Interventions for safer sex behaviors among college students.
|Abstract:||Safer sex behaviors (monogamy, sexual abstinence, correct and consistent condom usage) are important for prevention of sexually transmitted diseases and HIV/AIDS among college students. The purpose of this article was to review studies addressing interventions for safer sex behaviors among college students. A search of seven databases (CINAHL, MEDLINE, ERIC, Academic Search Premier, Scopus, Web of Science, and Social Sciences Citation Index) was conducted for the time period between 1990 and February 2010. A total 11 intervention studies related to safer sex behaviors were extracted. Information-motivation-behavioral skills model was commonly used for interventions promoting safer sex.|
College students (Health aspects)
Disease transmission (Health aspects)
AIDS (Disease) (Health aspects)
Sex (Health aspects)
Safe sex (Health aspects)
Condoms (Health aspects)
HIV (Viruses) (Health aspects)
|Publication:||Name: American Journal of Health Studies Publisher: American Journal of Health Studies Audience: Professional Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2010 American Journal of Health Studies ISSN: 1090-0500|
|Issue:||Date: Summer, 2010 Source Volume: 25 Source Issue: 3|
|Topic:||Canadian Subject Form: Sexual behaviour|
|Product:||Product Code: E197500 Students, College; 3069770 Prophylactics & Diaphragms NAICS Code: 326299 All Other Rubber Product Manufacturing SIC Code: 3069 Fabricated rubber products, not elsewhere classified|
Safer sex is important for protection against STDs (sexually transmitted diseases) and HIV/AIDS (Human Immunodeficiency virus/acquired immunodeficiency syndrome). Consistent and correct condom usage along with a monogamous relationship are two important aspects for STD and HIV/ AIDS prevention. The HIV/AIDS epidemic has grown to alarming proportions. At the start of 2010, there were an estimated 59 million HIV/AIDS cases in 194 reporting countries and territories. Of the 35 million living with HIV infection worldwide, about 3% live in the United States (Stine, 2010). Young adults continue to be a vulnerable population affected by HIV/AIDS. In 2009, about 22,000 adolescents aged 13-24 became infected with the HIV virus (Stine, 2010).
Determinants for engaging in HIV/AIDS related risky sexual behavior in college students are multiple such as low-self esteem and emotional distress (Ethier et al., 2006), gender along with improper social norms and inadequate condom use skills (Dilorio, Dudley & Soet, 2007), and various personality and demographic factors(Mehrotra, Noar, Zimmerman & Palmgreen, 2009). Some of the risk behavior pattern among adolescents' whites and blacks could be differentiated based on factors such as binge drinking, substance use, injection drug use and tobacco use (Hallfors, Iritani, Miller, & Bauer, 2007).
Behavioral interventions in the form of HIV/ AIDS prevention messages significantly improved the likeliness of condom usage among some Indonesian participants but didn't succeed in actual behavioral change (Turk, Ewing, & Newton, 2006). Harm-reduction approaches in HIV/AIDS counseling among adolescents address the barriers they have for engaging in safer sex, focus on perceptions that might affect risky behaviors, focus on safe sex planning and end in referral making (Pinto, 2000). It is in this backdrop that the purpose of this review article is to present studies addressing interventions for safer sex behaviors among college students.
The criteria for inclusion of studies were (1) publication in English language, (2) publication between 1990 and February 2010, (3) location of studies anywhere in the world, and (4) relating to interventions involving college students. Exclusion criteria were publications in languages other than English and studies published prior to 1990. A total of 11 studies met these criteria for interventions related to safer sex behaviors.
The studies that conducted interventions related to promotion of safer sex among college students are presented in Table I chronologically. The first interventional study (Turner, Korpita, Mohn, & Hill, 1993) was a randomized control trial which used a comprehensive health education intervention to alter risky behaviors towards safer sex behaviors which included increased condom usage and sexual abstinence. Te second study (Bryan, Aiken, & West, 1996) used a randomized experimental design to maintained greater sustainability of condom usage behaviors while the third interventional study (Ploem, & Byers, 1997) used information and communication skills training to enhance condom use sustainability. Information-motivation-behavioral skills model was used in the fourth study (Fisher, Fisher, Misovich, Kimble, & Malloy, 1998) for discussing AIDS preventative behaviors and in the fifth study (Singh, 2003) for enhancing self-efficacy towards condom usage. The sixth study (Chernoff, & Davison, 2005) used normative feedback with an unintended effect of decrease in number of sexual partners in women receiving the intervention. The seventh study (Kiene, & Barta, 2006) used computer-tailor based IMB (information-motivation-behavior skills) model to increase safer sex preparatory behaviors. The eight study (Sanderson, & Yopyk, 2007) used condom promotion videotape for enhancing self-efficacy towards condom usage and the ninth study (Labrie, Pederson, Thompson, & Earleywine, 2008) used decisional balance motivational enhancement intervention to increase condom use scores. The tenth study (Schmiege, Levin, Broaddus & Bryan, 2009) used group interventions to reduce HIV/STD risk. This randomized controlled study concluded that group--based psychosocial intervention with an added component of motivational enhancement therapy is better in reducing risky sexual behaviors. The last study (Kanekar, Sharma, Cottrell, Succop, & Bernard, 2010) addressed a vulnerable population of African-American college students. It concluded that there was no difference between a brief theory-based safer sex intervention and a comparison knowledge-based intervention in promoting safer sex behavior.
As shown in Table 2, effects sizes were calculated for all the 11 studies using G-Power analysis software 3.1.2(Erdfelder, Foul, & Buchner, 1996). Sample size, alpha values and power (0.80) were used to conduct the desired calculations.
The purpose of this article was to review studies addressing interventions for safer sex behaviors among college students and also to identify studies addressing interventions conducted among a target population of college students to promote safer sex behaviors (such as sexual abstinence, practicing monogamy and consistent and correct condom usage) between 1990 and February 2010.
Based on this review of intervention literature for safer sex among college students a total of 11 studies could be identified in last 20 years which used some kind of interventional strategy to change attitudes and behaviors of college students towards safer sex. The dearth of intervention literature in population of college students is surprising as we would expect a large number of interventions in these students. All the 11 studies used an experimental design in their interventional approach. A little less than 50 %(5 out of the 11) studies (Fisher, Fisher, Misovich, Kimble, & Malloy, 1998; Kiene, & Barta, 2006; Labrie, Pederson, Thompson, & Earleywine, 2008; Schmiege, Levin, Broaddus, & Bryan, 2009; Singh, 2003) identified, used the information-motivation-behavioral skills enhancement model and motivational component as a part of safer sex promotion tool. The remaining 6 studies used multicomponent (Bryan., Aiken, & West, 1996), normative feedback (Chernoff, & Davison, 2005), information about safer sex (Ploem, & Byers, 1997), condom promotion videotape (Sanderson, & Yopyk, 2007), and a comprehensive health education (Turner, Korpita, Mohn, & Hill, 1993), and theory-based components (Kanekar, Sharma, Cottrell, Succop, & Bernard, 2010).
It seems that the IMB (information-motivation-behavioral skills model has been the most popular model tried among college students to promote safer sex behaviors. This model has been well validated over 15 years of research with diverse populations and cross--cultural settings (Fisher, & Fisher, 2000). It has also shown promise in adults where it builds skills for risk reduction along with lower rates of unprotected intercourse and fewer sexually transmitted infections. Literature on using this model also supports a full model usage against a single component such as information only. (Cornman, Schmiege, Bryan, Benziger, & Fisher, 2007; Kalichman et al., 2005).
Also what was evident from this review was that despite use of theory based predictors for safer sex such as social cognitive variables (O'Leary, Goodhart, Jemmott, & Boccher-Lattimore, 1992 ; Raj, 1996) and health belief model constructs (Boone, & Lefkowitz, 2004), no theory-backed intervention for safer sex among college students could be extracted. Using a theoretical framework is essential when devising interventions as this provides a common language of views and ideas across researchers in safer sex and HIV prevention research. It is extremely important to examine interventions which emphasize key constructs of a theory (Glanz, Rimer, & Vishwanath, 2008). In promoting safer sex a meta-analyses of interventions conducted to increase condom use found that many key constructs of commonly used theories were changed by interventions. (Albarracin et al., 2005). These can be then further explored or rejected (Beaty, Wheeler, & Gaiter, 2004).
This review clearly establishes need for more interventions to promote safer sex behaviors among college students. Knowledge-behavior gap seems to be an important component to be addressed when researchers plan to devise a safer sex intervention. Theory-backed interventions should be seen more for promoting safer sex in the form of increasing condom usage, promoting sexual abstinence or sexual partner reductions (monogamous relationships).
RECOMMENDATIONS FOR FUTURE INTERVENTIONS
There is a large need of conducting interventions which change the attitudes and behaviors of college students towards safer sex. These interventions should promote protective factors at the same time work towards minimizing risky factors for safe sex behaviors. Future interventions should be based on behavioral change theories which must measure the constructs before and after the intervention to give credence to a theoretical approach as opposed to an atheoretical approach. Intervention researchers use multiple theoretical approaches and it is important that they develop psychometrically robust instruments to measure changes in the theoretical constructs.
In models and theories of health behavior change, a linear relationship is often implied when one assumes that change in constructs of knowledge, attitude, and behavior would lead to a corresponding changed behavior outcome. Complex systems and chaos theory complement the linear effect of behavior change in terms of alternative approaches of addressing any health behavior problem such as quitting tobacco, engaging in physical activity or risk-reduction and substance abuse behaviors (Resnicow, & Page, 2008). Future studies should address this paradigm in a quantitative or a qualitative way to promote healthy behavior change especially in the context of safer sex promotion to prevent sexually transmitted infections including HIV/AIDS among college students.
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Boone, T. L., & Lefkovitz, E. F. (2004). Safer sex and health belief model: considering the contributions of peer norms and socialization factors. Journal of Psychology and Human Sexuality, 16(1), 51-68.
Bryan, A. D., Aiken, L. S., & West, S. G. (1996). Increasing condom use: Evaluation of a theory-based intervention to prevent sexually transmitted diseases in young women. Health Psychology, 15(5), 371-382.
Chernoff, R. A., & Davison, G. C. (2005). An evaluation of a brief HIV/AIDS prevention intervention for college students using normative feedback and goal setting. AIDS Education and Prevention, 17(2), 91-104.
Cornman, D. H., Schmiege, S. J., Bryan, A., Benziger, T. J., & Fisher, J. D. (2007). An information motivation-behavioral skills model-based HIV prevention intervention for truck drivers in India. Social Science & Medicine, 64(8), 1572-1584.
Dilorio, C., Dudley, W. N., & Soet. J. (2007). Predictors of HIV risk among college students: A CHAID Analysis. Journal of Applied Biobehavioral Research, 3(2), p 119.
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Fisher, J. D, & Fisher, W. A. (2000). Theoretical approaches to individual-level change in HIV-risk behavior. In: J. Peterson and R. Diclemente. Editors, HIV prevention handbook, Plenum, New York, 3-55.
Fisher, J. D., Fisher, W. A., Misovich, S. J., Kimble, D. L., & Malloy, T. E. (1996). Changing AIDS risk behavior: Effects of an intervention emphasizing AIDS risk reduction information, motivation, and behavioral skills in a college student population. Health Psychology, 15(2), 114-123.
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Kanekar, A. S., Sharma, M., Cottrell, R., Succop, P., & Bernard, A. (2010). Theory-based safer sex intervention among African-American College Students. American Journal of Health Studies, 25(1), 52-59.
Kiene, S. M., & Barta, W. D. (2006).A Brief individualized computer delivered sexual risk reduction intervention increases HIV/AIDS preventive behavior. Journal of Adolescent Health, 39, 404-410.
Labrie, J. W., Pederson, E. R., Thompson, A. D., & Earleywine, M. (2008). A brief decisional balance intervention increases motivation and behavior regarding condom use in high-risk heterosexual college men. Archives of Sexual Behavior, 37, 330-339.
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Sanderson, C. A., & Yopyk, D. J. A. (2007). Improving condom use intentions and behavior by changing perceived partner norms: An evaluation of condom promotion videos for college students. Health Psychology, 26(4), 481-487.
Schmiege, S. J., Levin, M., Broaddus, M. R., Bryan, A. D. (2009). Randomized Trial of Group Interventions to reduce HIV/STD Risk and Change Theoretical Mediators among Detained Adolescents. Journal of Consulting and Clinical Psychology, 77(1), 38-50.
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Amar Kanekar, MBBS, MPH, CHES, CPH, PhD
Manoj Sharma, MBBS, PhD
Amar Kanekar, MBBS, MPH, CHES, CPH, PhD, is an Assistant Professor of the Department of Health Studies, East Stroudsburg University of Pennsylvania, 200 Prospect Street, East Stroudsburg, PA, 18301-2999. Phone: (570)-422-3748. Fax: (570)-422-3848. E-mail: firstname.lastname@example.org. Manoj Sharma, MBBS, PhD, is a Professor of the Health Promotion & Education, University of Cincinnati, PO Box 210068, Cincinnati, OH 45221-0068. Phone: (513) 556-3878. Fax: (513) 556-3898. E-mail: email@example.com
Table I. Interventions for promoting safer sex behaviors in college students Study Purpose Intervention/Design Turner study (Turner The purpose of this This was a non- et al., 1993). study was to assess randomized controlled sexual behaviors of trial where college students participants either following a received a comprehensive health comprehensive health education education intervention intervention (didactic lectures, small group discussions, prevention strategies for safer sex) or no seminar intervention. Bryan study (Bryan et The purpose of this Randomized al., 1996) study was to experimental design. hypothesise that Participants either condom promotion received one 45-min intervention will multicomponent safer produce changes in sex intervention or correlates of condom one 45-min stress use as per the management psychosocial model intervention unrelated to STDs Ploem study (Ploem, & The purpose of this Participants were Byers, 1997) study was to assess randomly assigned to the effect of two information group, AIDS risk reduction combination group and interventions on pretest-posttest college womens AIDS control groups related knowledge, attitudes towards condom and actual condom use at one month follow-up period Fisher study (Fisher The purpose of this Pre and post et al., 1998) study is to design, experimental design implement and was used and the evaluate an AIDS risk intervention reduction consisted of three intervention among 2-hr sessions using college students the information- motivation and behavioral skills model. (IMB model Singh study (Singh, The purpose of this 3 sessions 2003) study was to examine (information, the effect of an motivation and intervention based on behavioral skills) of information/ intervention program motivation / were given to behavioral skills to participants in the facilitate AIDS risk experimental group reduction behavior and the control group among college/ without intervention university students Chernoff The purpose of this Participants were study (Chernoff, and study was to develop assigned to the Davison, 2005) and evaluate a brief intervention group intervention using (normative feedback normative feedback in and goal setting order to increase instrument) and risk-reduction among control group college students (information related to AIDS prevention Kiene study (Kiene, The purpose of this The experimental & Barta, 2006) study was to develop group had an HIV and evaluate a prevention computer--delivered intervention which theory-based tailored was based on the HIV/AIDS risk information, reduction motivation and intervention behavioral skills model while the control group a nutrition education tutorial Sanderson study The purpose of this Participants were (Sanderson, & study was to examine randomly assigned to Yopyk, 2007) the effectiveness of receive one of two two condom promotion 30-min condom videotapes on promotion videotape self-efficacy, or to a wait-list intentions and control condition. behavior This study had an immediate and 4 month follow-up Labrie study (Labrie The purpose of this Within--subjects et al., 2008) study was to design was used and determine if participants were decisional balance randomly assigned to with motivational safer-sex interviewing promotes intervention group or safer sex practices alcohol-target during one meeting. intervention group. Decisional balance motivational enhancement intervention Schmiege study The purpose of this A randomized (Schmiege, Leven, study was to evaluate controlled design was Broaddus, & Bryan, three used. A total of 484 2009) interventions ethnically diverse (group-based theory adolescents were driven psychosocial randomized to three intervention (GPI), different groups. GPI + Group based Data was collected at motivational pretest, post-test enhancement therapy, and at 3-month and a control )based follow-up. as a harm reduction strategy in preventing risky sexual behaviors Kanekar study The purpose of this A randomized (Kanekar, Sharma, study was to controlled design was Cottrell, Succop, determine to what used where one group Bernard, 2010) extent constructs of (n=73) of college Social Cognitive students were offered Theory (i.e. a theory/based situational intervention and the perceptions for safer other group (n=68) sex, expectations for were given a safer sex, knowledge/based self-efficacy for intervention focusing safer sex, self- on HIV/AIDS and efficacy in sexually transmitted overcoming barriers diseases. for safer sex and self-control for safer sex) were changed after an SCT-based intervention compared to a non-theory (knowledge-based) intervention. Study Salient results Conclusion Turner study (Turner Experimental group A comprehensive et al., 1993). men reported a health education statistically intervention among significant increase college students can in sexual abstinence successfully alter (p<0.05). Number of sexual risk behaviors experimental group towards safer sex women who reported behaviors such as always using condoms increased condom increased compared to usage and sexual control group women abstinence. who showed a decrease. The difference at 3 months was significant (p=0.05). Bryan study (Bryan et (Analysis of The intervention al., 1996) covariance) showed increased significant effects intervention to use in predicted condoms at posttest directions for all as well as 6 weeks constructs except and 6 months later. A susceptibility and one-time intervention severity (p<0.001). with no booster At 6-weeks-more sessions induced participants in behavioral change experimental group that was maintained carried condoms even 6 months after (p<0.01), told intervention partners to use condoms (p<0.05). Ploem study (Ploem, & MANCOVA (Multiple An intervention Byers, 1997) analysis of supplementin AIDS covariance) were information with conducted followed by condom eroticization, univariate analysis condom normalization of covariance. and communication Combination group had skills training significantly more showed a sustained positive attitudes effect at improving towards condom use attitudes and than information sustained use of group. A significant condoms interaction between intervention and change in condom use Fisher study (Fisher was found (p<0.002). Findings from the use et al., 1998) The IMB model of this IMB model significantly were consistent with affected scores on model's emphasis on both indicators of identifying the information empirically construct, the identified deficits motivation construct in AIDS risk and the behavioral reduction construct at information, individual and group motivation and level (p<0.0001). behavioral skills in Condom used increased efforts to change significantly along behavior. with discussion about AIDS preventative behaviors Singh study (Singh, Analysis of The findings in the 2003) covariance was used present research for analysis which shows that showed the following information, results: Personal and motivation and social motivation to behavioral skills engage in AIDS risk essentially reduction behavior contribute to AIDS increased risk reduction considerably (p<0.05) behavior and there was a reduced perceived difficulty to engage in AIDS risk reduction (p<0.01) and also engagement in AIDS risk reduction behavior increased significantly (p<0.01). Chernoff MANCOVA (multiple Men in the study (Chernoff, and analysis of intervention group Davison, 2005) covariances) were reported a significant for significant increase condom usage for in condom usage with vaginal intercourse vaginal intercourse (p<0.001), number of whereas unexpectedly sexual partners women showed a (p<0.001), and significant reduction discussion of safer in the number of sex (p<0.001). . partners. The second effect was not expected given the brevity of the intervention Kiene study (Kiene, Analysis of This IMB & Barta, 2006) covariance was used (Information- which yielded the motivation- following important behavioral skills findings: Treatment model based computer group showed an tailored intervention increase in frequency showed increased of condom use condom use knowledge information compared and preparatory to the controls sexual behaviors (P<0.01). There was also an increase seen in the frequency of condom usage Sanderson study Analysis of (Sanderson, & covariance was Condom promotion Yopyk, 2007) conducted. Self- videos may be a efficacy for useful way of suggesting condom use increasing self- to a partner showed efficacy for condom significance use and intention to (p<0.03). Refusal to use condom and have sex without a reported condom use condom showed behavior among significant effect of college students. condition (p=0.03) and also intention to use condoms showed significant effect of condition (p=0.03). Labrie study (Labrie Participants The decisional et al., 2008) significantly balance intervention increased their helps in increasing condom use scores motivation to change from baseline at risky sexual behavior post-intervention among college (p<0.001) and at students. 30-day follow up (p<0.001). Forty percent who used condoms less than ninety percent of times showed 100% usage. Schmiege study A significant main Group based theory (Schmiege, Leven, effect was seen on driven psychosocial Broaddus, & Bryan, each of the intervention (GPI) 2009) theoretical mediators and GPI + in the arm getting motivational the GPI + enhancement therapy motivational are superior harm enhancement therapy reduction strategies components in for prevention of reduction in risky risky sexual sexual behavior behaviors among (p<0.05 & P<0.001). ethnically diverse Intentions populations. significantly predicted later risky sexual behaviors. Model fit the data adequately and explained 21% of the variance. Kanekar study The main effect of The dose of the (Kanekar, Sharma, time was significant theory-based Cottrell, Succop, (p<0.04) for the intervention was Bernard, 2010) construct of found to be self-efficacy in insufficient to overcoming barriers. promote safer sex Having been ever behaviors in a sample diagnosed with a of African-American sexually transmitted college students. disease (p<0.02) and Future interventions year in school need to increase the (p<0.01) were dose. significant demographic covariates for construct of self-efficacy in overcoming barriers and having been ever diagnosed with sexually transmitted disease (p<0.03) and ever having taken a sexuality class (p<0.01) were significant covariates for self-control for safer sex. Table 2. Effect size calculation of all the reported studies between 1990-February 2010 using G-Power 3.1.2 Name of the study Sample size Calculated Effect Size 1) Turner study N = 571 d = 0.06 (Turner et al, 1993) 2) Bryan study N = 198 d = 0.28 (Bryan et al., 1996) 3) Ploem study N = 112 d = 0.41 (Ploem, & Byers, 1997) 4) Fisher study N = 744 d = 0.06 (Fisher et al., 1998) 5) Singh study N = 200 d = 0.22 (Singh, 2003) 6) Chernoff study N = 155 d = 0.36 (Chernoff, and Davison, 2005) 7) Kiene study N = 157 d = 0.31 (Kiene, & Barta, 2006) 8) Sanderson study N = 220 d = 0.36 (Sanderson, & Yopyk, 2007) 9) Labrie study N = 315 d = 0.11 (Labrie et al., 2008) 10) Schmiege study N = 484 d = 0.33 (Schmiege, Leven, Broaddus, & Bryan, 2009) 11) Kanekar N = 141 -- study (Kanekar, Sharma, Cottrell, Succop, Bernard, 2010) Name of the study Type of Significance behavior 1) Turner study Abstinence p < 0.05 (Turner et behavior al, 1993) 2) Bryan study Telling p < 0.05 (Bryan et partners al., 1996) to use condoms 3) Ploem study Condom use p < 0.05 (Ploem, & behavior Byers, 1997) 4) Fisher study Condom use p < 0.01 (Fisher et behavior al., 1998) 5) Singh study Behavioral p < 0.05 (Singh, intention 2003) to engage in AIDS risk reduction 6) Chernoff study Condom use p < 0.01 (Chernoff, and at vaginal Davison, 2005) intercourse 7) Kiene study Condom use p < 0.05 (Kiene, & Barta, 2006) 8) Sanderson study Condom use p < 0.01 (Sanderson, self-efficacy & Yopyk, 2007) 9) Labrie study Condom use p < 0.01 (Labrie et intent al., 2008) 10) Schmiege study Risky p < 0.05 (Schmiege, Leven, sexual Broaddus, & Bryan, behavior 2009) 11) Kanekar Safer sex No study (Kanekar, behavior significance Sharma, Cottrell, Succop, Bernard, 2010)
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