High-Risk Sexual Behavior: Interventions With Vulnerable Populations.

High-Risk Sexual Behavior: Interventions With Vulnerable Populations. By Evvie Becker, Elizabeth Rankin, and Annette U. Rickel. New York: Plenum Press, 1998, 168 pages. Cloth, $39.50.

Authors Becker, Rankin, and Rickel have effectively and succinctly combined useful knowledge about the prevention of human immunodeficiency virus (HIV), sexually transmitted diseases (STDs), and unintended pregnancy prevention in one easy-to-read volume on sexual behavior interventions for high-risk women and men. They provide an overview of the behavioral risk factors and biologic consequences of risky sexual behavior, as well as the intervention strategies that work and those that do not work in reducing risky sexual behaviors. They also discuss the effects of ethnicity, culture, and social class on intervention effectiveness. In addition, the authors review the more familiar psychosocial mediators and moderators of sexual risk behaviors, as well as major theoretical models. They highlight the importance of involving the target community in the design of, and sometimes in the implementation of, interventions.

When examining the literature on effective behavioral interventions to reduce risky sexual practices, some find the glass half empty, others see it as half full. These authors find the glass more than half full; that is, they conclude that intervention strategies, when based on the major theoretical models, do show evidence of effectiveness. Still, they note that it is important to recognize the limitations in generalizing from one population to another. The authors note some similarities in barriers to behavior change across populations, especially in the presence of fear, lack of power, and discrimination, but also point out differences due to cultural and economic factors and individual psycho-social characteristics. The at-risk populations they focus on include (a) heterosexually active women who are the sex partners of men who inject drugs or who also have sex with men, (b) men who have sex with men, and, to a lesser extent, (c) injection drug users. Within these populations, the greatest needs exist among the socioeconomically disadvantaged, especially in communities of color and among youth in high-risk situations.

Although advances have been made recently in our understanding of sexual risk behavior, our knowledge of and ability to reduce sexual risk behaviors continue to be hampered by insufficient funding for sex research during the 1980s. The authors' vision is most evident, and most admirable, in their recognition that despite significant progress, we have a long way to go to achieve sustainable prevention success for all populations at risk for HIV infection, STDs, and unintended pregnancy. The following highlights the content of each chapter and some of their recommendations.

In Chapter 1, the authors clearly and convincingly describe the physical, emotional, societal, and economic consequences of risky sexual behaviors. Their focus is largely on the potential outcomes of unprotected sexual intercourse, such as HIV infection, other STDs, and unintended pregnancy.

Chapter 2 is an examination of the associated risk factors for risky sexual behavior. Here, the authors review the literature, which is now substantial. They conclude that the following are important mediators and moderators of risky sexual behavior: low self-efficacy; history of childhood abuse, including abuse due to homophobia, internalized homophobia, and drug and alcohol abuse; and other psychological factors, such as depression and dissociation. Also important are deficits in prevention knowledge, motivation, behavioral skills, coping mechanisms, social support, and gender equality. They discuss how ethnicity, cultural beliefs, and values can be barriers to intervention effectiveness. They also describe the contextual factors related to socioeconomic status and poverty, and how these factors moderate prevention effectiveness across racial and ethnic groups.

In Chapter 3, the authors describe five models of prevention (they use the term model loosely): (a) the Theory of Reasoned Action (Azjen & Fishbein, 1980), (b) the Stages of Change (Prochaska & DiClemente, 1984), (c) the Information, Motivation, and Behavior Model (Fisher & Fisher, 1992), (d) the Natural Opinion Leader approach (Kelly et al., 1991), and (e) Reducing the Risk, a school-based sex education curriculum for youth (Kirby, Barth, Leland, & Fetro, 1991). They first discuss the theoretical bases for each of the models and then summarize the research on each model in various populations. The discussion of the application of these models, however, is somewhat uneven. It would have been stronger if an explicit rationale had been provided when one model (e.g., the parsimonious Information, Motivation, and Behavior Model) was recommended over another.

In the use of theory in the development of effective interventions, some see the cup as half empty because there is still a long way to go in terms of enhancing intervention effectiveness across risk populations and sustaining effects over time. Others see the cup as more than half full because they see how far we have come and how much is now known about what is effective. We need to be optimistic realists here. For example, the authors cite the review of the HIV prevention literature by Choi and Coates (1994) as evidence that HIV prevention programs work. According to that review, 20 of 77, or 26%, of the studies of interventions with various populations, including gay and bisexual men, injection drug users, commercial sex workers, patients of STD clinics, adolescents, young adults (aged 18-29), and adult heterosexuals, produced long-term changes in risky sexual behavior. Clearly there are a growing number of examples of effective interventions (Sogolow et al., 1998). However, both reviews show that many interventions do not yield evidence of effectiveness. Because of the complex results in the literature in this area, Becker, Rankin, and Rickel endeavor to understand the factors that mediate the effectiveness of an intervention.

In Chapter 4, the authors offer a discussion of the influence of ethnicity and social class on risk factors, intervention design, implementation issues, and intervention effectiveness. They cite Bowser, Fullilove, and Fullilove (1990) who point out that many of the prevention barriers with racial/ethnic minorities are related to poverty and the social problems it creates. They suggest that the political and economic forces that perpetuate the current conditions will need to change before lasting impact on those who face the greatest risk will be achieved. Poverty, the drug trade, and high-risk sexual behavior are all interrelated. These conditions and behaviors serve to maintain the limited prospects for many and are especially acute with inner-city youth, who are the most vulnerable of all.

Although no single intervention to prevent HIV infection, STDs, or unintended pregnancy can change the social conditions of its target population, the authors state that it is important to consider the social context when designing interventions and setting realistic expectations for outcomes. The authors feel that prevention efforts should focus on helping members of ethnic minorities who are disproportionately at risk to recognize their risks and should provide them with usable prevention strategies. Such strategies should be developed in collaboration with the target community, should be delivered by members of the community, and should be sustainable. They further suggest that Fisher and Fisher's (1992) Information, Motivation, and Behavior Model for changing HIV-related risk behaviors can easily be tailored to fit the conditions in many communities of color. In general, such interventions (a) provide education about risks, (b) increase the motivation of the target audience to reduce risky behaviors using culturally-appropriate motivational messages for each ethnic group, and (c) provide training in safer-sex practices. The authors suggest ways to incorporate racial and ethnic beliefs and values into the prevention messages for various communities of color.

The authors also observe that for interventions with women of color to be successful, the prevention message and strategy must consider how cultural factors interact with gender issues and women's beliefs. They concluded that interventions for women must address "... the cultural beliefs that limit a woman's willingness to challenge the authority of men in sexual situations" and that "Interventions for Hispanic women were more successful when conducted in their homes with their family members and sexual partners present" (page 99). The authors also note that with Native Americans and Alaska Natives, very little intervention research on sexual behavior has been done. This is probably because the HIV infection rates among these groups are very low.

In Chapter 5, the authors review the behavioral intervention literature specific: to the target group (women in Chapter 5 and gay and bisexual men in Chapter 6), and then apply the theoretical models and the considerations of ethnicity and social class in developing research-based recommendations for intervention design. From their review and their experience, they make the following recommendations. For women, it is important that interventions be focused on changing perceptions about condom use. Interventions that associate condoms with responsibility and consideration for one's partner, rather than with promiscuity or lack of trust, may be more beneficial. Condoms should be made readily available and easy to purchase, to minimize the potential embarrassment many women feel when buying condoms. Programs that teach women how to be assertive in their relationships with men may be successful, but the authors caution that it is unrealistic to expect that women in coercive, manipulative, or violent relationships would use such strategies. For these women, further assistance and support will be required. Again, interventions based on Fisher and Fisher's (1992) Information, Motivation, and Behavior Model were found to be effective. Simply imparting information or teaching sex communication skills, however, is not enough in relationships where women may be less powerful than their male partners. Women in such situations need to learn ways to minimize their risk and potentially get out of them.

Regarding interventions for gay and bisexual men, the authors review a variety of risk-factor articles, but their review of the intervention literature for this population is weak. In this chapter, they discuss the key factors in sexual risk taking, such as the use of alcohol and drugs, partner coercion, grief, loss, and a history of trauma. They also address living with AIDS or partners who are HIV infected. Death, dying, and grief in the gay community is also discussed. Interventions that seem to work best for gay men (who are not treated as a homogeneous group) include forming informal social groups for social support, increasing expectations regarding self-efficacy in safer sex, achieving sexual satisfaction for both partners when using condoms, addressing faulty beliefs about personal risks, and building a sense of mastery of safer-sex skills, especially in relationships of differing durations (e.g., casual sex vs. long-term relationships). Substance use and abuse may also interfere with safer-sex practices. Finally, they conclude that bisexual men may have other prevention issues and risk profiles, and thus need interventions tailored to their needs. Although the authors are advocating individual-level change strategies and do mention the work by Kelly et al. (1991), most of the publications they cite draw on population-based surveys that reflect the effects of population-wide changes in the gay community. The authors' review of intervention studies for gay men had notable omissions (e.g., Peterson et al., 1996). This shortcoming was the main limitation of the book.

In summary, the authors review a plethora of theories and studies from the United States and abroad, and make sense of sometimes conflicting or controversial research findings. They address the latest research findings from HIV, STD, and unintended pregnancy prevention while focusing unerringly on their vision and goal: significantly reducing risky sexual behaviors and averting the transmission of sexually transmitted infections and unintended pregnancies. The authors note that strategies for changing the environment, such as policy and law reform, though not addressed in this volume, are important and complement the individual-level strategies they do describe. The limited focus is understandable; however, the inclusion of examples of integrated, multilevel approaches would have strengthened the book.

In conclusion, the authors provide an informative and condensed discussion of how integrating research findings from the fields of HIV, STDs, and unintended pregnancy prevention can help define better strategies for reducing the risky sexual behaviors. Although they mention no specific studies on the effectiveness of an integrated approach, the authors believe that integrating these strategies and tailoring them to specific cultural and socioeconomic contexts will enhance programs for the prevention of HIV, STDs, and unintended pregnancy. Although the authors address the importance of contextualizing prevention interventions, they offer few specific strategies. No studies are reported that specifically examine the effectiveness of tailored or contextualized interventions compared to those that are not. Thus, the need for specific guidance in such intervention strategies remains.

The ultimate effectiveness, even of multifaceted prevention interventions that include individual-level and community-level strategies, will be limited by our political will and by a social climate that fosters fear, discrimination, stigma, and generational poverty. Addressing these barriers is the next step. This will take courage, effort, and strategies not addressed in this book, but the potential for meaningful reductions in the suffering, disease, and economic consequences of risky sexual behavior seems well worth the effort.

This volume should be of interest to health professionals, students, and community members whose concern is the prevention of HIV, STDs, and unintended pregnancy. It should be especially helpful to those who design sexual behavior interventions.

REFERENCES

Azjen, I., & Fishbein, M. (1980). Understanding attitudes and predicting social behavior. Englewood Cliffs, NJ: Prentice-Hall.

Bowser, B., Fullilove, M., & Fullilove, R. (1990). African-American youth and high-risk AIDS behavior: The social context and barriers to prevention. Youth & Society, 22, 1, 54-66.

Choi, K., & Coates, T (1994). Prevention of HIV infections. AIDS, 8, 1371-1389.

Fisher, J., & Fisher, W. (1992). Changing AIDS risk behavior. Psychological Bulletin, 111, 455-474.

Kelly, J., St. Lawrence, J., Diaz, Y., Stevenson, L., Hauth, A., Brasfield, T., Kalichman, S., Smith, J., & Andrew, M. (1991). HIV risk behavior reduction following intervention with key opinion leaders of population: An experimental analysis. American Journal of Public Health, 81, 168-171.

Kirby, D., Barth, R., Leland , N., & Fetro, J. (1991). Reducing the risk: Impact of a new curriculum on sexual risk-taking. Family Planning Perspectives, 23, 253-263.

Peterson, J., Coates, T, Catania, J., Hauck, W., Acree, M., Daigle, D., Hillard, B., Middleton, L., & Hearst, N. (1996). Evaluation of an HIV risk reduction intervention for African-American homosexual and bisexual men. AIDS, 10, 319-325.

Prochaska, J., & DiClemente, C. (1984). The transtheoretical approach: Crossing traditional boundaries of change. Homewood, IL: Dorsey Press.

Sogolow, E., Kay, L., Semaan, S., Mullen, P., Johnson, W., Neumann, M., & Norman, L. (1998, July). Development of an HIV intervention studies database for providers and researchers. Paper presented at the XII World AIDS Congress, Geneva, Switzerland.

Deborah L. Rugg, Ph.D., Behavioral Intervention Research Branch, Division of HIV/AIDS Prevention-Intervention Research and Support, National Center for HIV, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA.