Program Operations Guidelines For STD Prevention

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Program OperationsGuidelines for STD PreventionCommunity andIndividual BehaviorChange Interventions

Table of ContentsFOREWARDiiiINTRODUCTIONProgram Operations Guidelines Workgroup MembersCommunity & Individual Behavior Change InterventionsSubgroup MembersCommunity & Individual Behavior Change InterventionsInternal/External ReviewersivviviiviiINTRODUCTIONBC-1IDENTIFICATION OF BEHAVIORS & CONTEXTS THATPLACE INDIVIDUALS AND COMMUNITIES AT RISKCommunity Needs AssessmentBehaviors That Influence RiskFactors That Influence RiskThe Contexts of RiskBC-2BC-2BC-3BC-4BC-4THEORETICAL MODEL FOR BEHAVIORAL INTERVENTIONSBC-5PREVENTION INTERVENTION PLANNINGHealth Communications PlanningBehavioral Surveillance Data MonitoringOutcome MeasuresFramework for Planning InterventionsBC-5BC-5BC-6BC-7BC-8TYPES OF INTERVENTIONSIndividual-Focused InterventionsCommunity-Focused InterventionsHealth Communication InterventionsPolicy-Focused InterventionsImportant Factors for Effective Behavioral Intervention ProgramsImplementation ConsiderationsKey Questions for the Development of InterventionsCommunity and Individual Behavior Change -16i

CONCLUSIONSAppendix BC-AExample of Planning ModelAppendix BC-BBehavior Change ModelsHealth Belief ModelTheory of Reasoned ActionSocial (Cognitive) Learning TheoryTranstheoretical Model (Stages of Change)Diffusion of InnovationEmpowerment Theory/Popular 0BC-21BC-22BC-23BC-24Program Operations Guidelines for STD Prevention

ForewordThe development of the Comprehensive STD Prevention Systems (CSPS) programannouncement marked a major milestone in the efforts of CDC to implement therecommendations of the Institute of Medicine report, The Hidden Epidemic, Con fronting Sexually Transmitted Diseases, 1997. With the publication of these STDProgram Operations Guidelines, CDC is providing STD programs with the guid ance to further develop the essential functions of the CSPS. Each chapter of theguidelines corresponds to an essential function of the CSPS announcement. Thischapter on community and individual behavior change interventions is one of nine.With many STDs, such as syphilis, on a downward trend, now is the time toemploy new strategies and new ways of looking at STD control. Included in theseguidelines are chapters that cover areas new to many STD programs, such as com munity and individual behavior change, and new initiatives, such as syphilis elimi nation. Each STD program should use these Program Operations Guidelines whendeciding where to place priorities and resources. It is our hope that these guidelineswill be widely distributed and used by STD programs across the country in thefuture planning and management of their prevention efforts.Judith N. WasserheitDirectorDivision of STD PreventionCommunity and Individual Behavior Change Interventionsiii

IntroductionThese guidelines for STD prevention programoperations are based on the essential functionscontained in the Comprehensive STD Preven tion Systems (CSPS) program announcement. Theguidelines are divided into chapters that follow theeight major CSPS sections: Leadership and ProgramManagement, Evaluation, Training and ProfessionalDevelopment, Surveillance and Data Management,Partner Services, Medical and Laboratory Services,Community and Individual Behavior Change, Out break Response, and Areas of Special Emphasis. Ar eas of special emphasis include corrections, adoles cents, managed care, STD/HIV interaction, syphiliselimination, and other high-risk populations.The target audience for these guidelines is publichealth personnel and other persons involved in man aging STD prevention programs. The purpose of theseguidelines is to further STD prevention by providing aresource to assist in the design, implementation, andevaluation of STD prevention and control programs.The guidelines were developed by a workgroup of18 members from program operations, research, sur veillance and data management, training, and evalua tion. Members included CDC headquarters and fieldstaff, as well as non-CDC employees in State STD Pro grams and university settings.For each chapter, subgroups were formed and as signed the task of developing a chapter, using evidencebased information, when available. Each subgroup wascomprised of members of the workgroup plus subjectmatter experts in a particular field. All subgroups usedcausal pathways to help determine key questions forliterature searches. Literature searches were conductedon key questions for each chapter. Many of the searchesfound little evidence-based information on particularivtopics. The chapter containing the most evidence-basedguidance is on partner services. In future versions ofthis guidance, evidence-based information will be ex panded. Recommendations are included in each chap ter. Because programs are unique, diverse, and locallydriven, recommendations are guidelines for opera tion rather than standards or options.In developing these guidelines the workgroup fol lowed the CDC publication “CDC Guidelines—Im proving the Quality”, published in September, 1996.The intent in writing the guidelines was to addressappropriate issues such as the relevance of the healthproblem, the magnitude of the problem, the nature ofthe intervention, the guideline development methods,the strength of the evidence, the cost effectiveness,implementation issues, evaluation issues, and recom mendations.STD prevention programs exist in highly diverse,complex, and dynamic social and health service set tings. There are significant differences in availabilityof resources and range and extent of services amongdifferent project areas. These differences include thelevel of various STDs and health conditions in com munities, the level of preventive health services avail able, and the amount of financial resources availableto provide STD services. Therefore, these guidelinesshould be adapted to local area needs. We have givenbroad, general recommendations that can be used byall program areas. However, each must be used in con junction with local area needs and expectations. AllSTD programs should establish priorities, examineoptions, calculate resources, evaluate the demographicdistribution of the diseases to be prevented and con trolled, and adopt appropriate strategies. The successof the program will depend directly upon how wellProgram Operations Guidelines for STD Prevention

program personnel carry out specific day to day re sponsibilities in implementing these strategies to in terrupt disease transmission and minimize long termadverse health effects of STDs.In this document we use a variety of terms familiar toSTD readers. For purposes of simplification, we willuse the word patient when referring to either patientsor clients. Because some STD programs are combinedwith HIV programs and others are separate, we will usethe term STD prevention program when referring toeither STD programs or combined STD/HIV programs.These guidelines, based on the CSPS program an nouncement, cover many topics new to program op erations. Please note, however, that these guidelinesreplace all or parts of the following documents: Guidelines for STD Control Program Operations,1985. Quality Assurance Guidelines for Managing thePerformance of DIS in STD Control, 1985. Guidelines for STD Education, 1985. STD Clinical Practice Guidelines, Part 1, 1991.The following websites may be useful: CDCNCHSTPDSTDOSHASurveillance in a SuitcaseTest Complexity DatabaseSample Purchasing SpecificationsSTD Memoranda of UnderstandingNational Plan to Eliminate SyphilisNetwork MappingDomestic ViolencePrevention Training CentersRegional Title X Training Centers HEDIS Put Prevention Into PracticeCommunity and Individual Behavior Change v/dls/clia/testcat.aspwww.gwu.edu/ t q.gov/clinic/ppipix.htmv

Program Operations Guidelines Workgroup MembersviDavid ByrumProgram Development and Support Branch, DSTDJanelle DixonHealth Services Research and Evaluation Branch, DSTDBob EmersonTraining and Health Communications Branch, DSTDNick FarrellProgram Support Office, NCHSTPMelinda FlockSurveillance and Data Management Branch, DSTDJohn GloverProgram Development and Support Branch, DSTDBeth MackeBehavioral Interventions and Research Branch, DSTDCharlie RabinsIllinois Department of Public HealthAnne RompaloJohns Hopkins School of MedicineSteve RubinProgram Development and Support Branch, DSTD, New York CityLawrence SandersSouthwest Hospital and Medical Center, AtlantaDon SchwarzProgram Development and Support Branch, DSTDJane SchwebkeUniversity of Alabama BirminghamKim SeechukProgram Development and Support Branch, DSTDJerry ShirahTraining and Health Communications Branch, DSTDNancy SpencerColorado Department of Public HealthKay StoneEpidemiology and Surveillance Branch, DSTDRoger TullochProgram Development and Support Branch, DSTD, Sacramento, CaliforniaProgram Operations Guidelines for STD Prevention

Community & Individual Behavior Change Interventions Subgroup MembersVicki BeckTraining and Health Communication Branch, DSTDLisa BelcherBehavioral Interventions and Research Branch, DSTDNick FarrellProgram Support Office, NCHSTPBeth MackeBehavioral Interventions and Research Branch, DSTDDusty SandersSouthwest Hospital and Medical Center, AtlantaKim SeechukProgram Development and Support Branch, DSTDCommunity & Individual Behavior Change InterventionsInternal/External ReviewersTom CylarProgram Development and Support Branch, DSTDKathleen EthierBehavioral Interventions and Research Branch, DSTDStacy HarperTraining and Health Communication Branch, DSTDFred MartichBehavioral Interventions and Research Branch, DSTDJan St. LawrenceBehavioral Interventions and Research Branch, DSTDBrad StonerWashington University Medical School, St. LouisSamantha WilliamsBehavioral Interventions and Research Branch, DSTDCommunity and Individual Behavior Change Interventionsvii

Community and IndividualBehavior Change InterventionsINTRODUCTIONHistorically, STD prevention programs have been basedon a biomedical model that focused on secondary pre vention by treating infected individuals. More recently,STD prevention programs have been encouraged tosupport more interventions that effect changes in be havior. Many behavioral interventions proven tochange behaviors that pose risks to health, includingsexual behavior, are highly effective. An advantage ofbehavioral interventions is that they are capable ofpreventing all STDs, while biomedical interventionsare specific only for certain STDs. If behavioral inter ventions could be widely implemented along with bio medical approaches, they are likely to have a substan tial effect on the prevention of STDs (IOM, 1997).This chapter presents a menu of options for pro gram managers who are seeking ways to implementcommunity and individual behavior change interven tions. These options should be tailored to the individualprogram based on an analysis of local risk issues. Pro gram managers should build partnerships with behav ioral scientists to accomplish this task.The Institute of Medicine’s report, “The HiddenEpidemic: Confronting Sexually Transmitted Diseases”indicates that there is little information related to be havior change interventions and STDs. (IOM, 1997)An NIH consensus panel recommended that “inter vention and behavioral research be given the highestpriority and coordinated with biomedical research;a paradigm shift to develop models that are domainspecific with regard to sexuality and recognition thatrisk behavior is embedded within personal, interper sonal, and situational contexts; research on individualCommunity and Individual Behavior Change Interventionsdifferences in human sexuality that takes into accountcognitive, affective, cultural, and neurophysiologicalvariables; studies on the direct effects of intoxicantson self-regulatory mechanisms; and studies regardingmaintenance of behavior change” (NIH, 1997).In addition, the Institute of Medicine report identi fied a number of STD interventions that could be ac curately evaluated if psychosocial and behavioral datawere available: reduce individual risk behaviors in populations withhigh prevalence of STDs; promote safer sex practices and such protectivemethods as condom use to reduce the likelihood ofthe acquisition of an STD; inform the public, especially adolescents and youngadults, to be aware of and to recognize symptomsof STDs; motivate prompt attempts to get medical treatmentfor symptoms and suspected exposure to STDs orif engaged in risky behavior, to get tested; and ensure access to medical care for those with STDs.The last three activities are limited by the absence ofany currently available comprehensive data collectionsystem for STD that would enable assessment or track ing of attitudes or knowledge, behaviors that produceor mitigate STD acquisition, or factors related to seek ing health care and access to treatment.Existing data and surveillance systems (e.g., Behav ioral Risk Factor Surveillance System, Youth RiskBehavioral Surveillance System, National Health In terview Survey, National Health and Nutrition Exami nation Survey, National Survey of Family Growth,National Household Survey of Drug Abuse, GeneralBC – 1

Social Survey) are currently inadequate for a behav ioral surveillance system for sexually transmitted dis eases. These surveys would require major revision ofquestionnaires to accommodate STD related questiondomains, e.g. sex partner characteristics, symptomrecognition, decisions concerning medical treatment,and major sampling design revisions to obtain infor mation for monitoring high-risk populations.There also is a need for information at the commu nity level for monitoring risk behaviors in local popu lations, planning and measuring community aware ness of prevention activities, assessing access to medicalcare and other related issues, and providing baselineinformation for evaluating unanticipated secularchanges in the community.Once a target population is identified, it is impor tant to determine the type of intervention to be imple mented. The three primary goals of individual- andcommunity-focused interventions are to prevent ex posure to STDs; to prevent the acquisition of diseaseif exposed; and to prevent transmission of infection toothers if infected. Comprehensive public health effortsfor behavior change should be in place that (1) helpindividuals develop and maintain STD prevention be haviors (both safe sexual behaviors and timely seek ing of treatment), and (2) enable communities to sup port STD prevention efforts (IOM, 1997).While there have not been rigorous assessments ofmany behavioral interventions for STDs, there is rea son to believe that they could have a substantial effecton the risk of acquiring and spreading STDs if therewere the resources and the national will to implementsome of these programs more widely (IOM, 1997).The literature on the effectiveness of HIV preventionprograms is applicable for developing other effectiveSTD prevention programs. Based on the National In stitutes of Health Consensus Development ConferenceStatement “Interventions to Prevention HIV Risk Be haviors”, the following conclusions were drawn (NIH,1997): Behavioral interventions to reduce risk are ef fective and should be implemented widely; legislativebarriers that discourage effective programs aimed atyouth, corrections, and IVDUs must be eliminated;and, although sexual abstinence is a desirable objec tive, programs must include instruction on safer sexbehaviors.BC – 2Recommendations STD prevention programs should develop andmaintain the capacity to implement commu nity and individual behavior change interven tions. STD prevention programs should develop andutilize a behavioral data system to help deter mine the choice of intervention to be imple mented and to evaluate intervention effective ness after implementation.STD program managers can accomplish this by devel oping working partnerships with the behavioral sci ence staff at local universities, STD prevention train ing centers, AIDS education training centers, or othersimilar institutions to obtain proper input and guid ance for developing, implementing, and evaluatingbehavioral science interventions. In lieu of this ap proach, behavioral scientists could be hired to be mem bers of the STD prevention program.Recommendation STD prevention programs should partner withlocal behavioral intervention experts or STDprevention training centers.IDENTIFICATION OF BEHAVIORS &CONTEXTS THAT PLACE INDIVIDUALSAND COMMUNITIES AT RISKCommunity Needs AssessmentThe Community Identification process (CID) was de veloped in 1989 by LTG Associates in collaborationwith DSTD and HIV. This process used qualitative andethnographic methods to gain information about val ues, beliefs, lifestyles, needs, and facilitators and bar riers to health care services from the perspectives oftarget populations and from the perspectives of thosepersons who have substantial contact with the targetpopulations. The process used semi-structured inter views with members of the target populations, theirgatekeepers, relevant interactors, and formal serviceproviders.Program Operations Guidelines for STD Prevention

The 1995 “Innovations in Syphilis Prevention inthe United States: Reconsidering the Epidemiology andInvolving Communities” projects (ISP) adapted theCID process in five communities in the southern UnitedStates, using the same methods and processes as theCID. These projects were aimed at improving partner ships with communities affected by syphilis, as well aswith other health and social service providers. Theyalso sought to identify social and behavioral factorsassociated with syphilis transmission and treatment.The Rapid Ethnographic Community AssessmentProcess (RECAP) was developed out of the ISP initia tive. Initially, a modified version of the ISP was con ducted in Guilford County, North Carolina in 1998.The goals of the assessment were to determine pointsof access for persons at behavioral risk for syphilis,ascertain culturally appropriate and acceptable syphi lis prevention messages and strategies, and to tailoroutreach and syphilis screening efforts. This processwas further refined in 1999 and became known asRECAP.The decision to undertake RECAP demands sus tained support before, during, and after the assessmentis launched. If programs have questions about RECAPor need assistance in deciding if it is appropriate fortheir area, they can call the Division of STD Preven tion at CDC. It is essential that the local program takeand lead the initiative. The site should discuss withtheir CDC program consultant and local partners whyRECAP makes sense in their area and how RECAPwill facilitate later interventions. Potential RECAP sitesshould identify local staff from the health departmentas well as community based organizations and othercommunity groups that will participate in RECAP. Thesite must also be willing to commit sufficient resourcessuch as staff, supplies, and office space to RECAP.Once a site has been selected, a pre-assessment meet ing is held in the area. Some topics that should be dis cussed at this meeting include: How does RECAP fit into the project area’s objec tive? In what areas will RECAP take place? What local staff will participate in the assessment? What local resources will the project area commitfor RECAP?Community and Individual Behavior Change Interventions How will the survey instruments need to be modi fied

Health Communication Interventions BC-11 Policy-Focused Interventions BC-13 Important Factors for Effective Behavioral Intervention Programs BC-14 Implementation Considerations BC-14 Key Questions for the Development of Interventions BC-16. Community and Individual Behavior Change Interventions i

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