The article by Plant et al1 in this issue of Sexually Transmitted Diseases adds further evidence to the recent literature,2,3 suggesting limited effectiveness of inSPOT, an online program that assists persons diagnosed with a sexually transmitted infection (STI) to notify their partners.4 The outcomes of these evaluation studies are disappointing and also somewhat perplexing. Given the enormous reach of the Internet and the relative ease and low cost with which online interventions can be implemented, would not one expect a more favorable outcome? Indeed, it was as a result of such favorable expectations that many health departments in the United States and abroad had signed up for the program long before studies had demonstrated or refuted its efficacy. And, inSPOT is not the only online intervention facing difficulties, reaching the appropriate populations and achieve sufficient scale to be effective prevention interventions.5 However, before abandoning these programs altogether, it is worth exploring why online interventions for HIV/STI prevention are so difficult to implement and what may be done to improve this.
A theoretical construct that may prove useful in providing a context for this discussion is the Health Belief Model. This model posits that one is more likely to change a risky health behavior (e.g., unprotected vaginal or anal sex) to the extent one believes that this behavior will put one at risk for a certain outcome (e.g., syphilis or HIV infection) and also to the extent one believes that such an outcome would pose a significant health risk (e.g., HIV–related morbidity and mortality).6 In addition, the model also recognizes other factors that will prompt behavior change, including “cues to action” (e.g., genital symptoms). Together, these factors lead to a “teachable moment” where one may be susceptible to prevention interventions that, to use another theoretical construct, may assist in moving the dial on the stage-of-change continuum.7 This dynamic, in my view, underlies the efficacy of brief interventions, including client-centered counseling8 or even showing a video9 when the exposed subjects are recruited from STI clinics, because clinic attendees usually seek STI services as a result of some “cue to action” (symptoms, partner with an STI), usually perceive themselves at (high) risk for STIs and are thus “in a teachable moment.”
With this construct in mind, we can consider online HIV/STI prevention interventions in relation to 2 groups of Internet users. By far, the largest group comprises people who do not perceive themselves (acutely) at risk for STI/HIV; there are no cues for action and there is no teachable moment. Most day-to-day users on Facebook or other social media would fall into this category and efforts to engage populations on these sites in STI/HIV prevention interventions will face an up-hill battle, although these persons may be sexually active and may be at high risk for STIs objectively. This is also true for people visiting sexually explicit sites, including dating sites for gay men. One might compare, somewhat facetiously, intervening in these sex environments as attempting to invite patrons of a gourmet restaurant to interrupt their meals and attend a workout-class next door. It is not that these people are necessarily averse of behavior change interventions, but this may not be the right place and not the right time. Also, it is not that we are not able to reach the people visiting sexually explicit Web sites. The inSPOT studies all showed that placing banner advertisement in dating Web sites resulted in significant traffic to the inSPOT Web site and significant numbers of messages sent to partners notifying them of a possible STI exposure.1 – 4 However, the proportion of attendees to these dating sites in need of the inSPOT services (i.e., those recently diagnosed with an STI) is likely very small, such that inappropriate use of the messaging service (e.g., sending cards as a practical joke), although rare, can easily overwhelm the appropriate use of the service.
Thus, Internet-based interventions aimed at populations with low-risk perception are not likely to be very efficient and may even be counterproductive. However, they may be much more productive when targeting Internet users who have a higher perception of risk and whose “cue to action” may actually lead them to go online and find information about STIs. It seems to me that much more can be done to appropriately and professionally serve this segment of the online population. For instance, when putting in a Google search for “pus from my penis,” one currently is likely to land on peer-based Web sites where advise may be bad (“try bathing it and using salt water solution”) or at best half-good (“when it's anything to do with your penis go to a doctor—you don't want it to fall off”).10 However, the point is that Web sites with more appropriate advise either do not make it higher in the Google search hierarchy or are absent as referrals from the Web sites that do. Ample room for improvement one would think.
One fares better with entering a diagnostic term like “gonorrhea,” which results in a link to the Centers for Disease Control and Prevention general public Web site, second on the list only after Wikipedia.10 Wikipedia is arguably the single most important general online resource for the lay public and probably for many STI service providers as well. However, no formal evaluation of STI-related contents on Wikipedia has been conducted, and although the concept of Wikipedia is that its content can be edited and augmented by users, no formal efforts have been undertaken to enhance the quality of STI-related contents by either the academic or the public health community. Finally, to the extent that the general public may easily reach bona fide sites with appropriate information (such as the Centers for Disease Control and Prevention general public site), it is here that innovative and interactive online interventions are needed and can be more effective in both reaching the at-risk population and affecting its behavior.
In summary, online interventions may be ineffective because they are “barking up the wrong tree.” Although risk perception and appraisal themselves may not be sufficient to achieve behavior change, these concepts from the Health Belief Model continue to be salient in segmenting the online audience to identify those most likely to respond appropriately to online messages, thus enhancing their effectiveness and diminish potential negative effects.
A cue to action?
1. Plant A, Rotblatt H, Montoya JA, et al.. Evaluation of inSPOTLA.org: An Internet Partner Notification Service. Sex Transm Dis 2012; 39:341–345.
2. Kerani RP, Fleming M, DeYoung B, et al.. A randomized, controlled trial of inSPOT and patient-delivered partner therapy for gonorrhea and chlamydial infection among men who have sex with men. Sex Transm Dis 2011; 38:941–946.
3. Rietmeijer CA, Westergaard B, Mickiewicz TA, et al.. Evaluation of an online partner notification program. Sex Transm Dis 2011; 38:359–364.
4. Levine D, Woodruff AJ, Mocello AR, et al.. InSPOT: the first online STD partner notification system using electronic postcards. PLoS Med 2008(21); 5:e213.
5. Rietmeijer CA, McFarlane M. Web 2.0 and beyond: risks for sexually transmitted infections and opportunities for prevention. Curr Opin Infect Dis 2009; 22:67–71.
6. Rosenstock I, Strecher V, Becker M. The health belief model and HIV risk behavior change. In: DiClemente R, Peterson J, eds. Preventing AIDS: Theories and Methods of Behavioral Interventions. New York, NY: Plenum Press, 1994.
7. Prochaska JO, Velicer WF. The transtheoretical model of health behavior change. Am J Health Promot 1997; 12:38–48.
8. Kamb ML, Fishbein M, Douglas JM Jr, et al.; Project RESPECT Study Group. Efficacy of risk-reduction counseling to prevent human immunodeficiency virus and sexually transmitted diseases: a randomized controlled trial. JAMA 1998; 280:1161–1167.
9. Warner L, Klausner JD, Rietmeijer CA, et al.; Safe in the City Study Group. Effect of a brief video intervention on incident infection among patients attending sexually transmitted disease clinics. PLoS Med 2008; 5:e135.
10. Results of Internet searches conducted by the author on February 1, 2012. The quotes are for illustrative purposes only and given the fluidity of Internet contents not necessarily reproducible.