Conducting Research in a Clinical Setting

As HHD researchers began to formulate their work, one fact was clear: any successful
approach with STDs among sexually active adults would have to encourage the use of
condoms, one of the most effective tools — along with abstinence and monogamous sexual relationships — against a wide variety of STDs. However, condoms are underutilized, especially among individuals who are most at risk, such as adults with multiple sex partners or those who have been previously treated for an STD.

STD clinics provide a strategic context for condom promotion, but STD clinic staff in the 1980s had few proven prevention programs to use. And, perhaps most problematic, they
have little extra time in the busy clinic schedule to provide prevention, even if it is available. Even with the advent of AIDS, little prevention was offered during a patient’s clinic visit — a lost opportunity that HHD researchers have tried to rectify.

Pioneering a Video-based Approach to STD Education:
Let’s Do Something Different

With funding to target African American male STD clinic patients, HHD investigators Millie Solomon and Bill DeJong began formative research. At the beginning, the research staff
wondered whether patients would want to talk to strangers about their sexual practices and health. They did. “They were eager to speak to someone who listened non-judgmentally to their stories,” says Solomon. Researchers learned about patients’ misconceptions about STDs, such as believing that good hygiene would protect them from STDs.

Solomon, who has a doctorate in education and a master’s degree in drama, says, “We wanted to start from formative research about what their attitudes and beliefs were and create an intervention that might motivate them or create incentives for preventive action.” From the outset, the HHD team persisted with one key question: Is this a usable product?” says O’Donnell. “Given the settings that we were operating in, we needed a pragmatic approach that would actually be used and would address the structural issues that clinics face about lack of staff, lack of time and training, and how to provide education.”

Their qualitative research led HHD investigators to propose a video that depicted dramatic vignettes mirroring the lives and beliefs of clinic patients in their language. “In the mid 1980s we examined the educational materials. They were basically brochures. They were little cartoons that would tell patients what to do. They were dead, pedantic. It had nothing to do with the experiences of the audience,” says Solomon. Video vignettes, on the other hand, are a way that people can see themselves on the screen and take in a message.“ Videos quickly transmit information and are an engaging way to show or model healthy or safe behaviors,” she says, adding, “they are also an excellent ice-breaker with sensitive issues.”

But at the time, brief education interventions were not highly regarded. “The prevailing attitude,” says Richard Duran, MSW, an HHD senior scientist, “was that a video alone won’t work, and everyone knows a 15-minute group won’t accomplish anything!” Some people wanted the CDC to put its resources instead into tracking patients’ sexual contacts.
The team’s pragmatism compelled them to persist: Can we create a small scale intervention and still engage participants and make a difference?

The CDC encouraged HHD to try something innovative and test it rigorously. “It was exciting to develop this relationship with the CDC because they were at a critical
moment in terms of policy setting and decisions about their resources,” says Solomon.

The end result, Let’s Do Something Different, focused on problems of communication and interpersonal skills. The video was tested with focus groups of patients and clinic staff, who responded enthusiastically.

Randomized Clinical Trials
From 1983 to 1986, Drs. Solomon and DeJong tested this video in a series of clinical trials in urban clinics with a mostly heterosexual African American adult population. This field trial was notable for its two innovations, the use of a video intervention, and the trial’s evaluation strategy. At the time of their clinic visit, participants in the study were given coupons to redeem for free condoms as a proximate measure for behavior change. The investigators tracked who redeemed their coupons to determine whether those who
saw the video were more likely to get their free condoms than were those who had received only regular clinic services. Indeed, the study showed that those who saw the video were significantly more likely to redeem their coupons.

One of the objectives of these initial clinical trials was to facilitate patient adherence to treatment. The team’s use of coupons with the videos drew on their previous research on
compliance with an unwieldy tetracycline pill-taking regimen. Simple changes in the packaging and video instruction made a striking difference. “We saw an incredible, ten-fold
increase if both the packaging and videotape were used,” says Solomon. The researchers’ hope now was that condom availability would prompt a similar improvement in compliance.

Expanding the Video-based Approach
With the growing AIDS epidemic, HHD in 1991 was well positioned to obtain new funding from the CDC to build upon the work of Drs. Solomon and DeJong. Dr. O’Donnell and her team began to build on findings from the previous studies, expanding the work in several important ways to be responsive to public health needs.

First, they built their understanding of ways that proven strategies in other fields and reliable theories could be applied to HIV prevention. “We had been focused on STDs, and HIV was in the periphery of our vision,” says Solomon. But their seminal 1986 paper, “Recent Sexually Transmitted Disease Prevention Efforts and Their Implications for AIDS Health Education,”marked a shift in direction. The paper was one of three that the World Health Organization accepted at its first-ever HIV Prevention Conference. The authors drew parallels between patient attitudes about AIDS and other STDs, and some of the key
behaviors, such as using condoms that are needed in preventing the spread of these disease. The paper argued that the approach of using vignettes and support groups could be extended to HIV prevention. Similarly, they noted, any AIDS prevention tool must acknowledge and address patients’ misgivings about using condoms, as the initial videos did.

Second, they built on their ideas by including women as well as men in their target population. Third, they applied the dramatic video approach used for African Americans in
Let’s Do Something Different to include Latinos, who were becoming increasingly at risk. Fourth, with input from the CDC, they expanded the video approach, so that videos
could be used not only as stand-alone interventions, but also as triggers for brief, small-group discussion sessions. These sessions were designed to reinforce the messages that
were provided on the videos. Again, the prevention program was designed with the end user in mind, and built to work within clinic realities. “From my clinic experiences, I had an
insider’s look at whether this intervention would really work,” San Doval says. “It’s not good enough just to develop an intervention and be able to show effects if nobody is
going to adopt it.What if they say, ‘it’s too complicated and we can’t use it in our clinic?’ ”

To develop new intervention materials, senior project director Alexi San Doval and field supervisor Richard Duran held focus groups with several hundred clinic patients in a large New York City public STD clinic. They also conducted in-depth interviews with clinic staff to better understand how a program could fit their needs and overcome potential barriers they foresaw, and observed clinic flow. In addition, HHD researchers DeJong and O’Donnell conducted a survey of STD clinic managers from across the country, listening carefully to practitioners’ advice about customizing materials for optimal use, content, design, and the physical packaging of materials. A community advisory board also contributed to the discussions. “It was an intense, inclusive process,” notes Duran. The investigators discovered that patients did not know that many types of condoms exist. They also learned several things contrary to what was expected. Patients liked humor in discussing the sensitive subject of sex, STDs, and HIV — humor helped engage their attention and made them open to suggestions for how to protect their health once they left the clinic. Although practitioners felt that patients would be reluctant to join a group and that one-on-one counseling was all that could be done, men and women reported that they liked talking about these issues in a group setting that was safe and protected their confidentiality.

The major finding from this research was clear: to be effective and to get used, an intervention needed to be brief and engaging.

The formative research also helped the research staff to identify key cultural considerations in targeting Latinos and Latinas with a video discussing sensitive sexual topics. In developing the video, staff worked hard to incorporate the values about gender roles and cultural expectations identified in their discussions with target group members. “If your message is crafted in a respectful way that reflects the group’s own values, then people will hear you,” says O’Donnell. The new video for Latino audiences was entitled Porque Si. Additionally, the intervention was modified to include a group viewing and discussion afterward for a subset of the participants. The intervention could be done in a single, one-hour session, fitting easily into the clinic flow. Patients who participated were
not delayed from seeing a doctor, and clinic staff could maintain their system of tracking and treating patients. Structural elements needed to run the intervention included a private room to show the video and hold a group discussion, and a skilled facilitator to guide the discussion.