session 3 hr intervention. Both
and bisexual men. In addition, a recent conditions were found to be effective, but
meta-analysis of HIV behavioral behavior change was more pronounced in
interventions for adolescents noted that the the 3-session condition.4
number of intervention hours in the studies Brief interventions for health
ranged from 0.3 hr to 35 hr, with a median promotion goals other than HIV prevention
of 4.5 hr.8 have become increasingly popular in recent
Intuitively, it would appear that longer years. For example, there is evidence
HIV interventions would be more effective demonstrating the effectiveness of brief
than shorter programs. The literature on interventions for problem drinking,
HIV interventions provides some support for smoking, and substance use.19-22 Evidence
this idea, but there has been a lack of of the effectiveness of brief behavioral
systematic research in which interventions interventions to prevent STDs/HIV would
of similar content but varying duration were have substantial tangible benefits because
compared. A meta-analysis of 12 HIV risk- brief interventions would be less expensive
reduction intervention studies that included and more feasible due to fewer logistical
behavioral outcomes as criteria found that constraints.
intervention duration was not significantly Very little is known about the
related to intervention effectiveness.10 comparative effectiveness of HIV
However, the authors found a trend toward prevention interventions that differ in
greater effectiveness for longer duration but contain similar content. The
interventions. A review of 40 HIV objective of this study was to evaluate and
interventions designed specifically for compare the effectiveness of two versions (6
adolescent populations14 found that hr vs. 3 hr) of a behavioral intervention that
intervention duration was significantly were similar in content but differed in
correlated with effectiveness for only one of duration. Because a greater “dose” of an
the six outcomes examined (number of sex intervention would be expected to have a
partners). A recent meta-analysis of HIV greater impact on participants, it was
interventions for adolescents8 found no hypothesized that a greater number of
significant relationship between number of positive effects would be found for the 6 hr
intervention hours and effect size, nor did versus the 3 hr intervention.
they find a significant relationship between
number of intervention sessions and effect METHOD
size. A review of HIV interventions for Overview
women15 concluded that interventions that Marines attending the Marine Security
used multiple sessions rather than a single Guard (MSG) school in Quantico, Virginia,
session were more likely to be effective for were exposed to either a 6 hr or a 3 hr
increasing condom use, but duration, per se, version of the STD/HIV Intervention
was not examined. Program (SHIP), a cognitive-behavioral
intervention to prevent sexually transmitted
3
diseases (STDs) and HIV among Marines. changes: (1) two of the three videos that
The 6 hr SHIP curriculum was given to were part of the 6 hr version of SHIP (“HIV
MSGs who attended the MSG school Legacy” and “Liberty Brief”) were omitted
between February 1998 and February 1999; (a third video called “Condom-Eze” was
the 3 hr SHIP curriculum was given to retained); (2) three of the longer small-group
MSGs who attended the school between exercises were omitted; and (3) all of the
March 1999 and February 2000. A pretest- slide/lecture modules included in the 6 hr
posttest design was used to evaluate the version were condensed.
effectiveness of the two versions of the A Navy corpsman and a civilian
intervention. instructor who were experienced in
delivering HIV prevention training jointly
Description of SHIP gave the SHIP training in both versions of
SHIP was originally developed in an SHIP. The 6 hr version of SHIP was
earlier project as an 8-hr intervention for delivered in three 2-hr sessions on
fleet Marines.23 The two shorter versions of consecutive days in a large classroom
SHIP that were developed for the MSG setting. The 3 hr version of SHIP was
school were modifications of the original 8- delivered in two 1.5-hr sessions on
hr course. The content and format of all consecutive days. There were no other
versions of SHIP were based on the differences between the 6- and 3 hr versions
Information-Motivation-Behavioral Skills of SHIP.
model,24,25 a cognitive behavior model
designed specifically to explain HIV risk- Subjects
reduction behavior. Both versions of SHIP Participants were students at the MSG
were designed to (1) expand the Marines’ school in Quantico, Virginia, whose mission
knowledge of STDs/HIV, (2) increase their is to train and screen Marines for MSG duty
motivation to engage in safe sexual in foreign countries. MSGs are Marines
behaviors, and (3) provide them with assigned to guard and protect U.S.
appropriate behavioral skills. embassies located all over the world,
SHIP used a variety of media (e.g., including Third World countries. All
videos, slides) to present information and prospective MSGs must graduate from the
included lectures, small group discussions, MSG school before being assigned to a U.S.
and other interactive group activities. embassy in a foreign country. The MSG
Specifically, slide-and-lecture presentations, school graduates five classes per year, with
games, group discussions, videos, and a an average of about 95 graduates (range 70-
condom demonstration were used to present 130) per class. A total of 1,044 Marines
the following content areas: (1) the were exposed to either the 6 hr or 3 hr
epidemiology of STDs and HIV/AIDS in version of SHIP. The 6 hr SHIP curriculum
adults; (2) the transmission and prevention was given to MSGs who attended the MSG
of STDs/HIV; (3) the signs, symptoms, and school between February 1998 and February
outcomes of common STDs; (4) the clinical 1999; the 3 hr SHIP curriculum was given to
course of HIV/AIDS; (5) sexual decision- MSGs who attended the school between
making; (6) alcohol use and abuse; (7) the March 1999 and February 2000.
impact of alcohol on unsafe sex and risk-
taking; (8) correct condom use; and (9) Measures
values and opinions related to STDs/HIV The questionnaires administered to the
risk behaviors. Alcohol impairment goggles MSGs before and after the intervention
were used to demonstrate the effects of a (pretests and posttests) consisted of a
simulated 0.20 blood alcohol level on measure of STD/HIV knowledge, 9
condom use. psychosocial scales, and a set of
The 3 hr version of SHIP was created demographic questions. The STD/HIV
from the 6 hr version through the following knowledge measure was composed of 21
4
true-false questions and 3 short-answer The analyses presented in this paper are
items and was developed specifically for this based only on the MSGs who (1) had linking
study. Scores for STD/HIV knowledge pretest and posttest questionnaires, and (2)
were obtained by summing the total number who reported a marital status of “Single” or
of correct responses, which yielded possible “Divorced/Widowed.” Married subjects
scores ranging from zero to 29. Higher were not included in the analysis. One
scores indicate a higher level of knowledge. hundred and eighty-eight subjects were
Coefficient alpha for the scale was .62, dropped either because they were discharged
which is sufficient for a knowledge scale. from the school prior to the administration
(Internal consistency reliability estimates are of the posttests or because we were not able
generally low on knowledge scales because to link their pretests and posttests. An
knowledge is a heterogeneous construct.) additional 54 subjects were dropped either
The 9 psychosocial scales included in because they were married or did not
the pretests and posttests were as follows: indicate their marital status. This resulted in
(1) Social Norms I,26 (2) Social Norms II,23 a total final sample of 802 subjects—400 for
(3) Attitudes Toward Condoms,27 (4) Self- the 6 hr SHIP condition and 402 for the 3 hr
Efficacy/Impulse Control,26 (5) Condom condition. For some analyses, sample sizes
Assertiveness,28 (6) Self-Efficacy for are smaller due to missing data.
Communicating With a New Sexual Chi square and t tests were performed
Partner,29 (7) AIDS Preventive Behavior,30 to determine if the participants in the 6 hr
(8) Behavioral Intentions, modeled after the and 3 hr SHIP conditions differed on any of
Intentions to Use Condoms scale by the demographic variables. Paired t tests
Sanderson and Jemmott,31 and (9) Perceived were performed comparing the participants’
Susceptibility to STDs/HIV.23 Coefficient pretest and posttest scores on the STD/HIV
alphas for the scales ranged in magnitude knowledge test and the 9 psychosocial
from .64 to .86. measures; separate t tests were performed
for the two intervention samples (6 hr and 3
Procedure hr SHIP conditions). To determine the
The evaluation of both versions of relative effectiveness of the two intervention
SHIP used a pretest-posttest design. The versions, analysis of covariance
pretest and posttest questionnaires were (ANCOVAs) were performed on the posttest
identical; each was made up of the scales scores for each measure, with pretest scores
previously described in the Measures as the covariate and version as the between-
section. Pretests and posttests were subjects factor.
administered to MSGs in a classroom setting
at the school. Pretests were administered RESULTS
approximately 2 weeks prior to the SHIP Demographic Characteristics of the
course, and posttests were administered Sample
approximately 1 week after course Demographic information about the
completion. To preserve participants’ participants is shown in Table I. A total of
anonymity, identifiers such as names or 802 Marines who completed the pretests and
social security numbers were not used on the posttests were included in the analyses. The
questionnaires. Instead, participants were overall sample was predominantly male
given instructions on how to create self- (94%). The majority of participants reported
generated identification numbers; these were White/Caucasian race/ethnicity (67%). Most
then used to match the pretest and posttests of the participants (58%) had high school or
for each individual. This method has been equivalent education, and 39% had also
used successfully in a number of other attended college. Age ranged from 18 to 33
STD/HIV investigations.32 years, with a mean of 21.80 years. Tenure in
the Marines ranged from .83 to 13.50 years
Analyses (mean of 2.86 years).
5
Statistical comparisons (chi-square tests Similarly, results for the Self-
and t tests) were conducted to determine if Efficacy/Impulse Control scale showed that
there were any demographic differences MSGs felt less confident about being able to
between the two intervention groups (see use condoms in difficult situations (e.g.,
Table I). No significant differences between when under the influence of alcohol) after
the groups were found (ps > .05). The two the intervention, t(368) = 2.85, p < .01.
groups were similar on age (M = 21.75 vs.
21.84) and tenure (years) in the Marine Effects of the 3 hr Intervention
Corps (M = 2.82 vs. 2.91). The gender The results of paired t tests comparing
distribution of the two groups was virtually the 3 hr intervention participants’ pretest and
identical: males made up 94% of each posttest means are shown in Table II.
group. (This distribution approximates the Similar to the 6 hr intervention, scores on
distribution of males and females in the the STD/HIV knowledge measure were
MSG population as a whole, P. C. Johnson, significantly higher after the 3 hr
personal communication, December 21, intervention than before, t(400) = -20.19, p
1999.) There was a nonsignificant difference < .01.
(p = .10) in the race/ethnic group For the 3 hr intervention participants,
distribution of the two groups: the 6 hr significant differences between pretest and
intervention group had a larger proportion of posttest means were found on Social Norms
White/Caucasian participants (70%) than the II, Condom Assertiveness, Self-Efficacy for
3 hr group (64%). Communicating With a New Sexual Partner,
Behavioral Intentions, and Perceived
Effects of the 6 hr Intervention Susceptibility to STDs/HIV. On Social
The results of the paired t tests Norms II, Behavioral Intentions, and
comparing the 6 hr SHIP participants’ Perceived Susceptibility to STDs/HIV, the
pretest and posttest are shown in Table II. differences were in the expected direction.
Consistent with our hypothesis, scores on Participants perceived greater social norms
the STD/HIV knowledge measure were supporting condom use, t(394) = -4.60, p <
significantly higher after the intervention .01, had stronger behavioral intentions to
than before, t(393) = -20.78, p < .01. have safe sex, t(389) = -5.06, p < .01, and
For the 6 hr intervention, significant felt more susceptible to STDs/HIV, t(389) =
differences between pretest and posttest -2.14, p = .03, after the intervention.
means were found on 4 of the psychosocial On Condom Assertiveness and Self-
scales: Social Norms II, Attitudes Toward Efficacy for Communicating With a New
Condoms, Self-Efficacy/Impulse Control, Sexual Partner, the differences were
and Behavioral Intentions. On Social Norms significant but in the direction opposite of
II, the difference was in the expected that hypothesized. On Condom
direction: subjects perceived greater social Assertiveness, MSGs felt less assertive
norms supporting condom use after the about suggesting condom use with a partner
intervention than they had before, t(391) = - after the intervention, t(396) = 3.38, p < .01.
4.61, p < .01. On Behavioral Intentions, the The results on Self-Efficacy for
difference was also as expected: participants Communicating With a New Sexual Partner
expressed stronger intentions to practice safe indicated that MSGs had lower self-efficacy
sex after the intervention, t(386) = -7.02, p < for communicating with a new partner after
.01. On Attitudes Toward Condoms and the intervention, t(396) = 3.96, p < .01.
Self-Efficacy/Impulse Control, the
differences were in the direction opposite of Comparison of 3- and 6 hr Interventions
that hypothesized. On Attitudes Toward To determine if intervention version
Condoms, MSGs actually expressed a less had an impact on the participants’ posttest
positive attitude toward condoms after the scores, ANCOVAs were performed on
intervention, t(388) = 2.61, p < .01. posttest scores for each measure, with
6
pretest scores as the covariate. These counterintuitive effects on attitudes toward
analyses revealed significant differences due condoms and self-efficacy/impulse control.
to version for 2 of the 9 psychosocial scales: It is surprising that the 6 hr version of
Attitudes Toward Condoms and Behavioral SHIP was not significantly more effective in
Intentions. Participants in the 6 hr condition changing knowledge and attitudes than the 3
showed a significant deterioration in hr version. It is possible that because the 3
Attitudes Toward Condoms, whereas the hr version ran at a faster pace than the 6 hr
attitudes of participants in the 3 hr condition version, and the material was presented in a
remained unchanged, F(1,781) = 5.69, p < very condensed style, it may have actually
.05. However, participants in the 6 hr been more effective in capturing and holding
condition showed more improvement in the Marines’ interest. (This was the
Behavioral Intentions than those in the 3 hr impression of one of the two instructors who
condition, F(1,776) = 4.69, p < .05. gave the training.) Another major difference
The analyses comparing the between the two versions of SHIP was that
interventions are summarized in Table III. in the 3 hr version, three of the more lengthy
Both the 3 hr and the 6 hr versions of SHIP small-group exercises were dropped. It may
appeared to produce a significant increase in be that these time-consuming activities did
STD/HIV Knowledge, Social Norms II, and not contribute much “added value” to the 6
Behavioral Intentions. Four positive and two hr program. The other major difference
negative effects were found for the 3 hr between the versions was that the 3 hr
intervention and three positive and two version omitted the two longer videos that
negative effects were found for the 6 hr were part of the 6 hr SHIP (“HIV Legacy”
intervention. Given the large number of and “Liberty Brief”). Although the course
statistical tests performed, relatively few evaluation data indicated that the Marines
differences due to intervention version were enjoyed watching these videos, it may be
observed. that they did not have a substantial impact
on their knowledge, attitudes, and
DISCUSSION behavioral intentions.
The purpose of this study was to A number of limitations of this study
evaluate and compare the effectiveness of a should be noted. One limitation was the
6 hr and a 3 hr version of a behavioral lack of random assignment of subjects to
intervention to prevent STDs/HIV. The intervention conditions. After the first year
results of this study revealed very few of SHIP’s implementation, the MSG school
differences between the 6 hr and 3 hr staff changed the amount of time allotted for
versions of the intervention. Both versions SHIP in the school schedule. Consequently,
were effective in increasing participants’ the MSGs who attended the school during
knowledge of STDs and HIV, and both led Year 1 received the 6 hr version of SHIP,
to significant increases on scales measuring and those attending the school during Year 2
social norms and behavioral intentions. received the 3 hr version. Although a
Viewed globally, both versions of the demographic comparison of the two groups
intervention produced about the same did not reveal any major differences,
number of positive effects on the differences between the two groups could
psychosocial scales. have existed on variables that were not
In addition to producing some positive measured. Another limitation of the study is
effects, both versions of SHIP were the large number of participants who
associated with effects that were contrary to participated in SHIP but who were lost from
expectation. The 3 hr intervention produced the sample of pretests and posttests due to
counterintuitive effects on condom attrition from the school or our inability to
assertiveness and self-efficacy for link their pretests and posttests.
communicating with a new sexual partner. Consequently, the present sample may not
Similarly, the 6 hr intervention produced be representative of the MSG population.
7
An additional limitation of this study was military. Just as brief or “minimal”
the fact that we did not examine the impact interventions have been developed for
of the intervention on behavioral outcomes smoking, problem drinking, and substance
such as condom use or on disease rates. use,19-21 it may be possible to develop short,
Despite these limitations, this study cost-effective behavioral interventions to
makes a contribution to the literature on encourage safer sexual behavior. If brief
HIV prevention interventions. This is one of STD/HIV interventions can be designed that
the only studies to date that has compared approach the effectiveness of more time-
the effectiveness of behavioral interventions consuming programs, this would allow
that vary in duration but are similar in resources to be allocated more efficiently
content. This is also one of very few and to a larger number of people. It is also
studies23,33 that have examined the possible that more individuals would be
effectiveness of an STD/HIV intervention in willing to participate in brief, as opposed to
a U.S. military population. more time-intensive, interventions. More
Clearly, more research is needed on the research is needed to determine whether
effectiveness of behavioral interventions that brief HIV prevention interventions can be
differ in duration. Evidence of the effective and to determine if, and under what
effectiveness of brief behavioral circumstances, intervention duration makes
interventions to prevent STDs/HIV would a difference in program effectiveness.
be of great practical benefit to the U.S.

Acknowledgments

We gratefully acknowledge the assistance of Henry M. Jackson Foundation for the
Donna Ruscavage, Cherrie Boyer, Mary- Advancement of Military Medicine. The
Ann Shafer, Patricia Gilman, Paul Johnson, views expressed in this article are those of
and Paul Purnell for their assistance with the the authors and do not reflect the official
design and implementation of this project. policy or position of the Department of the
This work was supported by U.S. Army Navy, Department of Defense, or the United
Medical Research and Material Command States Government. This research has been
Reimbursable 63105A under Work Unit No. conducted in compliance with all applicable
6816. This work was supported in part by Federal Regulations governing the
Cooperative Agreement No. DAMD17-98- protection of human subjects in research.
2-8007, between the U.S. Army Medical Approved for public release, distribution
Research and Materiel Command and the unlimited.

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