SEXUALLY TRANSMITTED diseases (STDs) continue to be a major preventable cause of morbidity in the United States. Although overall rates of gonorrhea have dropped below the Healthy People 2000 objective of 225 cases per 100,000 population,1 this figure can be misleading because STDs are disproportionately spread throughout the population.2 The risk for STDs remains particularly high among inner-city minority populations; nationwide, gonorrhea rates are about 40 times higher among African-Americans compared with whites and 6 times as high among Hispanics.3 Although most STDs can be successfully treated with antibiotics, an individual infected with an STD is at greater risk of developing a subsequent, and potentially more serious, infection. Repeat STD infections have been associated with infertility, ectopic pregnancy, cervical cancer, and acquired immunodeficiency syndrome.4
It is well established that patients seeking diagnostic and treatment services at inner-city public STD clinics are at high risk of acquiring new STD infections subsequent to their clinic visit.5 Repeat infections not only place these individuals at greater risk of suffering adverse health effects but also contribute to the transmission of disease within their community. Thus, providing effective prevention services to patients at the time of their clinic visit has the potential to make a significant impact on public health.6
Despite the opportunity afforded by the clinic visit, there are a number of significant barriers to providing STD clinic patients with effective risk reduction interventions, not the least of which is the lack of proven models that have been shown to promote long-term behavior change and reduce the incidence of repeat infections.7 Reporting on the public health response to STDs, Donovan and colleagues describe how prevention typically has been relegated to a distant second place in STD clinic programming, with most resources being used for treatment, despite recognition that a substantial proportion of those being treated will return at a later date with a new infection.8,9 Clinic-based physicians and other staff must often manage large numbers of patients in a cost-effective manner, ensuring that care is medically appropriate as well as sufficiently thorough to eradicate not just the symptoms of disease but the underlying infection.10 Given this clinical burden, staff may not have the time, knowledge, or skills required to educate or counsel patients effectively. In particular, they may not be adequately prepared to individualize prevention education to the needs of their patients.11
One model that has been proposed for addressing these barriers is video-based patient education. Over the past decade, videos have become an increasingly common vehicle for providing patients with basic information about their condition and its treatment. Videos have been used to educate patients about upcoming surgical procedures and to promote compliance with drug therapies.12 In addition to transmitting information, videos also have been found to be effective in surmounting the difficulties inherent in delivering behavioral change interventions to culturally and linguistically diverse populations seeking health care services.13–15 Using dramatic, soap-opera style story lines, actors can model desired behaviors, such as communicating with a sexual partner about condom use, in contexts that are familiar and culturally relevant to the intended audience. For example, evaluation studies have demonstrated that video-based educational interventions can be effective in improving knowledge about STDs, influencing attitudes that support safer sex behaviors, and increasing treatment compliance and condom acquisition behaviors.16–19 In a meta-analysis of studies on video-based STD prevention education, Healton and Messeri20 concluded that this strategy is effective for influencing patients' knowledge and attitudes.
A major advantage to video-based approaches is that educational benefits for patients can be achieved without imposing additional burdens on physicians to spend more time educating and counseling patients about prevention.21,22 Increasingly, physicians are encouraged to provide one-on-one prevention education to patients on a growing number of subjects related to their risk behaviors. A number of studies note the difficulties for physicians in putting such recommendations into practice, especially when delivering care in clinic settings with heavy patient loads where the emphasis remains on diagnosis and treatment. In a small study using unannounced standardized patients to assess human immunodeficiency virus (HIV) prevention in primary care, no providers followed U.S. Preventive Task Force guidelines on HIV prevention education practices.23 Although the Centers for Disease Control (CDC) issues similar guidelines for STD prevention services,24 the extent to which they are followed is unknown, although during exit interviews, a majority of patients have reported receiving little or no prevention education or counseling.25 The use of videos in such settings could help ensure that patients get the information and skills they need to prevent future disease.
Yet although videos have been shown to improve patient knowledge and attitudes, there has been insufficient evidence to conclude that they can have a positive impact on long-term behavior change or health outcomes. Establishing this link is an important step in understanding how videobased patient education can be used to supplement one-on-one patient-physician encounters. This article addresses a question critical both to expansion of STD prevention efforts and to the use and dissemination of video-based patient education. Can video-based STD prevention education affect behavior sufficiently to reduce rates of new STD infection among high-risk patients attending a public STD clinic?
During 1992, African-American and Hispanic men attending the Morrisania STD Clinic in the South Bronx were enrolled in a study of culturally relevant video-based prevention education. Participants received either regular clinic services or were exposed to one of two treatment conditions, video viewing only or video viewing followed by interactive group discussion. Upon enrollment, participants completed a survey eliciting sociodemographic information and STD risk factors. In addition, personally identifying information, including name and address, was collected and entered into a separate confidential clinic database.
To identify new STD infections among study participants, we matched personally identifying information from this database with information in the surveillance database maintained by the New York City Department of Health. This central surveillance database includes information on all incident STDs diagnosed in the city. Information entered into the surveillance system includes name, address, and initial treatment date. Thus, any study participant diagnosed with an STD in New York City subsequent to enrollment would be entered in the surveillance system.
A uniform definition of new STDs was applied to distinguish between the incident infections for which subjects sought treatment at the time of enrollment and those occurring subsequent to educational intervention. A new infection was defined as one diagnosed at least 30 days subsequent to study enrollment. To achieve a match between the databases and be assured that the match pertained to a new, rather than index, infection required the following data: subject's first and last name; street address; and initial treatment date. Matching was conducted approximately four times a year throughout 1992 and 1993.
Subjects were enrolled at a relatively uniform rate throughout 1992. Average date of enrollment was therefore approximately 6 months through the year. Allowing 1 month for identification of new infection, and conducting follow-up of subjects in the surveillance system through 1993, the average duration of follow-up was 17 months.
Subject Enrollment and Assignment to Treatment
A proportionate random sampling plan was designed to establish daily ethnic-specific enrollment quotas that reflected the demographics of the clinic population. In order of clinic arrival, each client received a registration number. All registered clients over the age of 17 were approached in consecutive order by registration number until the preset quotas were filled. Subjects were enrolled in one of three study conditions: video viewing only, video viewing followed by interactive group discussion, or control, which consisted of regular clinic services. Only one study condition was offered on any given day of clinic operation, with conditions assigned at random to clinic days. Each day, subjects agreeing to participate in the study were enrolled in the intervention offered on that day of clinic operation. Interventions were randomly assigned to days of clinic operation throughout 1992. Of 2,077 clients asked to participate in the study, 11 refused and 62 others who initially agreed to participate were called to other clinic appointments or otherwise unable to complete participation, for a sample of 2,004 and a response rate of 96.5%. All subjects, including those assigned to the control condition, provided informed consent. Subjects could only be enrolled in the study once and were not approached on return visits to the clinic. Distribution of subjects by treatment condition and ethnicity is provided in Table 1.
Video-based interventions were designed based on extensive formative research described previously.26 Two culturally appropriate videos were used in the interventions, "Let's Do Something Different" for African American audiences and "Porque SI" for Hispanics. Both videos provide information and correct misinformation about STDs and their prevention, portray positive attitudes about condom use, and model culturally appropriate strategies for encouraging condom use. In addition to being used by themselves, videos also were used as triggers for discussion in interactive sessions, which reinforced the STD/HIV risks associated with unprotected sex and provided an opportunity for participants to discuss problems they had encountered trying to use condoms and ways to overcome these barriers.
Patients in the control condition received regular clinic services that included a visit with a staff physician for diagnosis and treatment, and, according to Centers for Control guidelines, individual counseling about STD prevention and proper condom use. All participants were offered a selection of free condoms at the clinic as well as a coupon that could be redeemed for free condoms at an area pharmacy.
We conducted a survey of clinic records over an approximate 10% random sample of subject enrollment days. From this survey, we estimated that approximately 54% of subjects eligible for enrollment in the study on any given day had an incident STD (diagnosed as a result of the clinic visit on that day). However, the proportion of patients with an incident STD varied greatly from day to day ranging from 28% to 68%. All patients attending the clinic were eligible for enrollment whether they were diagnosed with an incident STD. Logistically, exclusion of patients without a newly diagnosed STD would have been difficult. Furthermore, we reasoned that virtually all patients visiting the clinic were at increased risk of acquiring an STD subsequent to study enrollment. Because the assignment of treatment condition was random by day of clinic operation, inclusion of patients without an incident STD did not bias study outcomes. Because some subjects did not have an STD at the time of enrollment, subsequent infections identified through the surveillance system were termed "new" rather than "reinfections."
Procedures for this study were approved by the Institutional Review Board of the New York City Department of Health. All participants provided written informed consent. Because all personally identifying information in the surveillance system must remain within the Department of Health, all matching was performed under the supervision of coauthor K.L. in his role as STD surveillance system manager. Once matching was achieved, a separate data file was generated. This file, used for all subsequent data storage and analysis, was stripped of all personally identifying data.
The primary outcome for this analysis is rate of new STD infection within the follow-up period. Using survival analysis, rates of new infection among those exposed and not exposed to video interventions were compared examining differences by ethnicity and self-reported number of sexual partners. We tested the hypothesis that STD infection rates would be lower among those exposed to video-based educational interventions than among those assigned to the control condition. All statistical tests were performed using the Wilcoxan statistic, which compares the average rank order of occurrence of new infection between groups. Analyses were performed on the personal computer version of SPSS (Chicago, IL).
The average age of study participants was 30.0 years. Selected sample characteristics are presented by ethnicity in Table 2. Over 60% of all subjects reported having had a prior STD, and the majority had been to an STD clinic before their current visit. About 72% of subjects reported having a main sex partner at the time of study enrollment. African-Americans were significantly more likely to report two or more sex partners in the past month than Hispanics (43.3% vs. 26.6%, p < .001). Over 99% of all participants reported that they regularly engaged in vaginal sex. Additional characteristics of participants are discussed in more detail elsewhere.27
The observed rate of new STD infection over the follow-up period was 24.2%. (Figure 1A) Hispanics were slightly less likely than African-Americans to acquire a new infection during the follow-up period (23.0% vs. 25.1%, Figure 1B), although this difference was not statistically significant. Among those participants with two or more sexual partners during the month preceding the clinic visit, the observed rate of new infection during the follow-up period was 27.9%, although for those with less than two partners the rate was 20% (p < .001, Figure 2).
Rate of new infection was significantly lower for those exposed to video-based prevention education compared with those receiving regular clinic services (22.5% vs. 26.8%, p < .04, Figure 3A). Among those exposed to video-based interventions, there were no significant differences in rates of infection between those who viewed the video only and those who viewed the video followed by interactive group discussion.
Subjects with multiple sex partners experienced the greatest impact of intervention. Among those reporting two or more sex partners during the month preceding the STD clinic visit, the rate of new infections was 27.9%. However, subjects with multiple partners in the control group had a 32.2% new infection rate, whereas those exposed to the intervention had a 24.8% new infection rate (p < 0.025, Figure 3B). This represents a 23% reduction in the rate of new infections among the group that is at greatest risk of an STD infection after a clinic visit.
Using the New York City STD surveillance system, we tracked rates of new STD infections among a sample of patients who visited a public STD clinic during 1992. Over an average of 17 months of follow-up, we found that approximately one in four were diagnosed with a new STD infection. Although the magnitude of this infection rate is sufficient cause for concern, it undoubtedly underestimates the true rate of new infection owing to a number of factors related to STD diagnosis and reporting. For example, a substantial proportion of entries in the surveillance system did not include date of diagnosis. Without a reliable date of diagnosis, we were unable to distinguish between a new infection and the index infection for which a participant sought treatment at the time of study enrollment. In addition, STDs are not reported to the surveillance system if treatment is sought outside of New York City, or if infection is undiagnosed during the follow-up period. Therefore, it is likely that some study participants who did develop a new STD during the follow-up period were not included in this analysis. Thus, it is reasonable to assume that the actual rate of new infection is somewhat higher than that which we observed. Among subjects in the control condition, we observed a new infection rate of approximately 19% over 1 year of follow-up. Based on our assumptions about missing data related to date of diagnosis or loss to follow-up, we estimate that the actual rate of new infection among the STD clinic patients whom we followed may be in excess of 25% per year. Reinfection rates of this magnitude have been reported elsewhere.28–31
At significantly greater risk were those men who reported having multiple sex partners in the month preceding their clinic visit. Consistent with self-reports of high-risk behaviors, these individuals were significantly more likely to acquire a new STD subsequent to study enrollment. In communities experiencing epidemic rates of STDs, reducing new infections among this high-risk group has the potential to result in the greatest overall reduction in STD infections.
Beyond obtaining descriptive indices of STD infection after a clinic visit, we attempted to determine the association between participation in a video-based patient educational intervention and infection rates. The likelihood of detecting differences in infection rates between patients receiving regular services and those exposed to video-based prevention is related to the overall reliability of, and any bias in, disease reporting. Although there appears to be some underreporting of new infections, we found no evidence for reporting bias by treatment site. Because treatment assignment was random, it appears unlikely that there would be a bias by treatment group, which would lead to either systematic underreporting of disease for those exposed to the video interventions or overreporting for those not exposed. Indeed, video interventions may have influenced patients to seek diagnosis and treatment in a more timely way. To the extent that this occurred, it would bias our findings toward the null hypothesis, since those exposed to interventions and subsequently reinfected were then more likely to be reported to the surveillance system within the follow-up period.
We chose to focus STD tracking on men for several reasons. First, the overall STD infection rate among women is lower, and thus fewer women would be expected to become infected during the follow-up period. Second, women represent a smaller proportion of STD clinic patients and, thus, without selective oversampling, there would be fewer women than men in our sample. These two reasons combined would result in a lower probability of detecting differences in infection rates. In addition, the most commonly reported STD, gonorrhea, is frequently asymptomatic among women. This relative asymptomaticity is known to delay diagnosis and treatment, and therefore reporting. Given the inevitable right censoring of our data owing to limited follow-up time, we were concerned that delays in diagnosis could lead to selective underreporting among women, as compared with men.
When ascertaining new STDs during follow-up, we did not attempt to identify specific diseases. Given that the likelihood of detection within a given time frame differs by type of STD, this failure to identify specific diseases could contribute to reporting bias. However, the likely direction of this bias would result in relative overdetection of disease among subjects enrolled in the interventions because they would be sensitized to the symptoms and public health issues related to STDs and thus seek treatment in a more timely fashion.
The single most important finding from this study is that among male STD clinic patients exposed to video-based interventions, there was an approximate 12% reduction in the rate of new STD infections over an average 17 months of follow-up. Furthermore, among subjects with multiple sex partners, the impact of intervention is nearly doubled, with a 23% reduction in rate of new infections.
We have demonstrated that exposure to video-based educational programs is associated with reduced rates of new STD infections among men attending a New York City STD clinic. Although previous work has shown that video-based programs delivered during a clinic visit can improve knowledge, influence attitudes, and increase condom acquisition, this is the first large-scale study to show a direct connection between video-based educational interventions and the health outcome of reduced STD infection rates.
This study directly addresses two of the major barriers to improved prevention efforts in STD clinics and similar settings. The first has been the lack of proven efficacy necessary to justify the costs of prevention program development and implementation. Here we have demonstrated that video-based patient education can result not only in immediate changes in knowledge and attitudes, but in the long-term behavior change required for reducing the incidence of repeat infections and thus protecting the health not only of those who visit the STD clinic but also their sexual partners in the community. The second barrier has been the emphasis on physician-delivered prevention services and the difficulty of finding time during brief patient encounters to make prevention an equal priority to diagnosis and treatment. As we have shown, video-based patient education can be effective in achieving some consistency of prevention services without placing additional demands on physician time.
Recently, against evidence to the contrary, policy analysts in search of ways to reduce health care costs have claimed that physicians already counsel patients regarding healthy behaviors and that additional programs to augment physician efforts may be duplicative and wasteful.32 Results such as those reported here show that video-based interventions can result in behavioral change. We believe these results support the argument for further research on innovative health promotion strategies such as video-based education and for implementation support for those programs that are shown to be effective. Although it is sometimes assumed that the educational messages delivered through health promotion programs will be most readily adopted by those at lowest risk, our findings suggest the opposite: Video-based education delivered in STD clinics can have an impact on a group at high risk such as men with multiple sex partners. Given the medical costs of diagnosing and treating STDs and the known links between STD and HIV infection, the benefits of providing video-based STD prevention education to such vulnerable populations appear clear.
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