Tentu Saja.docx

Tentu saja, iklan bukanlah satu-satunya media yang berpengaruh pada sikap tentang perilaku yang berhubungan dengan kesehatan. Banyak anak muda menganggap gambar di majalah yang menggambarkan merokok untuk mewakili perokok menarik, meyakinkan dan SOCI-mampu (Macfadyen et al. 2002). Asosiasi ini menegaskan dan memperkuat aspek-aspek positif dari merokok di kalangan perokok yang melihat mereka. Similarly, many popular television programmes make verbal or visual references to alcohol and portray its use as an acceptable personal coping strategy (Smith et al. 1988). Clearly, the state should not control the content of media images or television programmes. Nevertheless, the potential influence of such images has led some health promoters to work with the producers of television pro-grammes to reduce the overly positive portrayal of alcohol consumption given in some US soap operas (DeFoe and Breed 1989).

Minimising the costs of healthy behaviour The environment in which we live can either facilitate or inhibit our level of engagement in health-related behaviour. Poor street lighting, busy roads and high levels of pollution may inhibit some inner-city dwellers from taking exercise such as jogging or cycling; shops that sell healthy foods but that are a long way from housing estates may result in more use of local shops that sell less healthy foodstuffs, and so on. Making the environment safe and sup-portive of healthy activity presents a challenge to town planners and govern-ments. Such an environment should promote safety, provide opportunities for social integration and give the population control over key aspects of their lives. A number of projects, under the rubric of the 'Healthy Cities movement' (World Health Organization 1988), have attempted to design city environ-ments in ways that promote the mental and physical health of their inhab-itants. The movement initially involved cities in industrialised countries, but is now expanding to include cities in industrialising countries such as Bangladesh, Tanzania, Nicaragua and Pakistan. To be a member of the movement, cities have to develop a city health profile and involve citizen and community groups. Priorities for action include attempts to reduce health inequalities as a result of socio-economic factors (see Chapter 2), traffic con-trol, tobacco control, and care of the elderly and those with mental health problems (Kickbusch 2003). Unfortunately, this rather broad set of strategies has proved difficult to translate into measurable and concrete action. Indeed, as recently as 2006, O'Neill and Simard (2006) were still writing discussion papers on how to evaluate the effectiveness of the, by then, twenty-year-old programme. Nevertheless, where appropriate measures have been used and the principles of the healthy cities movement enacted, this does seem to influence health behaviour. Sharpe et al. (2004), for example, found that levels of moderate or vigorous exercise were greater in the general popula-tion when there was good street lighting, safe areas for jogging or walking,

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well-maintained pavements, and easy access to exercise facilities than where these did not exist. More specific studies have shown that environmental manipulations aimed at minimising the costs of engaging in exercise may result in significant change. Linegar et al. (1991), for example, took advantage of the closed com-munity of a naval base to manipulate both its physical and organisational environment. They established cycle paths, provided exercise equipment, and organised exercise clubs and competitions within the base. In addition, they gave workers 'release time' from other duties while they participated in exer-cise. Not surprisingly, perhaps, this combination of interventions resulted in significant increases in exercise, even among people who had not previously exercised. This combination of approaches is rarely possible, but the results indicate what is possible when there is the freedom to manipulate a wide range of environmental factors. A more 'doable' programme, intended to increase levels of exercise among women in a suburb of Sydney, was reported by Wen et al. (2002). They targeted women aged between 20 and 50 through a marketing campaign and increasing opportunities for participation in exer-cise. Their marketing included establishing community walking events, and initiating walking groups and community physical activity classes. Local council members were invited on to the project group to raise the profile of the project with council members and to ensure that the project fitted within the council's social and environmental plans. Pre- and post-project telephone surveys indicated a 6.4 per cent reduction in the proportion of sedentary women in the local population, as well as an increased commitment to pro-moting physical activity by the local council. Another area where the costs of healthy behaviour have been considered is that of needle-exchange schemes for injecting drug users. Needle-exchange schemes exchange old for new needles, preventing the need for sharing and reducing the risk of cross-infection of blood-borne viruses, including HIV and hepatitis. Where syringes cannot legally be obtained elsewhere, they are effective (Gibson et al. 2001). That said, one important study (Taylor et al. 2001) published since Gibson and colleagues' review, showed a reduction in the use of shared needles between 1990 and 1992 in Scotland following the introduction of needle-exchange schemes, but then a gradual increase in sharing in the following years despite their continued provision. These changes mirror some of the changes in risk behaviour in other populations at risk for HIV, where initial changes towards safer behaviour have dwindled, and riskier behaviour has returned over time (eg Dodds et al. 2004). The reasons for this are unclear but may relate to the relatively low profile given to HIV/AIDS awareness, at least in the UK, and increasing (inappropriate) beliefs that AIDS can be 'cured'.

Increasing the costs of unhealthy behaviour Making unhealthy behaviour difficult in some way (often through pricing) can act as a barrier to unhealthy behaviour and a facilitator of healthy behaviour. Economic measures related to public health have been largely confined to taxation on tobacco and alcohol. The price of alcohol impacts on levels of consumption, particularly for wines and spirits: beer consumption may be less sensitive to price (Godfrey 1990). These effects may hold not just

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for 'sensible' drinkers but also for those who have alcohol-related problems (Sales et al. 1989). Increases in tobacco taxation may also be the most effec-tive measure in reducing levels of cigarette smoking, with an estimated 4 per cent reduction in consumption for every 10 per cent price rise (Brownson et al. 1995). Hu et al. (1995) modelled the relative effectiveness of taxation and media campaigns on tobacco consumption in California. They estimated that a 25 per cent tax increase would result in a reduction in sales of 819 mil-lion cigarette packs, compared with 232 million packs as a result of media influences. Taxation seems to be a particularly effective deterrent among young people, who are three times more likely to be affected by price rises than older adults (Lewit et al. 1981). However, these findings must now be interpreted against attempts to avoid these costs. In the UK, for example, increasing levels of smuggled tobacco and alcohol from the continent (where tax levels are much lower) compete against higher prices in formal outlets. While prohibition may be seen as a necessary barrier by some, others have called for more modest barriers to availability. Godfrey (1990), for example, has suggested restricting the number of outlets for drugs such as alcohol. This would result in increasing transaction 'costs' as people have to travel further and make more effort to purchase their alcohol, and in reduced cues to con-sumption from advertising in shop windows and other signs. By contrast, increasing availability – as has occurred relatively recently in Sweden through the Saturday opening of alcohol retail shops – may result in an increase in consumption (Norström and Skog 2005). A more direct form of control over smoking has been the introduction of smoke-free work and social areas. These clearly reduce smoking in public places – and may impact on smoking elsewhere. Heloma and Jaakalo (2003) found that secondary smoke inhalation levels fell among non-smokers, while smoking prevalence rates at work fell from 30 per cent to 25 per cent fol-lowing a national smoke-free workplace law. Following a ban on smoking in Norwegian bars and restaurants, Braverman et al. (2007) reported significant reductions in the prevalence of daily smoking, daily smoking at work by bar workers, number of cigarettes smoked by continuing smokers, and the number of cigarettes smoked at work by continuing smokers. Restaurants and bars have expressed some concern that smoking bans will reduce their profits. Countering this claim, the US Centers for Disease Control and Prevention (2004) reported the outcome of a ban on smoking in all public work and social outlets, including restaurants and bars, in El Paso, Texas. Breaking the ban would result in a $ 5,000 fine. There was no reported fall in profits or consumption in any bar or restaurant. Even more encouraging are emerging data suggesting that such bans can positively impact on health. Although they do not provide absolute proof of an association between reduced smoking and reduced disease, a number of studies have now shown reductions in the number of admissions to hospital with myocardial infarc-tion both in the USA (eg Juster et al. 2007) and Europe (Barone-Adesi et al. 2006) since the ban was implemented.

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IN THE SPOTLIGHT

The binge drinking epidemic Despite some reductions in the consumption of alcohol throughout the population, many countries have recently reported significant increases in binge drinking, particularly among young people. This phenomenon has been reported, for example, in the UK, New Zealand, Australia, an area known as the vodka belt (Russia and other countries where vodka is the primary drink), but is less prevalent in South America and southern Europe. The causes of this behaviour are not fully understood, but the availability of cheap alcohol in supermarkets, clubs and pubs – and the culture of drinking while standing – is widely recognised as con-tributing to the phenomenon. The drinking culture contributes to significant personal harm, as well as having a substantial economic and social impact on the affected communities. Some cities have increased policing in response to the social problems. Some have made bars con-tribute to the cost of this policing. But one French town took their approach a stage further. They bought the bars! The city of Renne, in Brittany, has bought two bars in the centre of town and converted one into a DVD shop, and one into a restaurant in an attempt to reduce alcohol consumption in its centre. Time will tell whether this impacts on alcohol consump-tion . . . but you have to admit, it's a pretty bold approach to health promotion!

Health promotion programmes So far, we have looked at some broad approaches to behavioural change in large populations, and some of the underlying principles that underpin them. The next sections of this chapter examines how these, and some other, approaches have been used in health promotion programmes targeted at whole populations and more specific target groups within them. We consider a number of differing target populations, the approaches that have been used to change their behaviour, the theoretical models that have guided the inter-ventions, and their effectiveness.

Targeting coronary heart disease Some of the first health promotion programmes targeted at whole towns aimed to reduce the prevalence of key risk factors for CHD – smoking, low levels of exercise, high fat consumption and high blood pressure – across the entire adult population. The first of these, known as the Stanford Three Towns project (Farquhar et al. 1977), provided three towns in California with three levels of intervention. The first town received no intervention. The second received a year-long media campaign targeting CHD-related behaviour. Although the media programme preceded the stages of change model (Prochaska and di Clemente 1984; see Chapter 6) by some years, it followed a programme very similar to that suggested by that model. It started by alerting people to the need to

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Plate 7.2 For some, environmental interventions may be far from complex. Simply providing clean water may prevent exposure to a variety of pathogens in dirty water. Source: © Comic Relief UK, reproduced courtesy of Comic Relief UK

change their behaviour (itself a relatively novel message in the early 1970s). This was followed by a series of programmes modelling behaviour change – for example by broadcasting film of people attending a smoking cessation group or showing cooking skills. These were based on social learning theory (Bandura 1977; see Chapters 5 and 6) and were aimed at teaching skills and increasing recipients' confidence in their ability to change and maintain change of their own behaviour. This phase was followed by further slots reminding people to maintain any behavioural changes they had made, and showing images of people enjoying the benefits of behavioural change such as a family enjoying a healthy picnic (potentially impacting on attitudes and perceived social norms). In the third town, a group of individuals at par-ticularly high levels of risk for CHD and their partners received one-to-one education on risk behaviour change and were asked to disseminate their knowledge through their social networks. This strategy was used to provide another channel for disseminating information – through the use of people given the role of opinion leaders – and increasing motivation in both high-risk people and the general public. Accordingly, there were three levels of intervention, each of which was expected to result in a step-wise increase in effectiveness (see Table 7.1). The expected outcomes were found. By the end of the one-year programme, scores on a measure of CHD risk status based on factors including blood pres-sure, smoking and cholesterol level indicated that average risk scores among the general population actually rose in the control town, while they fell signific-antly among the general population who received the media campaign alone and to an even greater extent among those who lived in the town that received the combined intervention. After a further year, risk scores in the interven-tion towns were still significantly lower than those of the control town, although because scores in the media-only town continued to improve, there was no difference between the two intervention towns (Farquhar et al. 1990a).

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Table 7.1 The three levels of intervention in the Stanford Three Towns project Approach Ongoing health promotion activity

What it involved

Expected effect

A minimal intervention 'comparison' town

+/−

Year-long media campaign

Phase 1: alerting people to the need to change Phase 2: modelling change Phase 3: modelling continued change

+

Media campaign + high-risk intervention

Media as influence combined with dissemination of knowledge from lay experts

++

The European equivalent of this programme was established in North Karelia in Finland (Puska et al. 1985). This five-year programme differed slightly from the Stanford approach in that in addition to a media approach, it also changed environmental factors, encouraging local meat manufacturers and butchers to promote low-fat products, encouraging 'no smoking' restau-rants, and so on. It was generally considered to be a success, with reductions in a number of risk factors including blood pressure, cholesterol levels and smoking among men. However, its final summary paper showed that these reductions in risk factors were not consistently better than those in a control area, which received no intervention. Unfortunately, this apparent lack of success has been repeated in a number of subsequent large-scale interventions. A second study conducted around Stanford, called the Five City project (Farquhar et al. 1990b), for example, combined its previous media approach with an increased emphasis on community-initiated education and environmental interventions similar to the Karelia intervention. In a cohort followed for the duration of the inter-vention, the general population in the intervention area showed improve-ments in cholesterol levels, fitness and rates of obesity in the early stages of the intervention. However, by its end, the only differences between a com-parison area that did not receive the intervention and the intervention areas were on measures of blood pressure and smoking (the latter being perhaps the most important risk behaviour due to its links with so many other dis-eases). On this criterion, the intervention could be considered a modest suc-cess. Unfortunately, on a series of cross-sectional studies comparing control and intervention areas over time, smoking and risk levels for CHD did not differ at any time during the course of the programme – questioning the success of the intervention. A final US intervention to be considered here used virtually all the approaches so far considered in this and the previous chapter. The Minnesota Heart Health programme (Jacobs et al. 1986) used the mass media to pro-mote awareness and to reinforce other educational approaches. In addition, the programme established large-scale screening programmes in primary care settings, as well as a number of other interventions including telephone support, classes in the community and worksite, self-help materials and home correspondence programmes. Environmental interventions included healthy food labelling (low fat, high fibre, etc.), establishing healthy menus in

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restaurants, smoke-free areas in public and work areas, and increased phys-ical recreation facilities. Despite this complex and sophisticated approach, the programme had surprisingly little impact on health and health behaviour. Levels of smoking in the intervention areas, for example, differed little from those in the control areas, while the average adult weight in both control and intervention areas rose over the course of the study by seven pounds. Similar findings were found for another intervention known as the Community Intervention Trial for Smoking Cessation (COMMIT Research Group 1995), which did not change heavy smokers' behaviour and had only a marginal effect on light smokers. At first glance, these data appear disappointing. Indeed, they provide little encouragement to suggest that the approaches they used should be con-tinued. However, before they are dismissed, it is important to contextualise their findings. First, apart from the original Stanford study, they occurred at a time when there were significant changes in health behaviour and disease throughout the countries in which the studies were conducted. Rates of CHD fell by 20 per cent over the time they were running (Lefkowitz and Willerson 2001), and there was a general increase in health-promoting behaviour and a concomitant fall in health-damaging behaviour such as smoking. Why did these changes occur, and what implications do they have for interpretation of the results of the large-scale programmes considered above? Perhaps the experiences of the five-year Heartbeat Wales programme (TudorSmith et al. 1998) sum up those of all the programmes so far considered. This programme combined health education via the media with health screening and environmental changes designed to promote behavioural change. These included some of the first food labelling (low fat, low sugar, etc.) in the UK, establishing exercise trails in local parks, no-smoking areas in restaurants, the promotion of low-alcohol beers in bars, and so on. It also used doctors and nurses as opinion leaders within their own communities to argue the case for adopting healthy lifestyles. Remember that the interven-tions in each programme were compared with 'control' areas – areas that did not receive the intervention. However, these were not true 'control' areas in the sense that they received no intervention at all. They received whatever local health education programmes were being conducted at the time. In addition, any innovations conducted by these major research programmes could not be guaranteed to remain only in the intervention area. In the case of Heartbeat Wales, for example, its 'control' area was in the northeast of England, which itself was subject to large-scale heart health programmes conducted in England at the same time as Heartbeat Wales. It was certainly not a 'no intervention' control. In addition, innovations such as food labelling, originally conducted just in Wales, spread through to England via supermarkets such as Tesco over the course of the programme. It is perhaps not surprising, therefore, that although levels of risk factors for CHD fell in Wales over the five-year period of Heartbeat Wales, they did not fall any further than levels in the control area. The research programme essentially compared the effectiveness of two fairly similar interventions. In addition, the majority of health promotion affecting the population with regard to CHD is now probably provided by the mass media as part of its general reporting – through reporting and discussion of healthy diets, issues such as men's health, and so on. It is therefore increasingly difficult for any health

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promotion programme to add further to this information and result in a meaningful reduction in risk for CHD.

Reducing risk of HIV infection In contrast to interventions targeted at CHD, those targeted at sexual beha-viour in relation to HIV and AIDS appear to have been more successful (Merzel and D'Afflitti 2003). Summing up some of the key data, the US Centers for Disease Control and Prevention (1996) reported significant increases in rates of condom use with main or casual partners in areas that received interventions across a number of US cities in comparison with con-trol areas that had not. In addition, they reported significant increases in the rates of carrying condoms both among those at whom the intervention was targeted and among community members as a whole. In the intervention areas, an average 74 per cent increase in condom carrying was reported. In addition, among injecting drug users, although both intervention and control communities reported a similar rise in the use of bleach to clean their needles and other equipment, those who lived in the intervention areas who were not using bleach were more likely to be considering its use. Many of these positive outcomes have been achieved using an approach called peer education. In this, opinion leaders and others from specific com-munities are involved in projects and form a key part of the programme. The approach draws upon social learning theory, as these individuals provide particularly strong role models of change. Using people known and respected within a particular community makes their message salient and shows that appropriate change can be achieved. In one of the first studies using this approach, Kelly et al. (1992) tried to increase levels of safer sexual behaviour among patrons of gay bars in three small southern US cities. They identified and recruited key individuals in these bars and trained them to talk to patrons on issues of risk behaviour change and to distribute relevant health education literature. Following this intervention, levels of high-risk sexual behaviour fell by between 15 and 29 per cent. In a larger community trial conducted by the same team in eight US cities (Kelly et al. 1997), levels of unprotected anal intercourse fell from 32 to 20 per cent among men fre-quenting gay bars in the intervention group – in contrast to a 2 per cent rise among those in the control cities. The RESEARCH FOCUS below reports in some detail on an attempt to replicate this type of intervention in gay bars in East European countries. In a different approach to reducing risk of AIDS, Asamoah-Adu et al. (1994) engaged prostitutes in Ghana to provide peer education and distribute condoms to their fellow prostitutes, resulting in a significant reduction in unsafe sex. Overall, the women who took part in the intervention were more likely to use a condom than they were prior to the intervention. In addition, three years after the end of the formal programme, women who maintained contact with the project staff were more likely than those who disengaged from them to have continued using them. Merzel and D'Afflitti (2003) noted that the HIV/AIDS prevention programmes have been markedly more successful than those targeted at CHD. Why this should be the case is unclear. Perhaps the most obvious differ-ence between the interventions was the use of peers by those involved in HIV

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prevention – working with specific groups of people rather than trying to impose change from without. This may have been a crucial factor. Janz et al. (1996), for example, conducted a process evaluation of thirty-seven AIDS prevention programmes and concluded that the use of trained community peers whose life circumstances closely resembled those of the target popula-tion was one of the most important factors influencing acceptance of health messages. Similarly, Kelly et al. (1993) suggested that the use of peers and role models was an important means of delivering health messages. Merzel and D'Afflitti speculated that a second reason for these differences may lie in the natural history of the diseases that each programme was trying to influence. Coronary heart disease develops over time, and there is no marked increase in risk as a result of particular behaviour – 'One bar of chocolate won't do me any harm'. It is therefore relatively easy to minimise risk and put off behaviour change. By contrast, the risks associated with unsafe sex are highly salient. It can take relatively few unsafe sexual encounters to contract HIV, and the consequences can be catastrophic – so the imperatives of change are much more salient than in CHD. While the above studies allow comparison of interventions within the same culture, it should not be forgotten that AIDS is a global issue. Given the devastating impact of HIV/AIDS in Africa, interventions here and in other parts of the developing world are of paramount importance. Galavotti et al. (2001) described a model known as the Modeling and Reinforcement to Combat HIV (MARCH), which has been developed for use in developing countries. The intervention model has two main components: use of the media local influences of change. It uses the media to provide role models in 'entertainment that educates'. Interventions include testimonials from people living with HIV/AIDS and peer education similar to that used, for example, in the USA and UK. These provide information on how to change, and model steps to change in sexual behaviour. Serial dramas on television are also used to educate, because they involve the viewer emotionally with the action on the screen, increase its salience and encourage viewing. Interpersonal support involves the creation of small media materials such as flyers depicting role models progressing through stages of behaviour change for key risk behaviour, mobilisation of members of the affected community to distribute media materials and rein-force prevention messages, and the increased availability of condoms and bleacher kits for injecting drug users. In one study of effectiveness of the media elements of this approach (Vaughan et al. 2000), Radio Tanzania aired a radio soap opera called Twende N a W akati ('Let's go with the times'). This soap played twice weekly for two years with the intention of promoting reproductive health and family planning, and preventing HIV infection. In comparison with an area of Tanzania that did not receive national radio at the time of the study, people who lived in areas where the radio programme was received reported greater commitment to family planning and higher uptake of safer sex practices. In addition, attendance at family planning clinics increased more in the intervention than control area.

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RESEARCH FOCUS Amirkhanian, YA, Kelly, JA, Kabakchieva, E. et al. (2005). A randomized social network HIV pre-vention trial with young men who have sex with men in Russia and Bulgaria. AIDS, 19: 1897–905.

This study describes the outcomes of a social network HIV prevention intervention carried out among young gay men in Russia and Bulgaria. HIV prevention is particularly important in these countries as the prevalence of known HIV cases is increasing dramatically, and the criminalisation of homosexual behaviour in the Soviet era has meant that until recently many gay men remained hidden and received little HIV prevention information. Method The study involved a number of stages: Identification of social groups of gay men in bars and nightclubs by ethnographers. Groups were monitored and their leaders identified, approached and invited to take part in the study. Fifty per cent of those approached agreed to participate in the study. Group leaders were asked to identify nine group members – people they most liked to spend time with. These individuals were approached by the research team, and 93 per cent agreed to participate in the study. A total of 52 networks with 276 network members took part in the study. Their mean age was 22.5 years, and 92 per cent of respondents were unmarried, 49 per cent of participants were students, and 52 per cent were employed. Groups were randomly assigned to receive either the social intervention or no intervention. Among those receiving the intervention, all group members completed questionnaires to identify the most influential individuals within each social group. The network member with the highest social status score in each group was invited to attend an educational pro-gramme designed to help them teach other members of their group about HIV prevention. Measures Measures included the following: Psychosocial scales: included measures of five AIDS-related issues: knowledge and misconceptions about AIDS, risk behaviour and risk reduction steps, safer-sex peer norms, atti-tudes towards condom use and safer sex, strength of risk reduction behavioural intentions, and perceived risk reduction self-efficacy. L ifetime, past year, and past 3 months sexual risk behaviour: Participants reported how many times they had intercourse, and how many of these acts were condom-protected. Communication with friends about AIDS-related topics in the past 3 months. Social network leader training intervention Each social network leader attended a group training programme in which they learned how to communicate HIV prevention messages and personal risk reduction advice to their network members. The intervention involved five weekly group sessions, with four booster sessions over the next 3 months. They were asked to incorporate HIV prevention messages into natu-rally occurring conversations and to tailor messages to the particular risk issues of each friend. Results Network leaders attended an average of eight of the nine group sessions. Talk about AIDS with friends nearly doubled (from a mean of 3.5 times at baseline to 6.1 times at follow-up) among experimental network members but fell among control group members. continued

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Baseline to 3 -month follow-up outcomes: the intervention group evidenced significant increases dalam pengetahuan AIDS risiko, norma rekan seks yang lebih aman, dan niat pengurangan risiko. Secara keseluruhan, mem-bers jaringan eksperimental kurang mungkin untuk terlibat dalam hubungan seks tanpa kondom dengan wanita, bukan pria. Lebih semangat, pria dengan pasangan berganda dalam kondisi intervensi melaporkan tingkat yang lebih rendah dari hubungan seksual tanpa pelindung dan tingkat yang lebih tinggi dari penggunaan kondom. Dasar untuk 1 2 -month hasilpemeliharaan:Perbedaan antara kondisi menjadi atten-uated pada titik waktu ini. Namun demikian, peserta dalam kondisi intervensi kurang mungkin untuk terlibat dalam hubungan seks tanpa kondom, meskipun perbedaannya tidak begitu besar seperti pada 3 bulan follow-up. Efek intervensi terkuat yang ditemukan di antara peserta yang memiliki beberapa mitra di tiga bulan sebelumnya. Mereka pada kelompok intervensi melaporkan episode kurang dari hubungan seks tanpa kondom daripada di kondisi kontrol. Diskusi Makalah ini adalah yang pertama dari Eropa Timur untuk menggambarkan hasil dari intervensi jaringan sosial yang bertujuan untuk pengurangan perilaku seksual berisiko. Data menunjukkan bahwa pemimpin kelompok bersedia dan mampu memberikan informasi pencegahan terkait AIDS dan saran. Satu tahun pada dari intervensi, ada bukti mengurangi perilaku berisiko, particu-larly antara peserta yang memiliki banyak pasangan seksual. Hal ini memberikan dorongan untuk lebih menggunakan jenis intervensi mungkin dengan biaya-manfaat, ekonomi, analisis untuk menghalangi-tambang apakah itu tidak hanya efektif, tetapi juga biaya yang efektif. Satu peringatan metodologis penulis dicatat adalah bahwa seperti banyak penelitian perilaku seksual, penelitian ini mengandalkan laporan diri peserta dari perilaku mereka, berpotensi rentan untuk mengingat kesalahan dan presentasi diri Bias. Perubahan dalam jaringan kelompok kontrol pada akhir follow-up menunjukkan kemungkinan bahwa rinci dan berulang-ulang penilaian risiko perilaku mungkin telah menghasilkan efek reaktif dan perilaku juga dipengaruhi.