A Computer-based Approach to Preventing Pregnancy, STD, and HIV in Rural Adolescents

Published in the Journal of Health Communication (Vol. 12, pages 53-76), this study describes a computer- and internet-based intervention designed to influence several variables related to the prevention of pregnancy, sexually transmitted diseases (STDs), and human immunodeficiency virus (HIV) in adolescents living in rural areas of the United States (US).

This research was motivated by data - cited here - indicating that, although pregnancy, STD, and HIV prevention are an issue for all youth, prevalence rates are noticeably on the rise in rural America, particularly HIV rates. This is because rural teens frequently live in communities far from friends and socially sanctioned entertainment and find themselves isolated and bored, which places them at great risk for drug and alcohol use, as well as risky sexual activity. Furthermore, numerous factors that increase the risk of early sexual initiation, multiple partners, and unprotected sex among adolescents are often present in rural communities, such as low levels of education among parents, high poverty rates, and high rates of adolescent nonmarital birth. Conservative attitudes about adolescent sexuality may prevent comprehensive sex education.

These researchers have also observed that computers and other interactive technology are becoming increasingly common in health communication generally and in the area of pregnancy, STD, and HIV prevention, specifically. This may be because computer- and internet-based health promotion and disease prevention interventions offer certain advantages, detailed here, such as providing a cost-effective way to reach a large number of potential users, which is particularly useful in circumstances where alternative sources of information are limited, as is often the case in rural areas. These tools also enable the provision of audience segmentation and, thus, personalised risk assessments and feedback. Furthermore, educational materials delivered through this vehicle may be regularly updated and upgraded, and promote self-efficacy and model communication skills supportive of safe sex practices and STD prevention.

The researchers hypothesised that participants in the experimental school would score higher than participants in the control school on the following variables at the conclusion of the intervention: (H1) knowledge, (H2) condom negotiation skills, (H3) condom self-efficacy, (H4) attitudes toward waiting to have sex, (H5) situational self-efficacy, (H6) refusal self-efficacy, and (H7) perceived susceptibility to the potential negative consequences of sexual activity (i.e., pregnancy, STDs, and HIV).

The intervention was guided by the extended parallel process model (EPPM), which is concerned with the effects of 4 variables on behaviour change: susceptibility, severity, response efficacy, and self-efficacy. According to EPPM, in order for attitudes and behaviour to change in the desired direction, an individual must perceive a personally relevant (susceptibility) and serious (severity) threat, and they must perceive an effective means of reducing the threat (response efficacy) that they are capable of performing (self-efficacy).

The 7-week intervention included 6 computer-based activities. For example, during the CD-ROM portion of the "Choose Your Own Adventure" activity, students went on a virtual date and made choices that may have put them in a situation where their date wanted to have sex but they did not. The activity ended with various positive or negative outcomes based on the choices made through the adventure. Although the intervention was largely text-based, it did incorporate a variety of interesting and colourful graphics throughout, as well as a few relevant images. For example, the Choose Your Own Adventure CD-ROM included more than 150 images of various people, places, and STDs. To make the experience more interesting and realistic, many of these images were randomly selected at various points in the adventure so they would be different each time. Further, all text on the Choose Your Own Adventure CD-ROM was recorded, and it actually spoke to the participants as they went along. Another activity asked students to take everything they had learned over the past several weeks and to create a radio public service announcement (PSA) to prevent pregnancy, STD, and HIV among rural high school students. All but one of the activities (the Choose Your Own Adventure CD-ROM) were reproduced in hard copy for students who did not have computer or internet access. (However, more than 98% of those taking part in this study reported regular access to the internet, and 96% reported regular access to a CD-ROM drive). Most activities took about 15 minutes to complete, and were designed to be completed outside of regularly scheduled class time.

The study was evaluated using a pretest/post-test control group design with random assignment at the school level. Three hundred and twenty-six tenth-grade males and females enrolled in 2 rural Appalachian public high schools completed the survey at both points in time. Results indicate that the vast majority (88.5%) of students in the experimental school completed at least one activity. Further, both the overall programme and all but one of the activities were rated positively by participants.

Regarding the effects of the intervention, the data were consistent with 4 of the hypotheses. Perhaps most importantly, students at the experimental school were significantly less likely to initiate sexual activity. Similarly, though it did not quite reach significance (p = .055), students who were sexually active in the experimental school reported fewer sexual partners in the past 4 months than students who were sexually active in the control school. The experimental school had greater knowledge (H1), greater condom negotiation self-efficacy (H2), more favourable attitudes toward waiting to have sex (H4), and greater situational self-efficacy (H5) than the control school. There were no significant differences, however, between the experimental and control schools with regard to condom self-efficacy (H3) or refusal self-efficacy (H6). Unexpectedly, the control school scored higher than the experimental school on the susceptibility measure (H7).

The researchers conclude that the investigation provides evidence that even modest computer-based interventions can be effective at influencing several important mediating variables. They refer to the intervention as "modest" in that: it was optional, not required; it took place outside of school; and it contained 6 short activities, rather than a larger number of longer (full-class period) activities. Based on their own experience, the researchers encourage future computer- or internet-based interventions to:

• include activities similar to those that received high ratings here - the exception being activities similar to the radio PSA activity, which received low ratings and low participation;
• incorporate incentives, as they were fairly effective at encouraging student participation, and offer additional incentives to teachers/gatekeepers (who play vital role in reminding students about the intervention and encouraging students to participate);
• also provide hard copies of the activities for those who do not have regular access to computers or the internet;
• make the interventions shorter and incorporate a greater number and variety of activities;
• individually tailor messages based on earlier responses: such individual tailoring may range from the relatively simple (i.e., using the participant's name throughout the intervention), to the more complex (i.e., basing the types of activities one is asked to do, or the type of feedback one receives, on one's sensation seeking or impulsive decision-making levels, past behaviours, or relationship status);
• place an even greater emphasis on self-efficacy-related issues (e.g., refusal skills and delaying tactics), as well as on perceived susceptibility;
• consider other options besides working with schools, such as boys or girls clubs, church groups, or other community organisations.
  

In short, computer-based programmes may be a cost-effective and easily replicable means of providing teens with basic information and skills necessary to prevent pregnancy, STDs, and HIV.