1. use of evaluation findings and midcourse corrections; and
  2. sufficient resources.

The study's authors also concluded that some behaviorally based prevention programs are cost saving, and others are likely to be cost-effective relative to other health programs.

Theoretical Approaches to STD and HIV Risk Reduction

A number of theoretical approaches drawn from the social and behavioral sciences have been employed in developing STD prevention interventions (Cleary et al., 1986, 1995). These models were derived from efforts to promote change in nonsexual health-risk behaviors, such as smoking cessation, cardiovascular risk reduction, and cancer prevention. The dominant model guiding most STD prevention interventions has been social learning theory (also referred to as social cognitive or cognitive-behavioral theory), originally proposed by Bandura (1977). This approach postulates that specific skills are needed to alter risk behaviors. These skills can be imparted through modeling, rehearsal, or practice opportunities. Behavior change interventions have heavily focused on training participants in condom use skills, sexual assertiveness, safer sex negotiations and communication strategies, and self-management skills to deal with situations that might trigger vulnerability to high-risk sexual behavior (Kelly, 1994). Other theoretical approaches that are appropriately focused on the individual-level determinants of high-risk behavior and behavior change include the Theory of Reasoned Action (Ajzen and Fishbein, 1980) and the Precaution-Adoption Process (Weinstein, 1988).

At the community level, one approach that has been very popular over the past decade in STD prevention has been the "stages of change" formulation mentioned previously (Prochaska and DiClemente, 1983). This approach was originally developed to explain the process of changing health habits, primarily smoking, and postulates that people are at varying levels of readiness for change. Understanding the different levels of readiness for each person allows tailoring interventions that can successfully move the individual further along the continuum of change—towards action and then behavioral maintenance. While this approach has been widely discussed in the literature (Catania et al., 1990; O'Reilly and Higgins, 1991), there have been few empirical demonstrations of its utility in influencing behavior change at the community level.

Community-norm-change models that focus on influencing social or peer group norms regarding sexual behavior have proven particularly appropriate in studies of sexual risk practices of adolescents, heterosexual adults, and gay men. One approach for producing normative change at the community level is the "diffusion of innovation" model (Rogers, 1983) in which normative change attributable to advocacy by key, popular "opinion leaders" leads to accepted new



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