Safer Sex Intervention
Overview of the Intervention
The overall goals of the Safer Sex Intervention (SSI) are to reduce sexual risk behaviors, increase condom use, and prevent the recurrence of sexually transmitted infections (STIs) among sexually active young women. The target audience is sexually active adolescent girls and young women who are between ages 13 and 23 and have been diagnosed with an STI.
SSI is led by a female health educator and is appropriate for use in clinics or community-based organizations providing sexual health services to young women. It was designed to be delivered when the young woman has been diagnosed with and/or is being treated for an STI.
The intervention is administered one-on-one and face-to-face using in a single 30- to 50-minute session. One of two versions of the intervention may be used, depending on the young woman's stage of behavior change. The health educator determines which version of the intervention to use by asking the young woman to self-identify her stage of change on the Wheel of Change and discussing with her why she chose that stage. The intervention assumes that a young woman with an STI is not consistently engaging in safe sex behaviors and is, therefore, in an early stage of behavior change (i.e., Precontemplation or Contemplation).
The intervention includes booster sessions that were designed to coincide with the young woman's treatment schedule. These booster sessions include a review of the information covered in the first session, a reassessment of the young woman's stage on the Wheel of Change, hands-on condom practice using a penis model, and, if deemed appropriate by the health educator, condom negotiation role plays. In the original implementation, booster sessions were conducted at 1, 3, and 6 months after the initial visit.
Unique Features of the Intervention
- The intervention was designed to be delivered when a young woman has been diagnosed with and is being treated for an STI, when she is most likely to contemplate her behavior and be motivated to change it.
- Both the initial session and the booster sessions consist of one-on-one, face-to-face meetings with a female health educator.
- The intervention was designed to be delivered in a clinic or community-based organization that provides sexual health services to young women.
- There are two discrete intervention modules offered during the first session. Which module the participant receives depends on her stage of behavior change, as determined by self-assessment and discussion.
- The participant takes an active role in all activities and, in fact, determines the topics covered and the order in which they are discussed.
Research shows that programs are most effective if they are based on a sound theoretical framework. SSI draws upon several social science models and theories: Social Cognitive Theory (SCT), the Transtheoretical Model of Behavior Change (TMBC), and motivational interviewing.
According to SCT, an individual gains self-efficacy through practice. SCT can be used to instill health-promoting behaviors or to reduce risky behaviors associated with poor health. It is based on the premise that behavior change occurs by teaching knowledge, modeling healthy behaviors, changing outcome expectations, developing skills, building self-efficacy, and creating social supports for the desired behavior change.
In SSI, the tenets of SCT are apparent in activities that (1) impart knowledge (e.g., how to use and obtain condoms), (2) model talking about sex and using a condom (e.g., on the video), (3) develop awareness of the need for behavior change (e.g., consequences of unprotected sex or perception of risk), and (4) provide opportunities to build self-efficacy (e.g., practice putting on a condom or role playing talking to one's partner). Furthermore, the participant takes an active role in all activities. In fact, her responses and self-assessments determine what topics are covered and the order in which they are discussed.
TMBC is a model of intentional behavior change, which has been the basis for developing effective interventions to promote positive changes in health behaviors. Key constructs from other theories, including SCT, are integrated into this model. This model describes the stages of change that people go through to modify a problem behavior or acquire a positive behavior. These five stages are (1) Precontemplation, (2) Contemplation, (3) Determination (sometimes referred to as Preparation), (4) Action, and (5) Maintenance. When used in addiction interventions, a sixth stage, Relapse, is often included. In SSI, the intervention module that the participant receives is individualized according to her stage of change, as determined through self-assessment and discussion.
Motivational interviewing incorporates the principles of individual responsibility, internal attribution, and cognitive dissonance to move an individual from one stage of behavior to another. In SSI, these underlying principles are included in nearly every activity—every time the participant is asked to internalize the topic of discussion, take responsibility for what is being discussed, or evaluate the risks of her behavior.
SSI is one of several evidence-based programs available from Sociometrics designed to reduce teen pregnancy, STIs, and HIV/AIDS among adolescents. For more information, visit Sociometrics at www.socio.com/ and click on Effective Programs.
Evaluation Fact Sheet
SSI was evaluated with an opportunistic study design (at the time of STI treatment) that included baseline measurements and 1-, 3-, 6-, and 12-month follow-up measurements. The evaluation was conducted in an adolescent clinic and an in-patient service of a children’s hospital in a predominantly urban area.
Stratified by diagnosis of cervicitis or pelvic inflammatory disease (PID), subjects were randomized using two separate random number lists into either the intervention group (SSI program conducted by a female health educator) or the standard care group (e.g., STI transmission education at the discretion of the treating clinician). Of 239 eligible subjects, 123 were randomized into the two conditions: standard care (n = 63) and intervention (n = 60). For inclusion in the study, subjects needed to be female, younger than age 24, and in need of treatment for cervicitis or PID.
The study collected data from subjects at baseline and at 1, 3, 6, and 12 months after the initial intervention. Data collected at baseline covered topics such as the age of first sexual intercourse, number of sexual partners (life and last 3 months), use of drugs or alcohol before intercourse (ever and the last time), condom use with last sexual intercourse, number of main and non-main partners during the past 6 months, history of STIs or PID, and types of sexual intercourse engaged in (vaginal, oral, or anal).
At the 1-month follow-up, the intervention participants had significantly increased sexual risk knowledge (p = .02) and exhibited a greater increase in positive attitudes toward condom use compared with control group subjects (p = .007). The intervention group was also somewhat more likely to report frequently (p = .08) and consistently (p = .09) using condoms with non-main partners, although these differences were not significant.
At the 3-month follow-up, there were no reported dependent variable differences between the intervention and control groups.
At the 6-month follow-up, intervention subjects reported fewer instances of sexual intercourse with non-main partners than did those in the control group (p = .01). The intervention group was also less likely to report condom non-use during last sexual intercourse (p = .09, not significant). Consistent with findings at the 1-month follow-up, the intervention group had a greater increase in positive attitudes regarding condoms (p = .007) compared with the control group at the 6-month follow-up.
At the 12-month follow-up, intervention participants tended to have a somewhat decreased risk of having a main sexual partner compared with their control group counterparts (p = .07, not significant). Fewer intervention participants at the 12-month follow-up were likely to have had an STI recurrence than control group participants, but this difference was not significant (p = 0.17). The intervention group also showed steady positive progression along the Wheel of Change stages at each follow-up. By the conclusion of the evaluation, most participants who completed the exercise indicated that they were in the Action (38 percent) or Maintenance (25 percent) stage.
Although results with p > .05 are not statistically significant and must be interpreted with caution, these findings suggest that an individualized safer sex intervention can change attitudes and behaviors about condom use, reduce the number of sexual partners that an STI-infected young woman may have, and present secondary abstinence as an option.
Research Study Citation
Shrier, L.A., Ancheta, R., Goodman, E., Chiou, V.M., Lyden, M.R., & Emans, S.J. (2001). Randomized controlled trial of a safer sex intervention for high-risk adolescent girls. Archives of Pediatrics & Adolescent Medicine, 155(1), 73–79.
Safer Sex Intervention Adaptation Kit
Under a contract with the U.S. Department of Health and Human Services (HHS) Office of Adolescent Health (OAH), JBS Inc. subcontracted with ETR Associates to develop an adaptation kit for the Safer Sex Intervention. The Safer Sex Intervention Adaptation Kit contains practical tools and resources to guide adolescent reproductive health practitioners in making effective adaptations and maintaining fidelity to the program's core components.
This adaptation kit provides clarity on how SSI was designed, its core components, and the types of adaptations that are considered safe and those that should be avoided. For other available adaptation kits, go to Making Adaptations.