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EAAIDD DOI: 10.1352/1944-7558-119.3.276
An Interactive Multimedia Program to Prevent HIV Transmission in Men With Intellectual Disability Jennifer Wells, Khaya Clark, and Karen Sarno ‘‘A hallmark of the HIV/AIDS epidemic has been its impact on vulnerable populations.’’ (Groce, 2005, p. 215)
Abstract The efficacy of a computer-based interactive multimedia HIV/AIDS prevention program for men with intellectual disability (ID) was examined using a quasi-experimental within-subjects design. Thirty-seven men with mild to moderate intellectual disability evaluated the program. The pretest and posttest instruments assessed HIV/AIDS knowledge (high-risk fluids, HIV transmission, and condom facts) and condom application skills. All outcome measures showed statistically significant gains from pretest to posttest, with medium to large effect sizes. In addition, a second study was conducted with twelve service providers who work with men with ID. Service providers reviewed the HIV/AIDS prevention program, completed a demographics questionnaire, and a program satisfaction survey. Overall, service providers rated the program highly on several outcome measures (stimulation, relevance, and usability). Key Words: HIV prevention; intellectual disability; interactive multimedia; health promotion
The Centers for Disease Control and Prevention (CDC) continue to follow the HIV/AIDS epidemic in men. A new estimate of the annual number of new HIV infections in the United States shows that the HIV/AIDS epidemic is worse than previously known. At the end of 2009, the CDC estimated that 1,148,200 people in the United States were living with HIV/AIDS (CDC, 2012). Men account for approximately 73% of these cases, and, those most heavily affected by HIV are gay and bisexual men of all races (CDC, 2010). Of new infections, approximately 61% occur in gay and bisexual men, with another 27% occurring through high-risk heterosexual contact (CDC, 2011). HIV/AIDS has been largely ignored in the population of people with intellectual disability (ID). No recent epidemiological studies have been conducted, and there is a paucity of HIV prevalence data on people with ID (Brown & Jemmott, 276
2002; Servais, 2006). Although HIV surveillance efforts among people with disabilities are limited in the United States, estimates from international organizations indicate that people with disabilities have increased risk to HIV exposure (UNAIDS, 2009). Contributing to the susceptibility of men with ID to HIV/AIDS is sexual exploitation by men with and without ID (Sobsey, 1994; Sobsey & Doe, 1991) and the social marginalization of people with ID. Many individuals with ID are sexually active. In the population of adult men with mild to moderate ID, bisexual and homosexual behavior, although underreported, is not uncommon (Servais, 2006; D. Thompson, 1994). In a recent National Institutes of Health Phase I study conducted in the Pacific Northwest, 19% of male participants with ID self-identified as bisexual (Wells, 2011), whereas a national survey conducted by the National Center for Health Statistics
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reported 1.1% of men self-identified as bisexual (Chandra, Mosher, Copen, & Sionean, 2011). Men with ID are not infrequently involved in sexual behavior with other men; however, many are not gay identified. Sex between men who are not gay identified usually involves ‘‘trading favors’’ (Cambridge, 1997; D. Thompson, 1994). This may be evinced in institutions (N 5 46) wherein 89% of facilities report same-sex intercourse between consenting adult males with ID, and 56% of facilities reported same-sex sexual behavior between consenting females with ID (Gust, Wang, Grot, Ransom, & Levine, 2003). Although some same-sex behavior is institutional and out of convenience, some people with ID are gay identified (Allen, 2007). In fact, a relatively new movement, the Rainbow Support Group (RSG), is gaining ground state by state to help ensure people with ID are supported in relation to their sexual orientation (Allen, 2003). The RSG provides a forum in which sexuality and issues such as HIV prevention are discussed. Other studies showed the majority of men with ID who have sex with men are not gay identified; however, they engage in same-sex highrisk behaviors, often with men who do not have ID (Cambridge, 1997; D. Thompson, 1994). Men with ID who have sex with men without ID commonly engage in sexual acts that are emotionally and physically painful; are characterized by extreme power imbalance; and because of their passive aspect, entail unsafe sex practices (B. Thompson, 2002; D. Thompson, 1994). This behavior stands to increase the risk of HIV contraction by men with ID, and in turn, by women with ID who have sex with men with ID (Cambridge, 1996). The limited number of HIV prevention programs for people with ID led to the partial adaptation of an existing computer-based interactive multimedia (CBIM) HIV intervention designed for women with ID (Wells, Clark, & Sarno, 2011). Because the findings from the intervention for women were robust, the intervention was rewritten for men, and it was designed to strengthen male gender norms (Eckman, Huntley, & Bhuyan, 2004) around taking responsibility for their health and well-being through safer sex practices, such as consistent condom usage, or abstaining from sex with partners who are reluctant to engage in safer sex practices. The main adaptation to the program involved rewriting the narrator segments to make the language specific to men, creating new program graphics specific to men, and narrowing the J. Wells, K. Clark, and K. Sarno
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program scope. In the intervention program for women, the duration of the intervention was too lengthy. Therefore, in the intervention with men, content related to HIV testing was not included.
HIV/AIDS Prevention Content The current project was designed to cover the following content areas: (a) transmission of HIV through sexual contact; (b) HIV avoidance strategies (i.e., barriers and abstinence); and (c) taking responsibility for condom usage (i.e., what a condom is, where to purchase, where to store, how to put a condom on a model penis). Across all content areas, a total of 18 interactive items assessed user knowledge and skills. Each item provided correction and remediation for incorrect answers. In the transmission of HIV through sexual contact segment, four HIV/AIDS knowledge domains were addressed: (a) HIV is a virus that causes AIDS, (b) AIDS is a disease for which there is no cure, (c) semen and vaginal secretions are high-risk fluids, and (d) what constitutes sexual behaviors (e.g., activities that involve seminal and vaginal secretions). The first pre-skill to learn about HIV transmission through sexual contact is that the HIV virus is a ‘‘germ’’ that gets in the body and causes AIDS. The second pre-skill required for understanding that HIV transmission occurs through sexual contact is to recognize that sexual behavior consists of activities involving semen and/or vaginal fluid. To define sexual activities such as vaginal intercourse, the program used graphic overlays to highlight the body parts involved (see Figure 1). The program did not show actual sexual behaviors. Voice-over narration described the behavior and which parts
Figure 1. Graphic overlay of the human body. 277
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of the body are involved (i.e., ‘‘Vaginal intercourse is when the penis is on or in the vagina’’). In the HIV avoidance strategies section, the program presented video vignettes, grounded in Bandura’s social learning theory (1986), which showed examples of couples negotiating condom use. The vignettes were tailored to sexual orientation as indicated by program users at the beginning of the program. The three types of avoidance strategies were: (a) take responsibility for condom usage for insertive sex, (b) abstain from receptive sex if a partner is unwilling to use a condom, and (c) leave the situation to maintain a position of abstinence. The final program segment, taking responsibility for condom usage, addressed the physiology of the penis (e.g., discriminating between an erect and partially erect penis), condom use (how to put a condom on a penis), condom storage, and condom removal.
Intervention Design Explicit Instruction and Social Learning Theory The Phase I project, HIV/AIDS Prevention for Men with Intellectual Disabilities, was designed using explicit instruction (Archer & Hughes, 2011). This instructional methodology has been proven efficacious among people with ID (Carnine, 1980; Engelmann & Carnine, 1982; Gersten, White, Falco, & Carnine, 1982; Lockery & Maggs, 1982). The basic principles of explicit instruction are (a) identifying the sequence of skill components, (b) organizing the teaching of the skill components, (c) presenting a range of examples to allow practice of skills, and (d) providing immediate assessment with error correction and remediation as warranted. Bandura’s social learning theory underpins the video vignettes showing couples negotiating condom usage. This approach is characterized as vicarious learning through modeling (Bandura, 1986). Consistent with the HIV intervention for women with ID, the project used a knowledgebased, sociobehavioral skills model (Wells et al., 2011). Although the process for teaching decision making and social skills to people with ID is qualitatively different than the process for people without ID, the fundamental nature of the task is not different (Huang & Cuvo, 1997; Moffatt, Hanley-Maxell, & Donnellan, 1995; Valenti-Hein, 278
Yarnold, & Mueser, 1994; Wehmeyer & Kelchner, 1994). Generally, people with ID have slower cognitive processing skills, so they need more examples and nonexamples to recognize that a decision needs to be made and to communicate that decision in a socially appropriate manner. In the context of high-risk behavior, the ability to (a) recognize high-risk behavior and situations, (b) select an appropriate response, and (c) implement those decisions are all critical components of making responsible, prosocial decisions.
Interface Training Upon program login, a series of screens showed the users the types of interactive teaching items and the meaning of each response option. For example, the computer voice-over stated, On question screens you will be asked a question and then you will be able to use the mouse to answer that question or make a decision. There are several kinds of question screens. Each of these works a little differently. One kind of question screen is the Yes and No screen. This is how a Yes and No Screen looks. This screen has a thumbs-up button, and a thumbs-down button. Thumbs up means yes and thumbs down means no. Watch how it works. At this point in the interface training, a green circle highlighted the ‘‘thumbs up’’ button while the computer voice-over stated ‘‘yes.’’ After this, the ‘‘thumbs down’’ button was highlighted and the voice-over stated ‘‘no.’’ Subsequently, the user was prompted to listen to an example question and then to click on the thumbs up or thumbs down button. Figure 2 shows the green circle that appeared when the voice-over explained the ‘‘thumbs up’’ button. Another type of interactive teaching item was a Likert-type response format designed to assess condom use self-efficacy. In the training, the voiceover stated, Here is another type of question screen. On this type of question, you will be asked to decide how easy or hard something is. See the weight lifters on these buttons? You will use them to tell us what you think. This weight lifter has a very light weight; it is very easy to lift. This button means very easy. If you think putting on your socks is very easy, you would
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interviewer-administered techniques (Borgers, de Leeuw, & Hox, 2000; de Leeuw, Hox, & Kef, 2003).
Program Tailoring
Figure 2. Yes and no response options.
click on this button. This weight lifter has a heavier weight; it is not so easy to lift. This button means not so easy. If you think that putting on your socks is not so easy, you would click on this button. This weight lifter has a really heavy weight; it is really hard to lift. This button means really hard. If you think that putting on your socks is really hard, you would click on this button.
Upon completion of the pretest, the program was tailored by sexual orientation. A computer voiceover asked, ‘‘Who do you think about having sex with?’’ This screen determined the tailoring of the program by sexual interest (heterosexual, bisexual, or gay). Four graphical response options were presented (Figure 4). The image of a man and woman was the ‘‘bisexual’’ response option, the image with a woman was the ‘‘heterosexual’’ response option, the image of a man was the ‘‘gay’’ response option, and the image of an ‘‘X’’ was ‘‘I don’t think about having sex.’’ For those users who chose the latter option, the program presented the bisexual branch. Each branch presented the same factual content. The content was tailored visually according to sexual interest. For example, if a male program user was interested in sex with other men, all on-screen examples and vignettes showed men in relation to other men.
Overview of Studies 1 and 2
A-CASI is a technique in which a recorded voiceover reads questions to research participants. Because of low literacy levels among people with ID, this methodology is useful because no reading is required, and the format fosters more candid reports of sensitive behaviors and topics than
Men with mild to moderate ID (IQ 50–75; Jacobson & Mulick, 1996; The Arc, n.d.) completed the one-time intervention at the Principal Investigator’s (i.e., Jennifer Wells) research institute. After the evaluation with men with ID was completed, 12 service providers who work with men with ID were recruited to review the program and complete a demographics questionnaire and a professional customer satisfaction survey. Service providers were sent a copy of the program and measures to complete during a time most convenient
Figure 3. Likert-type response options.
Figure 4. Program tailoring response options.
In Figure 3, the bottom left circle indicates the ‘‘very easy’’ response option.
A-CASI Pretest and Posttest
J. Wells, K. Clark, and K. Sarno
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for them. Because the research activities for the two groups of participants were qualitatively different (i.e., within-subjects intervention for men with ID, and professional review of the program to assess usability), the results from each are presented as Study 1 and Study 2, respectively. In Study 1, the primary research question was, Is there a difference in research participant scores from pretest to posttest? The main research question in Study 2 was, Will service providers rate the program highly on all outcome variables?
Study 1 Method Participants. A convenience sample of 37 men with mild to moderate ID (Jacobson & Mulick, 1996) was recruited to participate in the evaluation by vocational and residential agencies serving people with ID. All research participants were from the Pacific Northwest. The racial and ethnic composition, residence type, employment, and relationship status of the research participants are shown in Table 1. The Oregon Research Institute Institutional Review Board approved the evaluation protocol prior to implementation. All research participants signed an informed consent statement.
Table 1 Demographic Characteristics Hispanic/Latino
N
%
1
2.7
3
8.1
1 26 4 3
2.7 70.3 10.8 8.1
11 26
29.7 70.3
28 7 2
75.7 18.9 5.4
Race American Indian or Alaskan Native Native Hawaiian or other Pacific Islander White Other Did not know race Type of residence Semi-independent Independent Relationship status Single Living with a partner Married
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Of those employed, 48.6% worked in sheltered employment, 13.5% worked in supported community jobs, 2.7% worked in independent community jobs, and 35% indicated some other type of employment. In terms of sexual orientation of the sample, 19% were bisexual, 3% were gay, 65% were heterosexual, and 14% indicated that they don’t think about having sex. Twenty-six percent said the last time they had sex they used a condom, 67% said the last time they had sex they did not use a condom, and 7.4% did not answer the question. Sixty-seven percent said they never talked to their partners about AIDS, 19% said they almost never did, 11% said they talked about it all the time, and 3% did not answer the question. Procedure and Setting. Men with ID were recruited through local agencies that serve people with ID. The study was a one-time event conducted at a research institute in Eugene, OR. Project staff administered informed consent. After providing in-person consent, research participants completed all evaluation activities. Research participants wore headphones as they used the interactive program. All 37 participants provided pretest and posttest data. Total participation time in the evaluation was approximately 1.5 hr. Upon completion of the evaluation, research participants were compensated $35.00 for their time. Measures. Research participants completed a 44-item structured interview and a 33-item ACASI pretest, watched the interactive computer program, and completed the A-CASI posttest and user satisfaction survey. The structured interview was composed of 44 questions related to sexual practices (e.g., How many partners do you have?), frequency of condom use, condom knowledge (e.g., Where are safe places to store condoms?), and condom application skill. In the condom application skill section, research participants were asked to demonstrate the steps associated with opening a condom package and putting a condom on a realistic model penis. The condom application skill was assessed with six items scored as either correct or incorrect by the interviewer as the participant put a condom on a model penis. Condom application also included one follow-up question (i.e., Can you use the same condom you’ve already used to have sex again?). The response options were ‘‘Yes,’’ ‘‘No,’’ and ‘‘I don’t know.’’ The number of correct items endorsed for each domain was summed and divided by the number of items to indicate proportion correct.
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The A-CASI pretest and posttest consisted of 33 items developed by other researchers in the HIV/AIDS field. Items from the Handbook of Sexuality-Related Measures (Davis, Yarber, Bauserman, Schreer, & Davis, 1998), HIV-Knowledge Questionnaire (Carey, Morrison-Beedy, & Johnson, 1998), A Measure of AIDS Prevention Information, Motivation, Behavioral Skills, and Behavior (Misovich, Fisher, & Fisher, 1998), the Multidimensional AIDS Anxiety Questionnaire (Snell & Finney, 1998), and the HIV Prevention Knowledge Test for Teenagers (Yarber & Torabi, 1998) were used. Both items and answer choices were adapted to interactive multimedia video format. The A-CASI pretest assessed knowledge in six domains. Six items assessed basic HIV knowledge (e.g., Can the HIV virus be cured?); five items assessed high-risk fluids (e.g., Can you get the HIV virus from blood?); seven items assessed HIV transmission (e.g., Can someone get the HIV virus from having oral sex?); and six items assessed condom facts (e.g., When do you need to use a condom?). Response options included ‘‘Yes,’’ ‘‘No,’’ and ‘‘I don’t know’’ for basic HIV knowledge, highrisk fluids, and HIV transmission. Response ranged from two to five options for condom facts. The number of correct items endorsed for each domain was summed and divided by the number of items to indicate proportion correct.
Results A within-subjects quasi-experimental design was used to analyze the feasibility of the interactive program. Paired t tests were used to examine pretest to posttest gains in study outcomes. A partial pointbiserial correlation coefficient, r (Rosenthal & Rosnow, 2008), computed as the square root of the t value squared divided by the degrees of freedom, was used to compare effects across the measures, using the conventions small (r 5 .14), medium (r 5 .36), and large (r 5 .51). Results of the paired t tests (see Table 2) show significant pretest to posttest gains for all domains assessed, with an average effect size of .67, a large effect. The percent increases, shown in the last column, from pretest to posttest were 14% (knowledge of high-risk fluids), 19% (condom use), 23% (basic HIV knowledge), 31% (condom application), 52% (HIV transmission), and 71% (condom facts). Program satisfaction, assessed at posttest, showed that 97% of the men with ID said they J. Wells, K. Clark, and K. Sarno
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liked the program; of those, 58% said they liked the program a lot. A majority of the men (70%) indicated that they learned something new from the program; the program was very ‘‘easy to use’’ (76%); the speed of the program was ‘‘just right’’ (84%); the length of the program was ‘‘just right’’ (57%); they would like to use the program more (92%); and thought their friends would like to use the program (78%). Finally, most participants indicated that none of the pictures (87%) or the language (97%) embarrassed them. The average time that research participants viewed the program was 90 minutes.
Study 2 Method Participants. Twelve professionals serving people with ID (vocational and residential programs, The Arc, brokerages and state and county agencies) in California, Oregon, and Washington completed the evaluation. Fiftyeight percent were women and 33.3% were men, and the gender of one provider was missing (8.3%). Three providers were Latino, and the rest were non-Latino (75%). The racial composition of the sample was 75% White, 8.3% Black, and 16.7% other. Fifty-eight percent identified their work area as vocational service provider, 17% as personal assistant/advocate, 8% as residential program worker, and 17% as ‘‘Other.’’ Their experience with sexually active men with ID ranged from 1.06 to 20 years (M 5 6.74, SD 5 5.91), and the average number of sexually active men in their caseloads was 6.74. Procedure and Setting. Professional participants were recruited via flyers sent to organizations serving people with ID. Professionals either e-mailed or called to get a full explanation of the research activities related to their review. After the verbal explanation, potential participants were mailed an informed consent and a demographics form with a self-addressed stamped envelope to facilitate return. Once the informed consent and demographics form were returned, participants were considered officially enrolled. Research staff mailed participants a program satisfaction survey and a copy of the interactive program. Service providers were instructed to complete the program satisfaction survey after they reviewed the interactive program. All professionals viewed the program at home on personal computers. This was a one-time event. Total participation time was 281
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Table 2 Descriptive Statistics and Paired T-tests Pretest
Posttest
Test statistics
Mean
SD
Mean
SD
t-value
p-value
r
% increase
.703 .692 .532 .552
.186 .209 .237 .202
.867 .789 .907 .839
.193 .081 .151 .210
4.47 2.64 11.37 7.03
,.001 ,.012 ,.001 ,.001
.59 .40 .88 .76
23 14 71 52
.726 .559
.152 .228
.865 .731
.089 .240
6.92 4.94
,.001 ,.001
.75 .63
19 31
ACASI HIV basic knowledge High-risk fluids Condom facts HIV transmission Structured interview Condom use Condom application
approximately 1.5 hr. Service providers were mailed a $75.00 check to compensate them for their time. Measures. Professional participants completed a demographics questionnaire and program satisfaction survey. The demographics questionnaire consisted of questions pertaining to gender, ethnicity, race, primary work area, years of experience, and current caseload of sexually active men. In addition, we asked whether their clients expressed concern about HIV/AIDS, and how concerned the professionals were about the possibility of clients contracting HIV/AIDS. The program satisfaction survey consisted of 50 questions in both quantitative and qualitative formats. Questions covered ease of use of the program and five areas of user satisfaction: stimulation, comprehension, relevance, persuasiveness, and usability.
Results On the demographics questionnaire, 67% said their sexually active clients were ‘‘not at all’’ or ‘‘very little’’ concerned about HIV/AIDS. However, all of these professionals were either ‘‘somewhat’’ or ‘‘very’’ concerned about their clients contracting HIV/AIDS (33.3% and 58.3%, respectively). All the reviewers rated program ease of use very highly. Those who used the mouse and interface training sections of the program thought they would be ‘‘very’’ to ‘‘somewhat’’ effective. Eighty-eight percent said that the sequence of the presentation of information was logical and that it was ‘‘very’’ (58.3%) or ‘‘somewhat’’ (8.3%) easy to navigate through the program. All thought that responding to the questions in the program was 282
either ‘‘very clear’’ (33.3%) or ‘‘mostly clear’’ (50%). Several reviewers commented that the program seemed too long. The questions related to relevance involved a series of queries pertaining to the actors used in the program, the extent to which clients might identify with the actors, and whether providers would recommend the program to other providers. Seventy-five percent said the men in the program seemed real, and 75% thought they sounded very natural. Eighty-three percent thought their clients would ‘‘very much’’ to ‘‘somewhat’’ identify with the men in the program. Eighty-three percent said the language was appropriate, and 83.3% did not believe the program was too graphic or explicit. Most of the professional reviewers (83%) said they were very likely to somewhat likely to use the program with their clients. In terms of stimulation questions, all of the professionals liked the program. Typical comments made concerning an overall impression of the program were, ‘‘Very impressive in its scope, content, relevancy and more importantly, in its ease of use!’’ Thirty-three percent believed that most of the men they serve would like the program, 58.3% said the program would very much grab the interest of their clients, and 83.3% felt the program would keep their interest. Finally, 83% of service providers said their clients would understand the information in the program. Overall, most providers believed the scope of the program was ‘‘just about right.’’ All thought the program addressed important issues, and 83.3% thought that HIV/AIDS education was ‘‘very important’’ for their clients. When asked for their final thoughts, a typical comment was,
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‘‘Great job. Thanks for your work! I am so glad that someone is addressing the issue of safer sex.’’
Discussion In the field of interactive multimedia for people with ID, this program is unique in that it was tailored by sexual orientation, which served to normalize, rather than stigmatize, the expression of sexuality outside of heterosexual relationships. In addition, the program emphasized mens’ responsibility for their own sexual health by including messages to promote the reduction of sexual risk taking (e.g., consistent condom usage). Results from the evaluation of the program by men with ID indicate that the program was effective in increasing HIV/AIDS knowledge, including high-risk fluids, HIV transmission, condom facts, and condom application skills. Given the relatively small sample size, coupled with the short duration of the intervention, the effect size estimates indicate that this study has both statistical and practical significance (B. Thompson, 2002). This is the second study conducted by the research team on HIV prevention for people with ID, and the results from both interventions suggest that a single-dose multimedia intervention for people with ID can positively affect both HIV knowledge and skills. These preliminary findings on the use of interactive multimedia for healthbased interventions for people with ID are particularly important given the increasing use of the Internet for health-related information (Cohen & Adams, 2011). The use of video, interactive teaching items, and audio voice-overs would allow users with low literacy levels to access complex health information. This project’s use of instructional training on the interface and item types has the potential to make interactive computer programs accessible to a wide range of users with different levels of computer experience. Findings from the evaluation of the program by service providers were equally robust. Specifically, it was encouraging that 83% of service providers believed that program content would be comprehensible to their clients. This is important because there are few existing health promotion programs designed for people with ID (Shogren, Wehmeyer, Reese, & O’Hara, 2006) and their caregivers. The program was designed for individual use or for group-based administration, making it a useful tool for caregivers who are in need of HIV prevention resources. The use of interactive J. Wells, K. Clark, and K. Sarno
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technology could be applied to other areas in which people often need skill training to achieve independence: employment, housing, transportation, and healthy aging. Within the context of supports for service providers and advocates, interactive programs could be used as a diagnostic tool that would reveal a client’s gap in knowledge or skills, thus providing information on the areas in which additional supports are needed.
Implications and Future Directions It is evident from our data, that CBIM is an efficacious method for teaching people with ID potentially life-saving information such as HIV/ AIDS prevention. The programs discussed in this paper are being used in and around Harare, Zimbabwe with all populations, not just people with ID. In settings where learners are not English speaking, the audio is translated through an interpreter into the native language of that region. The text-free nature of the programs allows all people to see and understand concepts being discussed in the program. According to a report issued by the TAAP Zimbabwe Project (A. Guma, personal communication, November 6, 2012), the program had been viewed by more than 1,100 individuals during October 2012, garnering ‘‘overwhelming support’’ from local community members and leaders. TAAP is very pleased with the software as it makes it easier for them to present information on HIV/AIDS prevention using a method that engages the learners, and is effective. Another benefit of CBIM is the ability to tailor program content to the specific needs of individual learners. For example, learners who make errors on interactive items receive immediate on-screen remediation followed by another opportunity to answer the question. Learners who do not make errors receive immediate positive feedback and move forward to the next item or content movie. This type of tailoring allows educators to see areas in which a learner might need more support. Tailoring by user preference (i.e., ‘‘who do you like to have sex with’’) personalizes the message and presents all content free of bias, which can be difficult to accomplish through person-to-person discussions about sex and sexuality. For older adults with mild to moderate ID, CBIM has been overlooked as a teaching tool. Our studies show that older adults with ID are indeed capable of using a computer and enjoy the 283
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experience. Youth with ID are exposed to computers during the school years. Thus, there is a need to develop interactive CBIM curricula that encompass the range of experiences people with ID are likely to encounter in community settings. There are many areas—including life skills, self-care, problem solving, health and wellbeing, aging-related issues, and independent living—for which CBIM is an appropriate and efficacious medium for teaching people with ID to achieve independence in all life areas. Future research should include the development of CBIM teaching programs and the testing of interactive teaching programs on tablet and smartphone technologies. As increasing numbers of people with ID purchase these devices, they should be considered viable venues for furthering the personal growth of people with ID across the lifespan.
Limitations One notable limitation of the present investigation is related to generalization. Research participants had mild to moderate ID, which makes it impossible to know whether interactive technology would be appropriate for populations with severe to profound ID. Future research can replicate these methods with a more varied sample of people with ID to explore whether knowledge and skill patterns presented here hold true or are dependent of IQ range. Another important limitation of this study is lack of data on knowledge and skill maintenance over time. To adequately capture the efficacy of multimedia technology as a pedagogical tool to support health, well-being, and independence over the life course requires more longitudinal research.
References Allen, J. D. (2003). Gay, lesbian, bisexual and transgender people with developmental disabilities and mental retardation: Stories of a rainbow support group. Binghamton, NY: Harrington Park Press. Allen, J. D. (2007). Supporting diversity in sexual relationships: On being gay, lesbian, bisexual, or transgender with an intellectual disability. Baltimore, MD: Brookes. The Arc. (n.d.). Intellectual disability. Retrieved from http://www.thearc.org/page.aspx?pid52543 Archer, A. L., & Hughes, C. (2011). Explicit Instruction: Effective and efficient teaching. New York, NY: Guilford Press. 284
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Bandura, A. (1986). Social foundations of thought and action: A social cognitive approach. Engelwood Cliffs, NJ: Prentice Hall. Borgers, N., de Leeuw, E., & Hox, J. (2000). Children as respondents in survey research: Cognitive development and response quality. Bulletin de Methodolgie, 66, 60–75. Brown, E. J., & Jemmott, L. (2002). HIV prevention among people with developmental disabilities. Journal of Psychosocial Nursing and Mental Health Services, 40(11), 15–21. Cambridge, P. (1996). Men with learning disabilities who have sex with men in public places: Mapping the needs of services and users in south east London. Journal of Intellectual Disability Research, 40, 241–251. Cambridge, P. (1997). How far to gay? The politics of gay in learning disability. Disabilty and Society, 12, 427–452. Carey, M. P., Morrison-Beedy, D., & Johnson, B. (1998). The HIV Knowledge Questionnaire. In C. M. Davis, W. Yarber, R. Bauserman, G. Schreer, & S. Davis (Eds.), Handbook of sexuality-related measures (pp. 313–315). Thousand Oaks, CA: Sage Publications. Carnine, D. (1980). Preteaching versus concurrent teaching of the component skills of a multiplication algorithm. Journal of Research in Mathematics Education, 11(5), 375–378. Centers for Disease Control and Prevention. (2010). HIV and AIDS among gay and bisexual men (CDC fact sheet). Atlanta, GA: Author. Centers for Disease Control and Prevention. (2011). Estimates of new HIV infections in the U.S., 2006-2009. Atlanta, GA: Author. Centers for Disease Control and Prevention. (2012). Monitoring selected national HIV prevention and care objectives by using HIV surveillance data–United States and 6 U.S. dependent areass– 2010. (17 No. 3. part A). Atlanta, GA: Author. Chandra, A., Mosher, W. D., Copen, C., & Sionean, C. (2011). Sexual behavior, sexual attraction, and sexual identity in the United States: Data from 2006– 2008 national survey of family growth (National Health Statistics Reports, No. 36). Hyattsville, MD: National Center for Health Statistics. Cohen, R., & Adams, P. (2011). Use of the Internet for health information: United States, 2009. Atlanta, GA: Centers for Disease Control and Prevention. Davis, C. M., Yarber, W., Bauserman, R., Schreer, G., & Davis, S. (Eds.). (1998). Handbook of
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sexuality-related measures. Thousand Oaks, CA: Sage Publications. de Leeuw, E., Hox, J., & Kef, S. (2003). Computerassisted self-interviewing tailored for special populations and topics. Field Methods, 15, 223–251. Eckman, A., Huntley, B., & Bhuyan, A. (2004). How to integrate gender into HIV/AIDS programs: Using lessons learned from USAID and partner organizations. Interagency Gender Working Group. Retrieved from http://www. prb.org/pdf04/HowToIntegrGendrHIV.pdf Engelmann, S., & Carnine, D. (1982). Theory of instruction: Principles and applications. New York, NY: Irvington. Gersten, R., White, W. A., Falco, R., & Carnine, D. (1982). Teaching basic discriminations to handicapped and non-handicapped individuals thorugh a dynamic presentation of instructional stimuli. Analysis and Intervention in Developmental Disabilities, 2, 305–317. Groce, N. E. (2005). HIV/AIDS and individuals with disability. Health and Human Rights: An International Journal, 8(2), 215–224. Gust, D. A., Wang, S. A., Grot, J., Ransom, R., & Levine, W. C. (2003). National survey of sexual behavior and sexual behavior policies in facilities for individuals with mental retardation/developmental disabilities. Mental Retardation, 41(5), 365–373. Huang, W., & Cuvo, A. J. (1997). Social skills training for adults with mental retardation in job-related settings. Behavior Modification, 21(1), 3–44. Jacobson, J. W., & Mulick. (1996). Manual of diagnosis and professional practice in mental retardation. Washington, DC: American Psychological Association. Lockery, M., & Maggs, A. (1982). Direct instruction research in Australia: A ten-year analysis. Educational Psychology, 2, 263–288. Misovich, S., Fisher, W., & Fisher, J. (1998). A measure of AIDS prevention information, motivation, behavioral skills, and behavior. In C. M. Davis, W. Yarber, R. Bauserman, G. Schreer & S. Davis (Eds.), Handbook of sexuality-related measures (pp. 328–331). Thousand Oaks, CA: Sage Publications. Moffatt, C., Hanley-Maxell, C., & Donnellan, A. M. (1995). Discrimination of emotion, affective perspective-taking and empathy in individuals with mental retardation. Education & J. Wells, K. Clark, and K. Sarno
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Training Mental Retardation & Developmental Disabilities, 30(1), 76–85. Rosenthal, R., & Rosnow, R. (2008). Essentials in behavioral research. New York, NY: McGraw Hill. Servais, L. (2006). Sexual health care in persons with intellectual disabilities. Mental Retardation and Developmental Disabilities, 12, 48–56. Shogren, K., Wehmeyer, M. L., Reese, R., & O’Hara, D. (2006). Promoting self-determination in health and medical care: A critical component of addressing health disparities in people with intellectual disabilities. Journal of Policy and Practice in Intellectual Disabilities, 2, 105–113. Snell, W., & Finney, P. (1998). The Multidimensional AIDS Anxiety Questionnaire. In C. M. Davis, W. Yarber, R. Bauserman, G. Schreer, & S. Davis (Eds.), Handbook of sexuality-related measures (pp. 351–353). Thousand Oaks, CA: Sage Publications. Sobsey, D. (1994). Violence and abuse in the lives of people with disabilities: The end of silent acceptance? Baltimore, MD: Paul H. Brookes Publishing. Sobsey, D., & Doe, T. (1991). Patterns of sexual abuse and assault. Journal of Sexuality and Disability, 9(3), 243–259. Thompson, B. (2002). ‘‘Statistical, ‘‘practical,’’ and ‘‘clinical significance’’: How many kinds of significance do counselors need? Journal of Counseling and Development, 80, 64–71. Thompson, D. (1994). The sexual experiences of men with disabilities having sex with men– Issues in HIV prevention. Sexuality and Disability, 12(3), 48–56. UNAIDS. (2009). Disability and HIV policy brief. Geneva, Switzerland: Author. Valenti-Hein, D. C., Yarnold, P. R., & Mueser, K. T. (1994). Evaluation of the dating skills program for improving heterosocial interactions in people with mental retardation. Behavior Modification, 18(1), 32–46. Wehmeyer, M. L., & Kelchner, K. (1994). Interpersonal cognitive problem-solving skills of individuals with mental retardation. Education and Training in Mental Retardation and Developmental Disability, 29(4), 265–278. Wells, J. (2011). HIV/AIDS prevention for men with intellectual disabilities. Eugene, OR: National Institute of Mental Health. Wells, J., Clark, K. D., & Sarno, K. E. (2011). A computer-based interactive multimedia program to reduce HIV transmission for women with intellectual disability. Journal of Intellec285
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tual Disability Researech. doi: 10.1111/j.13652788.2011.01482.x Yarber, W., & Torabi, M. (1998). HIV prevention knowledge test for teenagers. In C. M. Davis, W. Yarber, R. Bauserman, G. Schreer, & S. Davis (Eds.), Handbook of sexuality-related measures (pp. 361–364). Thousand Oaks, CA: Sage Publications.
Received 2/13/2012, accepted 9/10/2013.
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Authors: Jennifer Wells, Technology Assistance Institute for Intellectual Disability; Khaya Clark, Technology Assistance Institute for Intellectual Disability; Karen Sarno, Technology Assistance Institute for Intellectual Disability. Correspondence concerning this article should be addressed to Khaya Clark, 1000 Willagillespie Road, Ste 150, Eugene, OR 97401 ([email protected]).
A Multimedia Program to Prevent HIV in Men With ID
EAAIDD DOI: 10.1352/1944-7558-119.3.276
An Interactive Multimedia Program to Prevent HIV Transmission in Men With Intellectual Disability Jennifer Wells, Khaya Clark, and Karen Sarno ‘‘A hallmark of the HIV/AIDS epidemic has been its impact on vulnerable populations.’’ (Groce, 2005, p. 215)
Abstract The efficacy of a computer-based interactive multimedia HIV/AIDS prevention program for men with intellectual disability (ID) was examined using a quasi-experimental within-subjects design. Thirty-seven men with mild to moderate intellectual disability evaluated the program. The pretest and posttest instruments assessed HIV/AIDS knowledge (high-risk fluids, HIV transmission, and condom facts) and condom application skills. All outcome measures showed statistically significant gains from pretest to posttest, with medium to large effect sizes. In addition, a second study was conducted with twelve service providers who work with men with ID. Service providers reviewed the HIV/AIDS prevention program, completed a demographics questionnaire, and a program satisfaction survey. Overall, service providers rated the program highly on several outcome measures (stimulation, relevance, and usability). Key Words: HIV prevention; intellectual disability; interactive multimedia; health promotion
The Centers for Disease Control and Prevention (CDC) continue to follow the HIV/AIDS epidemic in men. A new estimate of the annual number of new HIV infections in the United States shows that the HIV/AIDS epidemic is worse than previously known. At the end of 2009, the CDC estimated that 1,148,200 people in the United States were living with HIV/AIDS (CDC, 2012). Men account for approximately 73% of these cases, and, those most heavily affected by HIV are gay and bisexual men of all races (CDC, 2010). Of new infections, approximately 61% occur in gay and bisexual men, with another 27% occurring through high-risk heterosexual contact (CDC, 2011). HIV/AIDS has been largely ignored in the population of people with intellectual disability (ID). No recent epidemiological studies have been conducted, and there is a paucity of HIV prevalence data on people with ID (Brown & Jemmott, 276
2002; Servais, 2006). Although HIV surveillance efforts among people with disabilities are limited in the United States, estimates from international organizations indicate that people with disabilities have increased risk to HIV exposure (UNAIDS, 2009). Contributing to the susceptibility of men with ID to HIV/AIDS is sexual exploitation by men with and without ID (Sobsey, 1994; Sobsey & Doe, 1991) and the social marginalization of people with ID. Many individuals with ID are sexually active. In the population of adult men with mild to moderate ID, bisexual and homosexual behavior, although underreported, is not uncommon (Servais, 2006; D. Thompson, 1994). In a recent National Institutes of Health Phase I study conducted in the Pacific Northwest, 19% of male participants with ID self-identified as bisexual (Wells, 2011), whereas a national survey conducted by the National Center for Health Statistics
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reported 1.1% of men self-identified as bisexual (Chandra, Mosher, Copen, & Sionean, 2011). Men with ID are not infrequently involved in sexual behavior with other men; however, many are not gay identified. Sex between men who are not gay identified usually involves ‘‘trading favors’’ (Cambridge, 1997; D. Thompson, 1994). This may be evinced in institutions (N 5 46) wherein 89% of facilities report same-sex intercourse between consenting adult males with ID, and 56% of facilities reported same-sex sexual behavior between consenting females with ID (Gust, Wang, Grot, Ransom, & Levine, 2003). Although some same-sex behavior is institutional and out of convenience, some people with ID are gay identified (Allen, 2007). In fact, a relatively new movement, the Rainbow Support Group (RSG), is gaining ground state by state to help ensure people with ID are supported in relation to their sexual orientation (Allen, 2003). The RSG provides a forum in which sexuality and issues such as HIV prevention are discussed. Other studies showed the majority of men with ID who have sex with men are not gay identified; however, they engage in same-sex highrisk behaviors, often with men who do not have ID (Cambridge, 1997; D. Thompson, 1994). Men with ID who have sex with men without ID commonly engage in sexual acts that are emotionally and physically painful; are characterized by extreme power imbalance; and because of their passive aspect, entail unsafe sex practices (B. Thompson, 2002; D. Thompson, 1994). This behavior stands to increase the risk of HIV contraction by men with ID, and in turn, by women with ID who have sex with men with ID (Cambridge, 1996). The limited number of HIV prevention programs for people with ID led to the partial adaptation of an existing computer-based interactive multimedia (CBIM) HIV intervention designed for women with ID (Wells, Clark, & Sarno, 2011). Because the findings from the intervention for women were robust, the intervention was rewritten for men, and it was designed to strengthen male gender norms (Eckman, Huntley, & Bhuyan, 2004) around taking responsibility for their health and well-being through safer sex practices, such as consistent condom usage, or abstaining from sex with partners who are reluctant to engage in safer sex practices. The main adaptation to the program involved rewriting the narrator segments to make the language specific to men, creating new program graphics specific to men, and narrowing the J. Wells, K. Clark, and K. Sarno
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program scope. In the intervention program for women, the duration of the intervention was too lengthy. Therefore, in the intervention with men, content related to HIV testing was not included.
HIV/AIDS Prevention Content The current project was designed to cover the following content areas: (a) transmission of HIV through sexual contact; (b) HIV avoidance strategies (i.e., barriers and abstinence); and (c) taking responsibility for condom usage (i.e., what a condom is, where to purchase, where to store, how to put a condom on a model penis). Across all content areas, a total of 18 interactive items assessed user knowledge and skills. Each item provided correction and remediation for incorrect answers. In the transmission of HIV through sexual contact segment, four HIV/AIDS knowledge domains were addressed: (a) HIV is a virus that causes AIDS, (b) AIDS is a disease for which there is no cure, (c) semen and vaginal secretions are high-risk fluids, and (d) what constitutes sexual behaviors (e.g., activities that involve seminal and vaginal secretions). The first pre-skill to learn about HIV transmission through sexual contact is that the HIV virus is a ‘‘germ’’ that gets in the body and causes AIDS. The second pre-skill required for understanding that HIV transmission occurs through sexual contact is to recognize that sexual behavior consists of activities involving semen and/or vaginal fluid. To define sexual activities such as vaginal intercourse, the program used graphic overlays to highlight the body parts involved (see Figure 1). The program did not show actual sexual behaviors. Voice-over narration described the behavior and which parts
Figure 1. Graphic overlay of the human body. 277
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of the body are involved (i.e., ‘‘Vaginal intercourse is when the penis is on or in the vagina’’). In the HIV avoidance strategies section, the program presented video vignettes, grounded in Bandura’s social learning theory (1986), which showed examples of couples negotiating condom use. The vignettes were tailored to sexual orientation as indicated by program users at the beginning of the program. The three types of avoidance strategies were: (a) take responsibility for condom usage for insertive sex, (b) abstain from receptive sex if a partner is unwilling to use a condom, and (c) leave the situation to maintain a position of abstinence. The final program segment, taking responsibility for condom usage, addressed the physiology of the penis (e.g., discriminating between an erect and partially erect penis), condom use (how to put a condom on a penis), condom storage, and condom removal.
Intervention Design Explicit Instruction and Social Learning Theory The Phase I project, HIV/AIDS Prevention for Men with Intellectual Disabilities, was designed using explicit instruction (Archer & Hughes, 2011). This instructional methodology has been proven efficacious among people with ID (Carnine, 1980; Engelmann & Carnine, 1982; Gersten, White, Falco, & Carnine, 1982; Lockery & Maggs, 1982). The basic principles of explicit instruction are (a) identifying the sequence of skill components, (b) organizing the teaching of the skill components, (c) presenting a range of examples to allow practice of skills, and (d) providing immediate assessment with error correction and remediation as warranted. Bandura’s social learning theory underpins the video vignettes showing couples negotiating condom usage. This approach is characterized as vicarious learning through modeling (Bandura, 1986). Consistent with the HIV intervention for women with ID, the project used a knowledgebased, sociobehavioral skills model (Wells et al., 2011). Although the process for teaching decision making and social skills to people with ID is qualitatively different than the process for people without ID, the fundamental nature of the task is not different (Huang & Cuvo, 1997; Moffatt, Hanley-Maxell, & Donnellan, 1995; Valenti-Hein, 278
Yarnold, & Mueser, 1994; Wehmeyer & Kelchner, 1994). Generally, people with ID have slower cognitive processing skills, so they need more examples and nonexamples to recognize that a decision needs to be made and to communicate that decision in a socially appropriate manner. In the context of high-risk behavior, the ability to (a) recognize high-risk behavior and situations, (b) select an appropriate response, and (c) implement those decisions are all critical components of making responsible, prosocial decisions.
Interface Training Upon program login, a series of screens showed the users the types of interactive teaching items and the meaning of each response option. For example, the computer voice-over stated, On question screens you will be asked a question and then you will be able to use the mouse to answer that question or make a decision. There are several kinds of question screens. Each of these works a little differently. One kind of question screen is the Yes and No screen. This is how a Yes and No Screen looks. This screen has a thumbs-up button, and a thumbs-down button. Thumbs up means yes and thumbs down means no. Watch how it works. At this point in the interface training, a green circle highlighted the ‘‘thumbs up’’ button while the computer voice-over stated ‘‘yes.’’ After this, the ‘‘thumbs down’’ button was highlighted and the voice-over stated ‘‘no.’’ Subsequently, the user was prompted to listen to an example question and then to click on the thumbs up or thumbs down button. Figure 2 shows the green circle that appeared when the voice-over explained the ‘‘thumbs up’’ button. Another type of interactive teaching item was a Likert-type response format designed to assess condom use self-efficacy. In the training, the voiceover stated, Here is another type of question screen. On this type of question, you will be asked to decide how easy or hard something is. See the weight lifters on these buttons? You will use them to tell us what you think. This weight lifter has a very light weight; it is very easy to lift. This button means very easy. If you think putting on your socks is very easy, you would
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interviewer-administered techniques (Borgers, de Leeuw, & Hox, 2000; de Leeuw, Hox, & Kef, 2003).
Program Tailoring
Figure 2. Yes and no response options.
click on this button. This weight lifter has a heavier weight; it is not so easy to lift. This button means not so easy. If you think that putting on your socks is not so easy, you would click on this button. This weight lifter has a really heavy weight; it is really hard to lift. This button means really hard. If you think that putting on your socks is really hard, you would click on this button.
Upon completion of the pretest, the program was tailored by sexual orientation. A computer voiceover asked, ‘‘Who do you think about having sex with?’’ This screen determined the tailoring of the program by sexual interest (heterosexual, bisexual, or gay). Four graphical response options were presented (Figure 4). The image of a man and woman was the ‘‘bisexual’’ response option, the image with a woman was the ‘‘heterosexual’’ response option, the image of a man was the ‘‘gay’’ response option, and the image of an ‘‘X’’ was ‘‘I don’t think about having sex.’’ For those users who chose the latter option, the program presented the bisexual branch. Each branch presented the same factual content. The content was tailored visually according to sexual interest. For example, if a male program user was interested in sex with other men, all on-screen examples and vignettes showed men in relation to other men.
Overview of Studies 1 and 2
A-CASI is a technique in which a recorded voiceover reads questions to research participants. Because of low literacy levels among people with ID, this methodology is useful because no reading is required, and the format fosters more candid reports of sensitive behaviors and topics than
Men with mild to moderate ID (IQ 50–75; Jacobson & Mulick, 1996; The Arc, n.d.) completed the one-time intervention at the Principal Investigator’s (i.e., Jennifer Wells) research institute. After the evaluation with men with ID was completed, 12 service providers who work with men with ID were recruited to review the program and complete a demographics questionnaire and a professional customer satisfaction survey. Service providers were sent a copy of the program and measures to complete during a time most convenient
Figure 3. Likert-type response options.
Figure 4. Program tailoring response options.
In Figure 3, the bottom left circle indicates the ‘‘very easy’’ response option.
A-CASI Pretest and Posttest
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for them. Because the research activities for the two groups of participants were qualitatively different (i.e., within-subjects intervention for men with ID, and professional review of the program to assess usability), the results from each are presented as Study 1 and Study 2, respectively. In Study 1, the primary research question was, Is there a difference in research participant scores from pretest to posttest? The main research question in Study 2 was, Will service providers rate the program highly on all outcome variables?
Study 1 Method Participants. A convenience sample of 37 men with mild to moderate ID (Jacobson & Mulick, 1996) was recruited to participate in the evaluation by vocational and residential agencies serving people with ID. All research participants were from the Pacific Northwest. The racial and ethnic composition, residence type, employment, and relationship status of the research participants are shown in Table 1. The Oregon Research Institute Institutional Review Board approved the evaluation protocol prior to implementation. All research participants signed an informed consent statement.
Table 1 Demographic Characteristics Hispanic/Latino
N
%
1
2.7
3
8.1
1 26 4 3
2.7 70.3 10.8 8.1
11 26
29.7 70.3
28 7 2
75.7 18.9 5.4
Race American Indian or Alaskan Native Native Hawaiian or other Pacific Islander White Other Did not know race Type of residence Semi-independent Independent Relationship status Single Living with a partner Married
280
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Of those employed, 48.6% worked in sheltered employment, 13.5% worked in supported community jobs, 2.7% worked in independent community jobs, and 35% indicated some other type of employment. In terms of sexual orientation of the sample, 19% were bisexual, 3% were gay, 65% were heterosexual, and 14% indicated that they don’t think about having sex. Twenty-six percent said the last time they had sex they used a condom, 67% said the last time they had sex they did not use a condom, and 7.4% did not answer the question. Sixty-seven percent said they never talked to their partners about AIDS, 19% said they almost never did, 11% said they talked about it all the time, and 3% did not answer the question. Procedure and Setting. Men with ID were recruited through local agencies that serve people with ID. The study was a one-time event conducted at a research institute in Eugene, OR. Project staff administered informed consent. After providing in-person consent, research participants completed all evaluation activities. Research participants wore headphones as they used the interactive program. All 37 participants provided pretest and posttest data. Total participation time in the evaluation was approximately 1.5 hr. Upon completion of the evaluation, research participants were compensated $35.00 for their time. Measures. Research participants completed a 44-item structured interview and a 33-item ACASI pretest, watched the interactive computer program, and completed the A-CASI posttest and user satisfaction survey. The structured interview was composed of 44 questions related to sexual practices (e.g., How many partners do you have?), frequency of condom use, condom knowledge (e.g., Where are safe places to store condoms?), and condom application skill. In the condom application skill section, research participants were asked to demonstrate the steps associated with opening a condom package and putting a condom on a realistic model penis. The condom application skill was assessed with six items scored as either correct or incorrect by the interviewer as the participant put a condom on a model penis. Condom application also included one follow-up question (i.e., Can you use the same condom you’ve already used to have sex again?). The response options were ‘‘Yes,’’ ‘‘No,’’ and ‘‘I don’t know.’’ The number of correct items endorsed for each domain was summed and divided by the number of items to indicate proportion correct.
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The A-CASI pretest and posttest consisted of 33 items developed by other researchers in the HIV/AIDS field. Items from the Handbook of Sexuality-Related Measures (Davis, Yarber, Bauserman, Schreer, & Davis, 1998), HIV-Knowledge Questionnaire (Carey, Morrison-Beedy, & Johnson, 1998), A Measure of AIDS Prevention Information, Motivation, Behavioral Skills, and Behavior (Misovich, Fisher, & Fisher, 1998), the Multidimensional AIDS Anxiety Questionnaire (Snell & Finney, 1998), and the HIV Prevention Knowledge Test for Teenagers (Yarber & Torabi, 1998) were used. Both items and answer choices were adapted to interactive multimedia video format. The A-CASI pretest assessed knowledge in six domains. Six items assessed basic HIV knowledge (e.g., Can the HIV virus be cured?); five items assessed high-risk fluids (e.g., Can you get the HIV virus from blood?); seven items assessed HIV transmission (e.g., Can someone get the HIV virus from having oral sex?); and six items assessed condom facts (e.g., When do you need to use a condom?). Response options included ‘‘Yes,’’ ‘‘No,’’ and ‘‘I don’t know’’ for basic HIV knowledge, highrisk fluids, and HIV transmission. Response ranged from two to five options for condom facts. The number of correct items endorsed for each domain was summed and divided by the number of items to indicate proportion correct.
Results A within-subjects quasi-experimental design was used to analyze the feasibility of the interactive program. Paired t tests were used to examine pretest to posttest gains in study outcomes. A partial pointbiserial correlation coefficient, r (Rosenthal & Rosnow, 2008), computed as the square root of the t value squared divided by the degrees of freedom, was used to compare effects across the measures, using the conventions small (r 5 .14), medium (r 5 .36), and large (r 5 .51). Results of the paired t tests (see Table 2) show significant pretest to posttest gains for all domains assessed, with an average effect size of .67, a large effect. The percent increases, shown in the last column, from pretest to posttest were 14% (knowledge of high-risk fluids), 19% (condom use), 23% (basic HIV knowledge), 31% (condom application), 52% (HIV transmission), and 71% (condom facts). Program satisfaction, assessed at posttest, showed that 97% of the men with ID said they J. Wells, K. Clark, and K. Sarno
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liked the program; of those, 58% said they liked the program a lot. A majority of the men (70%) indicated that they learned something new from the program; the program was very ‘‘easy to use’’ (76%); the speed of the program was ‘‘just right’’ (84%); the length of the program was ‘‘just right’’ (57%); they would like to use the program more (92%); and thought their friends would like to use the program (78%). Finally, most participants indicated that none of the pictures (87%) or the language (97%) embarrassed them. The average time that research participants viewed the program was 90 minutes.
Study 2 Method Participants. Twelve professionals serving people with ID (vocational and residential programs, The Arc, brokerages and state and county agencies) in California, Oregon, and Washington completed the evaluation. Fiftyeight percent were women and 33.3% were men, and the gender of one provider was missing (8.3%). Three providers were Latino, and the rest were non-Latino (75%). The racial composition of the sample was 75% White, 8.3% Black, and 16.7% other. Fifty-eight percent identified their work area as vocational service provider, 17% as personal assistant/advocate, 8% as residential program worker, and 17% as ‘‘Other.’’ Their experience with sexually active men with ID ranged from 1.06 to 20 years (M 5 6.74, SD 5 5.91), and the average number of sexually active men in their caseloads was 6.74. Procedure and Setting. Professional participants were recruited via flyers sent to organizations serving people with ID. Professionals either e-mailed or called to get a full explanation of the research activities related to their review. After the verbal explanation, potential participants were mailed an informed consent and a demographics form with a self-addressed stamped envelope to facilitate return. Once the informed consent and demographics form were returned, participants were considered officially enrolled. Research staff mailed participants a program satisfaction survey and a copy of the interactive program. Service providers were instructed to complete the program satisfaction survey after they reviewed the interactive program. All professionals viewed the program at home on personal computers. This was a one-time event. Total participation time was 281
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Table 2 Descriptive Statistics and Paired T-tests Pretest
Posttest
Test statistics
Mean
SD
Mean
SD
t-value
p-value
r
% increase
.703 .692 .532 .552
.186 .209 .237 .202
.867 .789 .907 .839
.193 .081 .151 .210
4.47 2.64 11.37 7.03
,.001 ,.012 ,.001 ,.001
.59 .40 .88 .76
23 14 71 52
.726 .559
.152 .228
.865 .731
.089 .240
6.92 4.94
,.001 ,.001
.75 .63
19 31
ACASI HIV basic knowledge High-risk fluids Condom facts HIV transmission Structured interview Condom use Condom application
approximately 1.5 hr. Service providers were mailed a $75.00 check to compensate them for their time. Measures. Professional participants completed a demographics questionnaire and program satisfaction survey. The demographics questionnaire consisted of questions pertaining to gender, ethnicity, race, primary work area, years of experience, and current caseload of sexually active men. In addition, we asked whether their clients expressed concern about HIV/AIDS, and how concerned the professionals were about the possibility of clients contracting HIV/AIDS. The program satisfaction survey consisted of 50 questions in both quantitative and qualitative formats. Questions covered ease of use of the program and five areas of user satisfaction: stimulation, comprehension, relevance, persuasiveness, and usability.
Results On the demographics questionnaire, 67% said their sexually active clients were ‘‘not at all’’ or ‘‘very little’’ concerned about HIV/AIDS. However, all of these professionals were either ‘‘somewhat’’ or ‘‘very’’ concerned about their clients contracting HIV/AIDS (33.3% and 58.3%, respectively). All the reviewers rated program ease of use very highly. Those who used the mouse and interface training sections of the program thought they would be ‘‘very’’ to ‘‘somewhat’’ effective. Eighty-eight percent said that the sequence of the presentation of information was logical and that it was ‘‘very’’ (58.3%) or ‘‘somewhat’’ (8.3%) easy to navigate through the program. All thought that responding to the questions in the program was 282
either ‘‘very clear’’ (33.3%) or ‘‘mostly clear’’ (50%). Several reviewers commented that the program seemed too long. The questions related to relevance involved a series of queries pertaining to the actors used in the program, the extent to which clients might identify with the actors, and whether providers would recommend the program to other providers. Seventy-five percent said the men in the program seemed real, and 75% thought they sounded very natural. Eighty-three percent thought their clients would ‘‘very much’’ to ‘‘somewhat’’ identify with the men in the program. Eighty-three percent said the language was appropriate, and 83.3% did not believe the program was too graphic or explicit. Most of the professional reviewers (83%) said they were very likely to somewhat likely to use the program with their clients. In terms of stimulation questions, all of the professionals liked the program. Typical comments made concerning an overall impression of the program were, ‘‘Very impressive in its scope, content, relevancy and more importantly, in its ease of use!’’ Thirty-three percent believed that most of the men they serve would like the program, 58.3% said the program would very much grab the interest of their clients, and 83.3% felt the program would keep their interest. Finally, 83% of service providers said their clients would understand the information in the program. Overall, most providers believed the scope of the program was ‘‘just about right.’’ All thought the program addressed important issues, and 83.3% thought that HIV/AIDS education was ‘‘very important’’ for their clients. When asked for their final thoughts, a typical comment was,
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‘‘Great job. Thanks for your work! I am so glad that someone is addressing the issue of safer sex.’’
Discussion In the field of interactive multimedia for people with ID, this program is unique in that it was tailored by sexual orientation, which served to normalize, rather than stigmatize, the expression of sexuality outside of heterosexual relationships. In addition, the program emphasized mens’ responsibility for their own sexual health by including messages to promote the reduction of sexual risk taking (e.g., consistent condom usage). Results from the evaluation of the program by men with ID indicate that the program was effective in increasing HIV/AIDS knowledge, including high-risk fluids, HIV transmission, condom facts, and condom application skills. Given the relatively small sample size, coupled with the short duration of the intervention, the effect size estimates indicate that this study has both statistical and practical significance (B. Thompson, 2002). This is the second study conducted by the research team on HIV prevention for people with ID, and the results from both interventions suggest that a single-dose multimedia intervention for people with ID can positively affect both HIV knowledge and skills. These preliminary findings on the use of interactive multimedia for healthbased interventions for people with ID are particularly important given the increasing use of the Internet for health-related information (Cohen & Adams, 2011). The use of video, interactive teaching items, and audio voice-overs would allow users with low literacy levels to access complex health information. This project’s use of instructional training on the interface and item types has the potential to make interactive computer programs accessible to a wide range of users with different levels of computer experience. Findings from the evaluation of the program by service providers were equally robust. Specifically, it was encouraging that 83% of service providers believed that program content would be comprehensible to their clients. This is important because there are few existing health promotion programs designed for people with ID (Shogren, Wehmeyer, Reese, & O’Hara, 2006) and their caregivers. The program was designed for individual use or for group-based administration, making it a useful tool for caregivers who are in need of HIV prevention resources. The use of interactive J. Wells, K. Clark, and K. Sarno
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technology could be applied to other areas in which people often need skill training to achieve independence: employment, housing, transportation, and healthy aging. Within the context of supports for service providers and advocates, interactive programs could be used as a diagnostic tool that would reveal a client’s gap in knowledge or skills, thus providing information on the areas in which additional supports are needed.
Implications and Future Directions It is evident from our data, that CBIM is an efficacious method for teaching people with ID potentially life-saving information such as HIV/ AIDS prevention. The programs discussed in this paper are being used in and around Harare, Zimbabwe with all populations, not just people with ID. In settings where learners are not English speaking, the audio is translated through an interpreter into the native language of that region. The text-free nature of the programs allows all people to see and understand concepts being discussed in the program. According to a report issued by the TAAP Zimbabwe Project (A. Guma, personal communication, November 6, 2012), the program had been viewed by more than 1,100 individuals during October 2012, garnering ‘‘overwhelming support’’ from local community members and leaders. TAAP is very pleased with the software as it makes it easier for them to present information on HIV/AIDS prevention using a method that engages the learners, and is effective. Another benefit of CBIM is the ability to tailor program content to the specific needs of individual learners. For example, learners who make errors on interactive items receive immediate on-screen remediation followed by another opportunity to answer the question. Learners who do not make errors receive immediate positive feedback and move forward to the next item or content movie. This type of tailoring allows educators to see areas in which a learner might need more support. Tailoring by user preference (i.e., ‘‘who do you like to have sex with’’) personalizes the message and presents all content free of bias, which can be difficult to accomplish through person-to-person discussions about sex and sexuality. For older adults with mild to moderate ID, CBIM has been overlooked as a teaching tool. Our studies show that older adults with ID are indeed capable of using a computer and enjoy the 283
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experience. Youth with ID are exposed to computers during the school years. Thus, there is a need to develop interactive CBIM curricula that encompass the range of experiences people with ID are likely to encounter in community settings. There are many areas—including life skills, self-care, problem solving, health and wellbeing, aging-related issues, and independent living—for which CBIM is an appropriate and efficacious medium for teaching people with ID to achieve independence in all life areas. Future research should include the development of CBIM teaching programs and the testing of interactive teaching programs on tablet and smartphone technologies. As increasing numbers of people with ID purchase these devices, they should be considered viable venues for furthering the personal growth of people with ID across the lifespan.
Limitations One notable limitation of the present investigation is related to generalization. Research participants had mild to moderate ID, which makes it impossible to know whether interactive technology would be appropriate for populations with severe to profound ID. Future research can replicate these methods with a more varied sample of people with ID to explore whether knowledge and skill patterns presented here hold true or are dependent of IQ range. Another important limitation of this study is lack of data on knowledge and skill maintenance over time. To adequately capture the efficacy of multimedia technology as a pedagogical tool to support health, well-being, and independence over the life course requires more longitudinal research.
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Received 2/13/2012, accepted 9/10/2013.
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Authors: Jennifer Wells, Technology Assistance Institute for Intellectual Disability; Khaya Clark, Technology Assistance Institute for Intellectual Disability; Karen Sarno, Technology Assistance Institute for Intellectual Disability. Correspondence concerning this article should be addressed to Khaya Clark, 1000 Willagillespie Road, Ste 150, Eugene, OR 97401 ([email protected]).
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