Sexually transmitted infections (STIs) are diseases that are typically transmitted through person-to-person sexual contact. The most common conditions include chlamydia, genital warts, and gonorrhea. Several serious health risks like infertility, fatalities to pregnant mothers and unborn babies, and severe health dysfunction of major organs may result. In the worse case, STIs can also cause Human Pappilloma Virus (HPV) and Acquired Immune Deficiency Syndrome (AIDS) which will consequently lead to death.
The UK Health Protection Agency reported that the overall number of STIs cases has risen from 235,000 to 356, 000 at GUM clinics in the UK from 1999 to 2008. The number of people being diagnosed with HIV remained high, with an estimated 83,000 cases reported in 2008, of whom over a quarter (27%) were unaware of their infections. The largest affected and increased new diagnosed group was aged between 16 and 24, representing 11% of the infected population. This rise indicated that there was an increasing trend in "at risk" sexual behaviour amongst adolescents in the UK. (HPA 2010).
In the view of this epidemic, this essay will review the behavioural and psychological determinants of at risk sexual behaviour based on health psychology theories and research. Previous examples of thought, attitudes or beliefs and theory-based interventions will be discussed. A newly designed cognitive-behavioural health promotion programme, aiming to reduce the incidence of sexual transmitted infections among high-risk adolescents, built upon a multiple domain model focusing on condom use, will be suggested.
Health Belief Model (HBM)
The HBM is derived from the value-expectancy theory that explains individual behaviour by understanding two core factors: perception of the health threat and perceived threat reduction. The perception of health threat consists of components of perceived susceptibility to the illness and perceived severity of the illness, whereas perceived benefits of the behaviour in reducing the threat of the illness and perceived barriers to the behaviour are the components that influence a behavioural evaluation. Other components such as cues to action, external variables, and health motives also influence behaviour (Rosenstock 1974). According to the model, the decision to practice a health-related behaviour (e.g. using condoms with a partner) would involve the consideration of a number of issues (e.g. at risk of STI transmission through unprotected sex). Threat perception would involve consideration of the likelihood of encountering such risk and the severity of the subsequent illness (e.g. long-term health issues). Behavioural evaluation involves the belief of the effectiveness of proper use of condoms, and barriers like the consideration of the embarrassment of buying condoms, negotiation with partners about condom use, or less pleasure during sex. The final decision of behaviour may also be determined by cues to actions such as the influence of individual experience or media concerning safe sex.
The behavioural intervention conducted by Ford, Wirawan, Fajans, Meliawan, McDonald, & Thorpe (1996) aiming to increase community knowledge, awareness and perceived susceptibility and severity to STIs among a targeted group of low-cost female sex workers, pimps and male clients. The outreach group education programme included free condom distribution and sex education related to condom use. Participants filled out questionnaires to evaluate their perception of high-risk sexual behaviour and condom use at baseline and post-intervention. Results showed that participants demonstrated an increased knowledge of AIDS and STIs with greater condom use between sex workers and male clients being noted compared to baseline. Further analysis indicated that factors such as education and information brochure influence the likelihood of condom use. Therefore, a HBM-based education programme may be a feasible and effective intervention.
Protection Motivation Theory (PMT)
Rogers (1983) proposed the PMT that illustrate the behavioural intention to direct and sustain protective behaviour. The theory initiated two independent appraisal processes: threat appraisal and coping appraisal. Threat appraisal focuses on individual's perception of their susceptibility and severity of the threat, which are seen to inhibit maladaptive responses. For example, people may consider the seriousness of STIs and their chance of developing a disease in the future. Levels of fear will trigger how individuals perceive themselves to be vulnerable to this heath threat. An increasing motivation to engage in safe sex behaviour will result when intrinsic (e.g. feeling secure) and extrinsic (e.g. approval from partners) rewards are linked to the maladaptive response. Individuals may believe that practising safe sex helps regulate health and that facilitates the love between partners. Conversely, coping appraisal focuses on the belief that recommended behaviour will be effective in reducing threat (i.e. response efficacy) and the belief of an individual's capability of performing the recommended behaviour (i.e. self-efficacy), will increase adaptive responses. For example, individuals may consider the extent to which wearing condom would reduce the chance of getting STIs and whether they are capable to accept it. The perceptions of response efficacy and self-efficacy serve to increase the probability of adaptive responses. However, response costs or barriers like (e.g. availability of condoms, money to buy condoms) may inhibit the performance of the adaptive behaviour.
The PMT-based intervention conducted by Kyes (1995) employed STIs education to encourage positive attitudes toward safe sex among college students. The study identified four PMT components (perceived severity, perceived vulnerability, response efficacy, and self efficacy) that influence participant's intentions to engage in adaptive behaviours. The study presented photographs of diseased genitals (high severity) and messages that condoms were effective in STIs risk reductions (high response efficacy) to the participants. The results showed that participants reported positive attitudes toward condoms use and STI precautions. A strong intention to use condoms in the future was also found. It was suggested that presenting a high-risk condition to participants significantly produced the strongest perception of STIs severity, but the messages about condoms use did not show any significant change in response efficacy, although severity and efficacy messages also showed greatest intentions to engage in safe sex.
Theory of Planned Behaviour (TPB)
According to TPB, the proximal determinant of behaviour is based on an individual's intention to engage in that behaviour. The theory depicts behaviour as a function of behavioural intentions and perceived behavioural control. Behavioural intentions consist of three components: attitudes toward the specific action, subjective norms regarding the action, and perceived behavioural control. The relationship between intentions and perceived behavioural control also reflects how individuals engage in behaviour they intend to perform by having perceived behavioural control exerting both direct and interactive (with behavioural intentions) effects on behaviour (Ajzeb 1988,1991). For example, individuals may consider that sex is still enjoyable (attitudes) even when they use condoms, their intentions may also be influenced by the expectations that their peers also use condoms (perceived norm). Control beliefs about proper use of condoms and intentions to reduce at risk behaviour facilitate the behaviour of practising safe sex.
Jemmott, Jemmott, and Fong (1992) conducted a TPB-based study called 'Be Proud! Be Responsible' intervening with high-risk young Black male teenagers. The study employed a black male role model as strategy to teach AIDS-related knowledge and weaken the problematic attitudes among the intervention group. The control group received information about career opportunities. Participants filled out questionnaires at baseline, immediately after intervention and three-month post-intervention. The results showed that the intervention group demonstrated less favourable attitudes and reductions in intentions towards high-risk sexual behaviour than the control group. Participants also reported having fewer sex partners and intercourse, and using condoms more consistently. The study revealed that a male facilitator was effective to influence participants' attitudes and sexual behaviour with the enhancement of greater AIDS knowledge.
Social Cognitive Theory (SCT)
The SCT outlines the crucial factors that influence behaviour. Self efficacy and outcome expectancies (physical, social, and self evaluative) are the core SCT components. Self efficacy is the belief that an individual's capabilities to exercise control over the course actions that require certain attainments. In adopting a desired behaviour, individuals usually initiate outcome expectancies that encourage an individual to consider the pros and cons of a behaviour that determine the positive and negative outcome expectancies when making a decision of whether to act or not. For example, individuals may believe they can get their partners to use condoms (self efficacy) all the time so as to avoid HIV (outcome expectancies).In attempt to execute these into action, other variables such as goals, socio-structural factors (facilitators and impediments) and opportunity structures interact throughout the behavioural change process. (Bandura, 1977, 1992, 2000a, 2000b). SCT has been shown in a study of sexually active adolescents aged 13 to 15 (Dilorio, Dudley, Soet, Watkins, & Maibach 2000). The study examined the role of self-efficacy, outcome expectances, and the perception of peer attitudes toward sexual activity and the use of condoms. It showed that self-efficacy was directly associated with condom use, through the effect of self-efficacy on outcome expectancies. Participants who showed confidence in putting on a condom and being able to refuse intercourse with their partners were shown to be more likely to use condoms consistently. In addition, it may be suggested that only personal attitudes about favorable outcome expectancies to self influence individual's confidence in negotiating safer sex precautions.
The National Institute of Mental Health (NIMH) Multisite HIV Prevention Trial Group (1998, 2001) employed the relationship between SCT constructs and a selected behavior, aiming to reduce sexual at risk behaviour. The intervention explored the role of self-efficacy, outcome expectancies, and goal setting. Participants were randomly assigned to either the intervention group who received feedback about outcome expectances, condom use and non-use and goal setting or the control group who received a one-hour education session on HIV. Results showed that the intervention group showed a significant increase in consistent condom use and sexual abstinence compared to the control group. At twelve-month follow-up, self-efficacy, physical, social, and outcome expectances reported were significantly higher than the control, suggesting that SCT was effective in influencing the cognitions and behaviors of individuals.
The Transtheoretical model (TTM)
The TTM includes different constructs: the stage of change model, the pros and cons of changes, and the process of change. It attempts to integrate different constructs from different theories into a single coherent model. The stages of change model consist of five stages: pre-contemplation, contemplation, preparation, action and, maintenance. The first three stages are pre-action stages and the last two stages are post-action stages. (DiClemente & Prochaska 1982; Proshaska & DiClement 1983). For examples, individuals at pre-contemplation stage may consider themselves not being necessary to use condoms, whereas individuals at maintenance stage may consider using condoms is worthwhile to reduce the chances of getting STIs.
The TTM study conducted by Picciano, King & Roffman (1999) targeted homosexual men who had not engaged in safe sex and those who are ambivalent about it to increase their commitment towards safe sex. The initial assessment of the intervention was conducted via telephone, participants were asked questions about their recent sexual activity, the potential benefits and losses of practicing safe sex, high risk situations, and confidence in individuals' ability to avoid at risk sex. At one-week follow-up, participants received brief personalized feedback from the counsellor employing Motivational Interviewing strategies about unprotected sex behaviour to enhance their readiness to make changes. The study was integrated with the TPB, measures including attitudes, normative beliefs, perceived control, and intentions regarding condom use, were employed to guide the assessment. At a further six-week follow-up, a significant number of participants who reported to have unprotected sex before intervention and those who were at the stage of pre-contemplation or contemplation with regard to their readiness for changing risky behaviours , showed significantly less incidence of unprotected unprotected sex, thus demonstrating success of applying the readiness to change in in engaging safe sex behaviour.
AIDS risk reduction model (ARRM)
The ARRM explains the influence of psychological and social (word missing here???) towards changes to sexual behaviour incorporating several variables from other health theories, including HBM, SCT, emotional influences, and interpersonal processes. The stages consist of labelling of at risk behaviour, making a commitment to change, and taking action through information seeking, obtaining remedies, or enacting solutions. These variables are based on individuals' knowledge, attitudes and behaviours and goals are associated with the stages. (Catania, Kegeles & Coates 1990). For example, individuals may believe putting themselves at risk of STIs is undesirable (labelling), and consider whether changes can reduce such risk then think they can do it (response efficacy influence commitment). The availability of resources (e.g. condoms) may also affect the actual action enacted.
Since previous research has been shown to be effective in intervening individual high-risk sexual behaviour using different theories, a newly designed multi domain model integrating the theories mentioned is introduced via computers. The behavioural objective of the intervention is to reduce the incidence of STIs among sexually active adolescents who engage it high-risk sexual behaviour.The program aims at altering heterosexual adolescents at risk sexual behaviour by encouraging condom use, since this target group contribute a significant proportion among the population being infected. The intervention will be a brief intervention that focusing on the components of perceived threat (susceptibility and severity) and perceived benefits of practicing safe sex, which subsequently influence the attitudes toward proper condom use. An important core component, self-efficacy also include the perceived barriers of using a condom. Others variables like perceived norms, behavioral intentions, situational contextual, socio-structural factors, will interplay throughout the behavioral change process, and finally forming a preparatory behaviour based on stages of change which directs the actual behaviour.
Several health education kiosks, equipped with a touch screen monitor, computer, and printer, are distributed near university or college locations for adolescents (e.g. cafe, sports centre). Teenagers aged 16 or above are free to register an account. Questions are presented in text, and answer questions by touching the right choices on the screen.
Once teenagers log in, they are asked to fill out their demographic information on age, gender, ethnicity, drinking, smoking, diet, exercise habits and sexual behaviour. Sexual behaviour is assessed using self-reported risk behaviour survey to elicit information about the frequency of sexual activities and unprotected sex in the past six months. They are also required to provide their history of STI, if any. The 5 minutes screening procedure will be used as baseline data to evaluate participants no risk or at risk behaviour of unsafe sex. Participants who score a high percentage score (e.g. 50%) are in the screening test are regarded as high-risk group. They are randomly assigned either to receive the intervention or to the assessment-only control condition. Randomization is conducted separately by gender and is stratified by scores. The assessment is administered at pre-intervention and post-intervention (six-month and nine-month follow-up). The transition helps control the internal validity since an external event might change the participants' behaviour, thus leading to a confounding to the results.
At intervention level, high-risk participants are asked to further complete a self-report of survey covering the domain of their beliefs of STI, STIs risk knowledge, personality traits of high-risk behaviour, self-efficacy for condom use, norms of using condom among peers, social psychological, socio-economic status, and situational factors that influence the change of condom use, and participants' readiness to change the unsafe behaviour.
The intervention group received a programme address bf the beliefs about STIs, participants are present information about STIs (e.g. photographs of diseased genitals, and HIV/AIDS knowledge). To enhance participants' perceived benefits of condom use, the message that condom is the most effective way to prevent STIs will be delivered. To help participants to overcome their perceived barriers of condom use, free condoms are distributed. Negotiation skills and discussion of condoms use with their partner are taught to boost self efficacy. Once the intervention process is completed, the intervention group receive a personalised feedback report showing their level of at risk status, and social norms of others about using condom. The feedback would recommend participants to modify their current pattern of unsafe sexual behaviour at a level commensurate with participants' current stage of readiness to change. Through intervening with the variables that might influence participants' behaviour, participants are encourage to set personal goals, build motivation, and make commitment to change. At the end, participants can either authorize themselves to view the feedback and STIs information on the touch screen monitor again at any time or print them out. However, the control group did not receive any feedback and presentation of the intervention programme. Both group were ask to re-access the kiosks after 6 months and 9 months.
In addition, the design randomized and theory based. The intervention allows students to control their own learning environment, move at their own pace, and get access to sensitive health topics. The program also increases participants' self-disclosure of their risk status. If the intervention shows significant reductions in engaging unsafe sexual behaviour than the control group, this programme will to be success in reducing the incidences of STI among adolescents. In conclusion, adolescents are the future pillars to the society, and the importance of maintaining their well-being should not be neglected. Although attempting to promote safe sexual practice in condom use is a changeling is a challenge task, researchers may consider applying the strong predictors derived from the health theories in psychology regarding to the trend of adolescents beliefs and perceptions. A multi-domain cognitive-behavioural intervention may be one of the effective and feasible method to cope with individuals' at risk behaviour. Last but not least, to achieve the optimal outcome, the importance of emotion, practice and information support are important.
