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Data observation and cross-section analysis reached the following statistical conclusions. First, the information system development cost, had a positive correlation with the loan and bills discounted in each bank, and the total assets. Second, internal system development personnel and the system operation personnel were not always accorded the privileges of other sector personnel. Therefore, there were few possibilities for these personnel to move between banks through the labor market. Finally, banks with independent strategy, which do not take the guidelines from the Bank of Japan and governments into account, invest in information systems more positively accompanied with the increase of the loan arid bills discounted and the total assets than banks of the dependent type.

The following is a correction for a typographical error in Chapter 12: Chap. 12 P. 285, line 21, the sentence “Overall, 62% of high school students had sexual intercourse before the age of 13, a decrease from 1991.” should read “Overall, 6.2% of high school students had sexual intercourse before the age of 13, a decrease from 1991.”

STDs comprise a wide variety of pathogens, including viruses, bacteria, fungi, and protozoa, along with an equally broad range of clinical manifestations, from mild infections localized to the genitalia to more serious diseases affecting reproductive health, the central nervous system, heart, or the immune system. The fundamental reason for placing these diverse biological agents and their sequelae under the same category of STDs is that they share a common mode of transmission—that is, a common human behavior. Given that the category of STDs is defined according to a common behavior rather than a common biological pathogen or sequela, one would expect behavioral interventions to have been at the center of historical and current strategies to prevent and control STDs. Historically, however, the opposite has been true: compared with epidemic infectious diseases such as plague and cholera, which garnered significant public health attention, STD control was relegated to private physicians and largely ignored by public health officials, except for behavioral efforts aimed largely at “marginal” groups such as prostitutes or military personnel. This chapter explains why behavioral interventions for STD control have been a relatively neglected area of public health programs.

It should be noted that the term “behavioral interventions” has come into use relatively recently (since the 1980s), while behavioral science itself is a 20th-century creation. To avoid the anachronistic practice of imposing modern categories onto the past, it is important to explain past practices within their own historical context. The categories that people in the past used to describe and explain their STD prevention and control activities often developed from fundamentally different conceptions of disease transmission, public health, and human behavior. I have retained the original language (the “pox” instead of syphilis, if that was the term commonly used) to underscore the need to understand disease control efforts in context. Similarly, depending on the context, I will refer to the historic terminology used to characterize populations, groups, behaviors, and diseases, such as prostitutes rather than commercial sex workers.

Adverse health consequences from sexual behavior, such as infections with STDs, are conservatively estimated to be at least threefold higher in the United States than in any other developed country (1). This disparity in disease prevalence and the serious personal, social, and financial consequences of sexually transmitted infections are generating a growing body of literature that describes the development, implementation, and evaluation of behavioral interventions addressing STD/HIV prevention. These interventions are designed to inform, change attitudes and perceptions, modify social norms, promote sexual health and reduce risky behaviors, transform social contexts, and alter policies that are facilitators or barriers to healthy behaviors. However, a careful review of the literature reveals that exhortations to intervene and recommendations for interventions far outnumber credible interventions that have been subjected to a thorough statistical evaluation demonstrating their effectiveness.

Up to the present, interventions for STD/HIV prevention have been implemented primarily at the individual, small-group, and community-levels, with varying degrees of population coverage associated with these efforts (2). A source of confusion for many consumers of this research is that not all of these intervention efforts are correctly labeled as “behavioral” interventions. Intervention strategies that are described in the literature can range from atheo-retical to theoretical; from straightforward information provision to complex multi-method, multi-component programs; from minimally to rigorously evaluated; and from individual to multilevel programs. Some may be grounded in beliefs about how things should work in the real world; others are empirically grounded in evidence about how things actually happen. The objective of this chapter, then, is to describe and evaluate theoretical approaches to behavior change; to review the basic structure of behavioral interventions; and to summarize interventions conducted at various individual, group, and community levels.

Biomedical interventions for STD are not new. In fact, the 19th century discoveries related to syphilis in large part presaged the biomedical model of intervention. Three major discoveries at the dawn of the 20th century set the stage for subsequent medical advances: the identification of as organism responsible for syphilis; a complement fixation blood test that could diagnose the presence of the organism; and the identification by Paul Ehrlich of an arsenical, salvarsan (though not the magic bullet hoped for), that could kill the organism (1). Subsequently, the availability of penicillin and the publication of Surgeon General Thomas Parran's “Shadow on the Land” contributed to the national effort to control syphilis transmission, supported by the National Venereal Disease Control Act (1938), the model for modern public health interventions based on the biomedical model. However, as this book demonstrates, the array of available interventions aimed at preventing and controlling sexually transmitted infections (STIs) now include many other non-medical approaches. Nevertheless, in many ways biomedical interventions are still the critical mainstay of prevention, and new biomedical approaches are constantly being evaluated and added to the armamentarium.

In considering biomedical interventions, we have found that the Anderson-May equation, = , serves as a useful framework (2). In this construct, , the reproductive number, is the average number of secondary cases associated with an index case; is the measure of transmissibility, given exposure; is the average number of susceptibles exposed during the period of infectivity; and is the average period of infectivity. Although biomedical interventions may affect any of these transmission parameters, two of these, —duration of infectivity, and b—transmissibility, are most directly affected and are the focus of this chapter. Some aspects of are addressed by biomedical interventions (e.g., vaccines); however, this parameter is primarily affected by sexual behaviors that are addressed elsewhere in this book.

STD/HIV prevention efforts, including education, information, and counseling, have frequently been used to motivate individuals to reduce their risk behaviors. Many of these prevention approaches are drawn from theories that link risk behavior to individual psychological processes such as cognition, beliefs, attitudes, self-efficacy, and perception of risk (1). Although these approaches can help individuals initiate risk-reduction steps and make short-term changes in their risk behaviors, most individual beliefs, attitudes, and, ultimately, behaviors are influenced by the larger environmental and community contexts within which they reside (2). Therefore, long-lasting maintenance of protective behaviors is likely only when peer group social norms, relationships, the environment, and public health policies support personal behavior change effort (2,3). Thus, prevention may also target the community, or special groups of individuals at higher risk for, or more vulnerable to STD/HIV (4). This chapter will focus on and provide examples of STD/HIV interventions that target couples, small groups, and communities.

The term “structural intervention” is a relative newcomer to a longstanding mode of implementing changes beyond the individual in order to change health behaviors and health outcomes. As such, there remain variations in the precise definition of the term. In 1995 there was increasing use of the term applied to HIV/AIDS interventions. Sweat and Denison (1) differentiate structural levels of causation from other macro-levels in that structural interventions influence laws, policies, and standard operational procedures implemented through activism, lobbying, and changes in policy. Interventions that they review pair structural-level intervention with those that are environmental (influencing living conditions, resources and opportunities, and recognition of other levels of causation). O'Reilly and Piot (2) portray structural intervention as synonymous with “enabling approaches” (3). These are defined as interventions that change the social or physical environment to enable changes in determinates of risk. Interestingly, this is categorized as environmental intervention by Sweat and Denison (1). O'Reilly and Piot (2) differentiate structural interventions from other interventions including the community level, described as those pertaining to a fixed geographical area. More recent writers have included community-level interventions as a type of structural intervention (4). Thus, there is clearly disagreement in the limits of what may be considered a structural intervention.

Some of the difficulties in finding a clear definition of structural intervention are reflections of the multi-disciplinary aspects of public health, where different theoretical frameworks and terms refer to similar concepts (5). In addition, structural interventions may be linked to other levels of intervention either directly or indirectly. For example, implementation of a national immunization program might be considered a structural intervention because of the policy and organizational changes. However, this same intervention is dependent on 1) a biomedical intervention preventing infection by increasing host resistance to infection by altering biological factors; 2) community-level intervention using messages to increase vaccination acceptability; and 3) individual level intervention involving patient care by health care providers, and so on. These latter three interventions may have been developed independently through research, indirectly instilling a multi-level approach to the program, or implemented as part of the structural intervention directly, as part of a multilevel intervention program.

Behavior change is an effective strategy in curbing the spread of sexually transmitted infections (STIs). As a first step, we must communicate healthful behaviors to the public. Unfortunately, research has repeatedly shown that knowledge alone is not always enough (1–3): Being aware of a healthful behavior does not necessarily translate into engaging in it. Sexual behavior, in particular, has strong social components that involve a web of social relations, expectations, issues regarding confidence in one's abilities, beliefs about risk, and the perceived severity of STIs and their sequelae. Therefore, a successful prevention campaign must not only be educational, but also persuasive.

The goal of changing sexual behaviors is to ultimately decrease the rate of disease transmission. Transmissibility can be decreased by correct and consistent condom use, delaying the initiation of sexual activity, mutual monogamy, decreasing numbers of sex partners, no concurrency, and promoting use of available vaccines against STIs (e.g., hepatitis B) (4). Duration of infectious-ness can be reduced by promoting rapid health evaluations for symptoms of STI and by screening high-risk asymptomatic populations. Therefore, to decrease the rate of spread, we have to target social behaviors explicitly by using persuasive communication to instill behavior change. This approach is at the core of disease prevention—halting the spread of communicable diseases (whether curable, incurable, or chronic) by changing behaviors as a primary prevention strategy, or changing behaviors after infection to prevent further spread. In both instances, social marketing, concretely based on researched theories of behavior change, is a necessary step in order to maximize effectiveness of prevention campaigns.

Partner notification (PN) for STDs is widely acknowledged as a cornerstone of STD control, although suitable evaluation data are generally sparser than one would like for programs of national scope. The basic rationale for PN is that the sex partners of patients infected with STD ought to be notified of their exposure to STD, followed by evaluation and treatment (1). Public health professionals (provider referral) or infected patients (patient referral) are the two principal groups of people through which partners can be notified. Ideally, notification is accompanied by various forms of education and counseling pertaining to disease and means of exposure (1–3). Education and counseling, however, are by no means assured.

We begin this chapter with a description of PN history and current practice in the United States and review studies of its effectiveness to provide context for the interventions we describe in subsequent sections. After background comments, the chapter is organized around interventions requiring public health professional involvement followed by interventions that do not. Although the main focus of the chapter is on PN in the United States, we have not ignored studies conducted elsewhere.

Much of the time, the popular construction of health care is reactive—a woman is hit by a car, the ambulance arrives within a certain time, the medics have suitable training, and the hospital has the staff with the necessary skills and the best equipment for them to use. But, as the old proverb reminds us, an ounce of prevention is worth a pound of cure. Routine health Care–Seeking and provision is part of that ounce, and sexual health care, here, mainly for disease or infection control, is part of high-quality comprehensive health care (1,2).

For this chapter, we will focus on sexual health Care–Seeking and provision both in the sense of a recommended routine event (e.g., a yearly check-up) and as a reaction to suspicion of a sexually transmitted infection or disease, includ ing human immunodeficiency virus (HIV) infection. HIV transmission pres ents perhaps the most critical rationale for improved health Care–Seeking and provision because unrecognized HIV infection persists in part due to lack of routine testing (3) and, in turn, increases the risk of complications and further transmission. We also include studies from the perspectives of the provider and system, as well as the patient, so some interventions covered herein opti mized health Care–Seeking through improving access and availability.