This article is excerpted from Rigor, Collaboration, and Care: Two Decades of HIV/AIDS Prevention Research (2003), produced by EDC’s Health and Human Development Programs. It describes the development of culturally sensitive educational videos that have produced positive behavior changes among African American and Latino men and women.

The 1980s were a frustrating time for clinics treating patients with sexually transmitted diseases (STDs). The same patients kept coming back, suffering from repeat infections and continuing to have unprotected sex with multiple partners. Clinic staff, busy providing treatment, had little time or resources for prevention. Frustration was plaguing the research community as well. STDs were rampant in some communities, with those patients at heightened risk for getting and spreading HIV/AIDS. Condoms were known to be effective against the spread of STDs, but many patients did not use them.

Looking for innovative ways to prevent HIV/STDs, the Centers for Disease Control and Prevention (CDC) enlisted the expertise of EDC’s division of Health and Human Development Programs (HHD) and its Center for Research on High Risk Behaviors.

From this partnership of almost 20 years emerged innovative, rigorously researched, practical interventions that have shown success in reducing STD infection and improving condom use. Lessons from its success have given momentum to promising new ventures in HIV prevention. The intervention, known as VOICES/VOCES, has evolved into a showcase project for CDC, which has asked HHD to test it further for potential use in clinics, jails, and community settings throughout the country.

HHD’s Research Method

Much of HHD’s research and evaluation work in STD/HIV and other disease and risk prevention measures changes in human behavior and in the ability of systems—schools, universities, workplaces, community agencies, clinics, hospitals—to deliver health promotion and prevention programs. In our HIV/STD work, we zeroed in on these key research questions:

• How can we best provide prevention education to clients of STD clinics and other health services that serve men and women at risk for both STD and HIV infection?
• Can prevention programs lead to behavior change and better health outcomes?
• What does it cost to provide effective STD/HIV prevention?
  How can we use evidence of effectiveness to help agencies garner the resources for better prevention programs?
• Does the money spent on prevention reduce the human costs and financial burden of disease and its treatment?
• What supports, such as training and technical assistance, can assist STD clinics, family planning clinics, community health centers, and other health services to implement and sustain better prevention programs?

To answer these questions, we drew on a variety of qualitative and quantitative methods:

• Formative and social marketing research to produce culturally and gender relevant prevention programs that meet the needs of both the patient and the provider.
• Randomized clinical trials to assess the effectiveness of interventions in promoting safer behaviors and reducing disease.
• Dissemination research to better understand the research-to-practice continuum, examining the process of technology transfer and the costs of prevention programs.
• Replication studies to examine how programs are implemented by community agencies and whether interventions developed and evaluated in the research setting are equally effective when delivered by agency providers.
• National dissemination and training and technical assistance to support community agencies as they seek to implement and sustain proven prevention interventions.

In the [HHD] studies … scientists looked at self-reports of HIV/STD knowledge and two different indicators of behavior change: condom acquisition and repeat STD infections. Outcomes showed that when compared to adults receiving routine clinic services, clients who participated in the interventions demonstrated the following:

• Fewer repeat STD infections
• Greater likelihood of redeeming coupons to get condoms and the intention of using them regularly
• Increased motivation to change behaviors that place them at risk.
• Increased knowledge about HIV and STDs

Designing an Intervention

In the 1980s, HIV/AIDS emerged as a public health crisis, casting a spotlight on the longstanding problem of sexually transmitted infections. Nineteen percent of new HIV cases occur[ed] among Hispanics, who represent[ed] only 12 percent of the total U.S. population at that time. Gonorrhea [and syphilis rates were] also much higher among Hispanics [as compared to whites].

Our work in STD prevention began with an innovative idea: Can we create an educational video that motivates STD clinic clients to protect their health? [Our] early 1980s video, Let’s Do Something Different, offered at the major STD clinic in Massachusetts, was shown to be effective in motivating STD patients to take the medication prescribed to them by clinic staff and to get and use condoms.

This research provided a springboard for what has now become the VOICES/VOCES project (Video Opportunities for Innovative Condom Education and Safer Sex) and addresses the combined problems of STD and HIV. With continued funding from the CDC, [HHD’s] Lydia O’Donnell has continued this early work and led an expanded team to develop, evaluate, and disseminate brief, video-based prevention interventions. Instrumental to the success of this work has been the long-term involvement of Alexi San Doval, senior project director, and Richard Duran, field supervisor. [The EDC team] created several new videos in the mid 1990s, including the bilingual and award-winning Porque Si, designed for Latino men and women.

“Without Alexi and Richard’s knowledge of the system and how the clinics operate, we could not have collected anywhere near the amount of data that we did,” O’Donnell says. Through these multiple efforts, HHD investigators have cultivated intensive involvement of community members in the development process, a key factor in the effectiveness of our approach. In multiple focus groups and clinic observations involving patients and staff, HHD researchers learned what educational messages are most important to convey and how these messages can be delivered with the greatest impact. Community advisory boards have helped guide the development process. Thus the team includes not only expert researchers and practitioners, but also community expert

The Human Touch

Before coming to HHD, Richard Duran spent years counseling drug addicts and STD patients. He had managed clinics, taken phone calls, and checked patients in. He knew first-hand how overworked clinic staff were. And he knew that the clinic trial must not interfere with getting patients seen and treated as efficiently as possible, and that clinic staff often resent the presence of researchers.

“There were a lot of behind-the-scenes, day-to-day things that you have to work out with the staff. We touched everybody’s work in the clinic, from the registration person to the nurses to the doctors. We tried to see how we could do our job without interfering with their job,” says Duran, recalling that they declined an invitation to occupy one of the nicer offices, opting instead for an out-of-the-way cubicle that wouldn’t displace clinic staff.

Working with patients also required sensitivity. Privacy and confidentiality were paramount, and the videos helped people discuss touchy issues as they affected the characters in the vignettes. Duran also ran some of the groups of patients participating in the study. It helped people in an embarrassing situation to open up, Duran says. “Each group was new. It’s live. You don’t know what the next person is going to say, and what’s going to happen in the group. Part of the human condition is that misery does love company. It’s nice when you walk into a room and you’re feeling really bad about your life now and you say, ‘Wow, there are six other people here who feel just like me. I just feel like I have some support here.’”

Disseminating VOICES/VOCES to a Wider Audience

In 1997, the CDC selected the VOICES/VOCES program for inclusion in the Replicating Effective Programs project (REP), its flagship initiative to build a bridge between research and practice. Through REP, HHD developed and tested a technical assistance package of materials to aid replication in other clinics and health care settings. HHD found that with brief technical assistance, the intervention could be successfully implemented with similar audiences. In a study of the costs and cost-effectiveness of the VOICES/VOCES program, researchers found that [the intervention] is feasible and cost-effective when targeted to STD clinic clients at high risk of contracting and transmitting infections, indicating that this strategy should be considered for inclusion in HIV prevention programming. With the REP nomination, and additional evidence about the feasibility of replication, VOICES/VOCES became one of the first proven HIV prevention programs to be disseminated through a federally sponsored national training and technical assistance network.

With funding from the CDC, HHD staff have started to forge new partnerships with clinics, including a new clinic in Puerto Rico. The HHD team will provide clinics with VOICES/VOCES materials, training, and technical assistance, while clinic staff will take on the challenge of implementing the program in their busy settings. HHD researchers will then evaluate the effectiveness: Are there demonstrable improvements in patient knowledge, attitudes, and intentions to adopt safer behaviors? Are clients who receive the intervention more likely to redeem coupons for condoms? And are there fewer new STD infections among those who have been exposed to the intervention?

In addition, as the study progresses, evaluators will monitor and identify factors that lead to success or failure in implementing the intervention and look for ways to improve the process for practitioners to conduct these types of interventions.