Soap opera video on handheld computers to reduce young urban women's HIV sex risk

Development of a Video-Delivered Serial Drama Designed to Reduce Community Homophobia and HIV Stigma, Decrease Sexual Risk Behavior, and Increase HIV Testing Among Black Youth

This article describes the development of a video serial drama intervention that was designed to address factors that influence HIV in the United States among Black youth. These include HIV testing, sexual behaviors not protected by condoms, negative attitudes towards sexual minorities, and HIV stigma. Behavior-change principles (social learning theory and education-entertainment) and input from members of the priority audience formed the basis of this 27-episode (3 minutes each) drama for dissemination on multiple platforms, including in public spaces or privately online. The developmental process, specifically involving members of the population of interest and use of behavioral theory, enriched the narrative elements and likely ensured intervention acceptability, enhancing effectiveness. Public health practitioners and prevention programmers may want to consider using this intervention and/or the narrative communication approach when intervening to change behavior.

The Impact of Mass Media-Delivered Family Planning Campaigns in Low- and Middle-Income Countries: A Meta-Analysis of Advertising and Entertainment-Education Format Effects

Effective family planning methods are shown to save lives, contribute to gender equality, and boost economic development. Mass media communication campaigns in low- and middle-income countries have been effective in increasing contraceptive use, although the strategies that increase the likelihood of success are unclear. The present study uses meta-analyses to uncover the average effect of media campaigns on family planning behaviors in low- and middle-income countries and to examine the effectiveness of two communication strategies: entertainment-education and advertising/public service announcements. Results indicated that mass media-delivered family planning campaigns have a positive impact on family planning behaviors: d = 0.19, 95% CI [0.15, 0.24] for women (k = 64), d = 0.16, 95% CI [0.11, 0.21] for men (k = 27), and d = 0.20, 95% CI [0.17, 0.23] for an undifferentiated target group of men and women (k = 37). The use of an entertainment-education format, often in addition to campaign advertising messages, was associated with greater campaign success rates for women. Men, however, responded negatively to education-entertainment and positively to campaigns using only advertising and public service announcement formats. Recommendations for future family planning mass media campaigns and academic research opportunities are discussed.

Evaluation of a Mobile Phone App for Providing Adolescents With Sexual and Reproductive Health Information, New York City, 2013-2016

The New York City (NYC) Department of Health and Mental Hygiene released the Teens in NYC mobile phone application (app) in 2013 as part of a program to promote sexual and reproductive health among adolescents aged 12-19 in NYC. The app featured a locator that allowed users to search for health service providers by sexual health services, contraceptive methods, and geographic locations. We analyzed data on searches from the Where to Go section of the app to understand the patterns of use of the app's search functionality. From January 7, 2013, through March 20, 2016, the app was downloaded more than 20 000 times, and more than 25 000 unique searches were conducted within the app. Results suggest that the app helped adolescents discover and access a wide range of sexual health services, including less commonly used contraceptives. Those designing similar apps should consider incorporating search functionality by sexual health service (including abortion), contraceptive method, and user location.

A systematic review of randomised control trials of sexual health interventions delivered by mobile technologies

Background

Sexually transmitted infections (STIs) pose a serious public health problem globally. The rapid spread of mobile technology creates an opportunity to use innovative methods to reduce the burden of STIs. This systematic review identified recent randomised controlled trials that employed mobile technology to improve sexual health outcomes.

Methods

The following databases were searched for randomised controlled trials of mobile technology based sexual health interventions with any outcome measures and all patient populations: MEDLINE, EMBASE, PsycINFO, Global Health, The Cochrane Library (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Cochrane Methodology Register, NHS Health Technology Assessment Database, and Web of Science (science and social science citation index) (Jan 1999–July 2014). Interventions designed to increase adherence to HIV medication were not included. Two authors independently extracted data on the following elements: interventions, allocation concealment, allocation sequence, blinding, completeness of follow-up, and measures of effect. Trials were assessed for methodological quality using the Cochrane risk of bias tool. We calculated effect estimates using intention to treat analysis.

Results

A total of ten randomised trials were identified with nine separate study groups. No trials had a low risk of bias. The trials targeted: 1) promotion of uptake of sexual health services, 2) reduction of risky sexual behaviours and 3) reduction of recall bias in reporting sexual activity. Interventions employed up to five behaviour change techniques. Meta-analysis was not possible due to heterogeneity in trial assessment and reporting. Two trials reported statistically significant improvements in the uptake of sexual health services using SMS reminders compared to controls. One trial increased knowledge. One trial reported promising results in increasing condom use but no trial reported statistically significant increases in condom use. Finally, one trial showed that collection of sexual health information using mobile technology was acceptable.

Conclusions

The findings suggest interventions delivered by SMS interventions can increase uptake of sexual health services and STI testing. High quality trials of interventions using standardised objective measures and employing a wider range of behavioural change techniques are needed to assess if interventions delivered by mobile phone can alter safer sex behaviours carried out between couples and reduce STIs.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-016-3408-z) contains supplementary material, which is available to authorized users.

"Is Your Man Stepping Out?" An Online Pilot Study to Evaluate Acceptability of a Guide-Enhanced HIV Prevention Soap Opera Video Series and Feasibility of Recruitment by Facebook Advertising

Love, Sex, and Choices (LSC) is a 12-episode soap opera video series developed to reduce HIV risk among at-risk Black urban women. We added a video guide commentator to offer insights at critical dramatic moments. An online pilot study evaluated acceptability of the Guide-Enhanced LSC (GELSC) and feasibility of Facebook advertising, streaming to smartphones, and retention. Facebook ads targeted high-HIV-prevalence areas. In 30 days, Facebook ads generated 230 screening interviews: 84 were high risk, 40 watched GELSC, and 39 followed up at 30 days. Recruitment of high-risk participants was 10 per week, compared to seven per week in previous field recruitment. Half the sample was Black; 12% were Latina. Findings suggest GELSC influenced sex scripts and behaviors. It was feasible to recruit young urban women from a large geographic area via Facebook and to retain the sample. We extended the reach to at-risk women by streaming to mobile devices.

A systematic review of sexual health interventions for adults: narrative evidence

Recent work has explored the intersection between sexual health (as construed by the World Health Organization and others) and public health domains of action in the United States of America. This article reports the narrative results of a systematic review of sexual health intervention effects on public health-relevant outcomes. To qualify, interventions had to be based on the principles (1) that sexual health is intrinsic to individuals and their overall health and (2) that relationships reflecting sexual health must be positive for all parties concerned. Outcomes were classed in domains: knowledge, attitudes, communication, health care use, sexual behavior, and adverse events. We summarized data from 58 studies (English language, adult populations, 1996-2011) by population (adults, parents, sexual minorities, vulnerable populations) across domains. Interventions were predominantly individual and small-group designs that addressed sexual behaviors (72%) and attitudes/norms (55%). They yielded positive effects in that 98% reported a positive finding in at least one domain; 50% also reported null effects. The most consistently positive effects on behaviors and adverse events were found for sexual minorities, vulnerable populations, and parental communication. Whether via direct action or through partnerships, incorporating principles from existing sexual health definitions in public health efforts may help improve sexual health.

Use of digital media technology for primary prevention of STIs/HIV in youth

STUDY OBJECTIVE

The relevant literature was reviewed to identify issues in research evaluating digital media technology (DMT) interventions for the primary prevention of STIs/HIV in adolescents and young adults.

METHOD

A literature search with relevant key terms was conducted in PubMed, for articles with studies that included: (a) participants between 11-29 years; (b) use of one or more of the following forms of DMT: interactive digital video or CD-ROM, computer, text messaging, or Internet; (c) evaluation of an STI/HIV primary prevention intervention; and (d) use of a cognitive, psychosocial, behavioral, or biological outcome.

RESULTS

Twenty-nine studies were identified and included in the review. Based on the review of these studies, 7 main issues were discussed and recommendations for improving future research were offered. The 7 main issues were: (a) need for a balance between universal application and specific sub-group focus, (b) lack of a developmental framework, (c) challenge of applying DMT in resource limited contexts, (d) rapidly changing nature of DMT, (e) lack of biological outcomes, (f) lack of comparison/control groups to assess the impact of DMT, and (g) limited temporal follow-up.

CONCLUSIONS

There is increasing literature evaluating the effectiveness of DMT for preventing STIs/HIV among adolescents and young adults. A careful consideration of 7 main issues identified in the literature can improve the design and evaluation of these interventions and enhance our understanding of their effectiveness.

Sexual health interventions: a meta-analysis

In the second of two companion papers, we conducted a meta-analysis of sexual health interventions in three domains. The interventions chosen for the meta-analysis were a subset of studies presented in a narrative review (the first of the two companion papers); these in turn were selected on the basis of fit to principles derived from the World Health Organization (WHO) and other definitions of sexual health. Studies (n=20) were drawn from Medline and PsycINFO databases (English language, adult populations, 1996-2011) and fell into three domains: knowledge, attitudes, and sexual behaviors. We estimated intervention effects via Hedges' g, using the random-effects approach. Initial estimates revealed a large effect for knowledge, g=1.32 (95% CI=0.51-2.14), and smaller effects for attitude change, g=0.17 (0.11-0.24) and behavior, g=0.21 (0.13-0.29). After removing outliers to produce more precise estimates, the final effect sizes for knowledge, attitudes, and sexual behavior were, respectively, 0.25 (0.03-0.48), 0.18 (0.12-0.24), and 0.18 (0.11-0.24). Interventions yielded positive effects across populations and in all the domains studied.

A randomized controlled trial of soap opera videos streamed to smartphones to reduce risk of sexually transmitted human immunodeficiency virus (HIV) in young urban African American women

BACKGROUND

Love, Sex, and Choices (LSC) is a soap opera video series created to reduce HIV sex risk in women.

METHODS

LSC was compared to text messages in a randomized trial in 238 high-risk mostly Black young urban women. 117 received 12-weekly LSC videos, 121 received 12-weekly HIV prevention messages on smartphones. Changes in unprotected sex with high risk partners were compared by mixed models.

RESULTS

Unprotected sex with high risk men significantly declined over 6 months post-intervention for both arms, from 21-22 acts to 5-6 (p < 0.001). This reduction was 18 % greater in the video over the text arm, though this difference was not statistically significant. However, the LSC was highly popular and viewers wanted the series to continue.

CONCLUSION

This is the first study to report streaming soap opera video episodes to reduce HIV risk on smartphones. LSC holds promise as an Internet intervention that could be scaled-up and combined with HIV testing.

The effectiveness of mobile-health technology-based health behaviour change or disease management interventions for health care consumers: a systematic review

BACKGROUND

Mobile technologies could be a powerful media for providing individual level support to health care consumers. We conducted a systematic review to assess the effectiveness of mobile technology interventions delivered to health care consumers.

METHODS AND FINDINGS

We searched for all controlled trials of mobile technology-based health interventions delivered to health care consumers using MEDLINE, EMBASE, PsycINFO, Global Health, Web of Science, Cochrane Library, UK NHS HTA (Jan 1990-Sept 2010). Two authors extracted data on allocation concealment, allocation sequence, blinding, completeness of follow-up, and measures of effect. We calculated effect estimates and used random effects meta-analysis. We identified 75 trials. Fifty-nine trials investigated the use of mobile technologies to improve disease management and 26 trials investigated their use to change health behaviours. Nearly all trials were conducted in high-income countries. Four trials had a low risk of bias. Two trials of disease management had low risk of bias; in one, antiretroviral (ART) adherence, use of text messages reduced high viral load (>400 copies), with a relative risk (RR) of 0.85 (95% CI 0.72-0.99), but no statistically significant benefit on mortality (RR 0.79 [95% CI 0.47-1.32]). In a second, a PDA based intervention increased scores for perceived self care agency in lung transplant patients. Two trials of health behaviour management had low risk of bias. The pooled effect of text messaging smoking cessation support on biochemically verified smoking cessation was (RR 2.16 [95% CI 1.77-2.62]). Interventions for other conditions showed suggestive benefits in some cases, but the results were not consistent. No evidence of publication bias was demonstrated on visual or statistical examination of the funnel plots for either disease management or health behaviours. To address the limitation of the older search, we also reviewed more recent literature.

CONCLUSIONS

Text messaging interventions increased adherence to ART and smoking cessation and should be considered for inclusion in services. Although there is suggestive evidence of benefit in some other areas, high quality adequately powered trials of optimised interventions are required to evaluate effects on objective outcomes.

Feeling good in your own skin: the influence of complimentary sexual stereotypes on risky sexual attitudes and behaviors in a community sample of African American women

Although negative racial stereotypes may affect the mental and physical health of African Americans, little research has examined the influence of positive or complimentary racial stereotypes on such outcomes. More specifically, this study explored the relationship between African American women's endorsement of complimentary stereotypes about their sexuality and attitudes/behaviors that have been associated with sexual risk. Data were gathered from 206 African American women as part of the Black Women in the Study of Epidemics project. Multivariate regression models were used to examine associations between women's endorsement of complimentary stereotypes about their sexuality and selected sex-related attitudes and behaviors. Participants' endorsement of complimentary sexual stereotypes was significantly positively associated with beliefs that having sex without protection would strengthen their relationship (B = .28, SE = .10, p < .01) and that they could use drugs and always make healthy choices about using protection (B = .31, SE = .09, p < .01). Significant positive associations were also found between complimentary sexual stereotypes and the number of casual sexual partners women reported in the past year (B = .29, SE = .15, p = .05) as well as their willingness to have sex in exchange for money or drugs during that time (B = .78, OR = 2.18, p < .05). These findings suggest that endorsement of complimentary sexual stereotypes by African American women can lead to increased risk behavior, particularly relating to possible infection with HIV or other sexually transmitted infections.

Streaming weekly soap opera video episodes to smartphones in a randomized controlled trial to reduce HIV risk in young urban African American/black women

Love, Sex, and Choices is a 12-episode soap opera video series created as an intervention to reduce HIV sex risk. The effect on women's HIV risk behavior was evaluated in a randomized controlled trial in 238 high risk, predominately African American young adult women in the urban Northeast. To facilitate on-demand access and privacy, the episodes were streamed to study-provided smartphones. Here, we discuss the development of a mobile platform to deliver the 12-weekly video episodes or weekly HIV risk reduction written messages to smartphones, including; the technical requirements, development, and evaluation. Popularity of the smartphone and use of the Internet for multimedia offer a new channel to address health disparities in traditionally underserved populations. This is the first study to report on streaming a serialized video-based intervention to a smartphone. The approach described here may provide useful insights in assessing advantages and disadvantages of smartphones to implement a video-based intervention.

"The anticipation alone could kill you": past and potential clients' perspectives on HIV testing in non-health care settings

HIV testing in non-health care settings is an effective strategy for increasing the proportion of persons aware of their infection. We conducted 21 focus groups with 186 past and potential clients in five U.S. cities to explore attitudes and experiences related to HIV counseling and testing in non-health care settings. Qualitative analysis yielded several key themes. HIV-related stigma and fear emerged as a main theme throughout the discussions. Knowing one's HIV status quickly and accurately was of primary importance; HIV prevention counseling was secondary. Participants prioritized a supportive, nonjudgmental environment with adequate privacy and confidentiality. Provision of immediate emotional support, medical information, and linkage services to HIV-infected clients were considered essential. Staff with HIV-specific skills to address clients' emotional and informational needs was considered a strength of non-health care testing programs. Frequently, however, participants compared non-health care settings unfavorably to health care settings regarding privacy, competency, confidentiality, and test accuracy. Recommendations for enhancing counseling and testing services in non-health care settings are discussed.

An alternate HIV preventive strategy: sex scripts in media for women of color

New cases of HIV/AIDS among women of color in the United States highlight the continuing need for the public and private sectors to develop alternate preventive strategies. The author discusses the conceptual basis for using television sex scripts to incorporate women of color relational needs (trust, romance, sexual pressure) to promote HIV risk-reduction messages through a process of association with the television storyline. Sex scripts are a source of implicit knowledge about how to behave in situations that involve sexual intimacy. The article suggests that sexual scripts prevention messages build on the agency of women through the use of power theory-that is supporting woman's self-power by participating in sexual behavioral change. Implications for sexual equality in media programming are discussed.