A number of group cognitive interventions have been tested in well–controlled studies. They draw from different models of behaviour change, but all involve the development of skills and cognitive frameworks to help people sustain safer behaviour. Some methods are more labour intensive than others, and some could be adapted to other media. All have been proven to work with particular populations.

The first was a 12-session AIDS risk reduction programme targeted at gay men during the late 1980s in the US state of Mississippi. The programme recruited 104 men at high risk for HIV infection and randomised them into two groups: immediate intervention vs four-month delay. The delay group served as a short- term control group.

Baseline data showed that participants in both groups used condoms in approximately 23% of all instances of anal intercourse. However, the study report does not differentiate between anal intercourse with regular partners and casual partners.

Programme participants were then exposed to a series of workshops on safer sex, assertiveness training, how to deal with risky sexual situations, how to avoid sex when intoxicated, how to raise the topic of safer sex and how to deal with safer sex within relationships.

Four months after the intervention participants had used condoms in 66% of all instances of anal intercourse, whilst members of the control group had used condoms in just 19% of all instances of anal intercourse. This rate of condom use was sustained during over two years of follow–up, and 60% of subjects completely refrained from unprotected anal intercourse during the follow–up period (Kelly).

Despite the short period of controlled study, it is reasonable to argue that this intervention had a significant effect on behaviour, but it raises the question of whether or not the success of the intervention was dose–related i.e. would a similar effect have been seen with six or even one workshop instead of twelve?

A US study shows that such methods can be translated to other population groups. A study of 197 African–American and Hispanic women with sexual histories suggesting HIV risk were invited to participate in a programme based at a Milwaukee primary health care clinic. They were randomised to two groups. One received a five-session HIV risk reduction programme led by female group leaders. Women in the control group attended five sessions on unrelated health topics.

The HIV risk reduction programme included skills training in condom use, sexual assertiveness, examination of the circumstances which triggered risky behaviour for individuals and peer support for efforts to change behaviour. All skills training was developed with the assistance of a focus group to ensure that it was culturally appropriate.

Three months after the conclusion of the programme women in the intervention group reported condom use in 56% of sexual encounters involving vaginal intercourse. This was up from baseline of 26%. The number who used condoms at any time during the preceding three months rose from 43% to 66%. Participants also reported using condoms with a larger proportion of their male partners than at baseline. In contrast no changes in any of these variables were reported in the control group. Moreover, the women in the intervention group tended to have a more complete understanding of HIV risks, to have a more accurate personal estimation of their risk, and to view themselves as more personally vulnerable to HIV infection (Kelly 1992).

The study evaluation also looked at the quality of the skills developed by women to see whether the skills training component might have contributed to behaviour change. After three months women who had received skills training were rated by blinded evaluators as significantly more effective in resisting pressure to have sex without a condom, and in persuading a partner to postpone sex until a condom could be obtained.

Another US study piloted an intervention aimed at pregnant women which used a novel measure of efficacy: the use of credit cards which could be redeemed at local pharmacies to obtain condoms or spermicide. The programme enrolled 206 young single pregnant women in Akron and randomised them to one of three groups: HIV prevention, general health promotion and no intervention.

Women in the HIV prevention group were exposed to four small group sessions of 1 to 2 hours, which began after the fourteenth week of pregnancy. The group sessions focussed on the development of a sound `health action' plan. To enhance cross–group consistency, sessions were built around the use of culturally relevant health videos. The thematic content of the health promotion and HIV prevention was linked, but specific content differed. For example, if participants were invited to focus on activities which might have a negative impact on the foetus, the health promotion group would be directed to discuss the impact of smoking and drinking, whilst the HIV groups would look at mother–to–baby transmission of HIV. Skills development included negotiation and assertiveness skills, role playing, problem solving and aversive conditioning (imagining adverse consequences of behaviour).

All study participants were also given credit cards that could be used only at local pharmacies to obtain either condoms or spermicide. The uptake of condoms and spermicide was used to measure the impact of the workshops. Interestingly there was no significant difference in the uptake of condoms or spermicide between the HIV prevention and health promotion groups, but there was a difference in behaviour: women in the HIV prevention group were more likely to use condoms or spermicide with their partners, and had a stronger intention to do so, after three and six months of follow up. However, the benefits obtained from the HIV prevention intervention were only moderately greater than those obtained from the health promotion group (Hobfoll). Both groups did better on all scores (HIV–related knowledge, safer sex intentions and behaviours, discussion of HIV risk with partners and condom usage) than the no–intervention control group.

This study would suggest that free condom availability needs to be supported by educational activity and skills training if it is to be translated into safer behaviour.

A number of other US programmes have also provided controlled evidence of the effectiveness of multiple session workshop programmes focussing on the development of knowledge and skills. These include a study of HIV prevention workshops with homeless youth in hostel accommodation (Rotheram–Borus), which demonstrated that the level of change was proportional to the `dose', with the greatest reductions in unprotected sex amongst those who attended 15 or more sessions during a period of three weeks' residence in a hostel (sessions lasted less than an hour).

Several studies discussed above (see Social learning in Understanding behaviour change above) also provide evidence of the success and replicability of the skills–based workshop approach (Jemmott). On the other hand, several randomised, controlled studies of group skills interventions show no advantage to participation in such programmes. A programme for 102 Los Angeles youths with an average age of 12 showed no significant change in 19 of 21 attitudes and opinions about sexual behaviour and condom use. Researchers speculated that the intervention was too short (Eight one hour sessions) and that the use of teenage mothers who achieved a good rapport with students may not have discouraged students from early sexual intercourse, but instead glamourised teen pregnancy (Kirby). Another skills–based intervention which included the use of a comic book, videotape and a group skills curriculum showed no difference in levels of condom use between the intervention group and control group at six months (Gillmore), but researchers suggested that the null result may be attributable to the fact that the sample group were recruited from juvenile detention centres, and may have had no opportunity to practice the skills learnt during the workshops!

The research literature leaves unanswered the question of how many workshops might be adequate in order to sustain behaviour change. Unfortunately, no evaluation exists of the workshop programme developed by Gay Men Fighting AIDS in the UK, which contains many of the elements described above. The Sex Day format has been delivered to several thousand men in the UK since its inception in 1992, but no research evidence has been collected on the behavioural effects of this one–session intervention. It has been argued that a controlled trial of such an intervention would be impossible because it would be difficult to distinguish the effects of the intervention from those of other HIV prevention activities. However, as the studies above show, this problem does not seem to have arisen for researchers looking at other high–risk populations.

References

Gillmore MR, et al. Effects of a skills–based intervention to encourage condom use among high risk heterosexually active adolescents, AIDS Education and Prevention 9, Supp A, 1997.

Hobfoll SE, et al. Reducing inner city women's risk actvities: a study of single, pregnant women, Health Psychology 13(5): 397–403, 1994.

Kelly J, et a. Behavioural interventions to reduce AIDS risk activities, Journal of Consulting and Clinical Psychology 57(1): 60–67, 1989.

Kelly J, et al: HIV/AIDS prevention groups for high risk inner city women: intervention outcomes and effects on risk behaviour, paper to American Public Health Association, Nov 1992.

Kirby D, et al: An impact evaluation of Project SNAPP: an AIDS and pregnancy prevention middle school programme, AIDS Education and Prevention 9, SuppA, 1997.