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Qualitative research is broadly defined as a set of interpretative, material practices that make the world visible by turning it into a series of representations (e.g., field notes, observations, interview recordings) through the study of things in their natural settings (1). In sexually transmitted infection (STI)/HIV research, qualitative research is the study of the words and the significance of certain behaviors and seeks to answer why people practice certain behaviors and to describe the social organization of sexual interactions. Qualitative data are words such as those collected verbatim in interviews or as transcribed in observation notes. This is to be contrasted with research, which is the study of numbers and often focuses on “how many” people practice “which different behaviors.” The aim of quantitative research is to find numerical patterns in responses to survey questionnaires or observed behaviors, the results of which indicate the magnitude of people's decisions and behaviors and how these are distributed across a study population. Both quantitative and qualitative research are essential to study the complex factors that sustain and feed STI epidemics throughout the world and work together to design interventions that change the course of such epidemics by reducing transmission. This chapter will examine how qualitative methods are applied within STI/HIV research; outline the main types of qualitative research approaches used in STI/HIV research, including advantages and disadvantages of each application; and discuss different sampling approaches. Contemporary examples of each method are given throughout.

While program evaluation is widely recognized as a core function of public health, differences in definition of “good evaluation practice” often lead to evaluations that are time consuming and expensive, and, most importantly, produce findings that are not employed for program improvement. This chapter offers simple, systematic guidelines to maximize the likelihood that the time and effort to evaluate will be translated into program improvement. The goal that findings be used for program improvement is fundamental to the discipline of program evaluation. An old adage says it best: “Research seeks to prove; evaluation seeks to improve.” And evaluators have responded with a variety of approaches/frameworks whose central premise is “utilization-focused” evaluation—that no evaluation is good unless its results are used (1,2). This chapter emphasizes how early steps of a good evaluation process can build the conceptual clarity about the program that is needed to choose the right evaluation focus. It reinforces these points with case-specific advice for those doing STD interventions.

Programs can be “pushed” to do evaluation by external mandates from funders or authorizers or they can be “pulled” to do evaluation by an internally felt need to examine and improve the program. STD programs are likely no different. State and local STD programs are pushed to evaluate by a mix of evaluation mandates in cooperative agreements or foundation mandates—which in turn reflect demands on foundations by their boards or on funding agencies like the Centers for Disease Control and Prevention (CDC) by the Office of Management and Budget and the Government Performance and Results Act (GPRA) and Performance Assessment and Rating Tool (PART) processes. Using the STD world as an example, CDC's Division of STD Prevention (DSTDP) now explicitly lists program evaluation as an essential activity within the Comprehensive STD Prevention Systems (CSPS) framework, and recent DSTDP Performance Measures Guidance (3) commits CDC's efforts to measuring performance and aligning with goals. This CDC emphasis is translated into pressure on states to evaluate; the Program Operations Guidelines require that programs monitor progress toward achievement of goals and objectives (4).

Cost-effectiveness analysis (CEA) is a commonly used tool to evaluate health care interventions. This chapter will introduce CEA, define it, and describe its limitations and its importance for analyzing behavioral interventions in HIV and STD prevention. The procedures used in conducting CEA and several examples follow.

During the past two decades, especially the years between 1985 and 1995, significant advances have been made in the development of behavioral interventions aimed at the reduction of high-risk behaviors associated with the transmission of sexually transmitted infections (STI) (1). The scientific effort that produced these interventions and demonstrated their efficacy was in large part driven by the advent of HIV infection and the incurable nature of this condition. Nonetheless, many of these interventions have considerable relevance for the prevention of STIs other than HIV. However, while the potential importance of these interventions has been recognized by the academic and public health communities, and while substantial resources have been devoted to the dissemination of these interventions into prevention practice, there is a general consensus that widespread adoption has been lacking in STI/HIV programs thus far. Apparently, changing the behaviors of prevention providers to adopt these interventions is as difficult, or perhaps even more difficult, than changing the behaviors of individuals for which the interventions were designed. At the same time, the incidence of HIV infection in the United States is stagnating at an unacceptable level of 40,000 new infections per year (2). An increasing proportion of these infections is occurring in minority populations and in women (3). While gonorrhea and syphilis rates are falling in general (4), the resurgence of these infections among men who have sex with men (MSM) (5,6) is troublesome and has instigated fears over an increase of HIV incidence in this population (7). Together, these trends have called for a re-examination of prevention strategies and the development of new interventions, as well as the revisiting of traditional models. For example, as HIV disease becomes increasingly manageable (and HIV-infected persons live longer and are infectious for longer periods of time), the focus of prevention efforts is changing from the prevention of HIV acquisition to the prevention of HIV transmission by infected persons through early detection and treatment (2). There are good reasons for such a shift in prevention focus; however, it would be unfortunate if such a change would come to the detriment of the remarkable progress that has been made in behavioral prevention research. Furthermore, it is doubtful that diagnosing and treating HIV infections will by themselves lead to a sufficient reduction in continuing HIV transmission and thus behavioral interventions aimed at those living with HIV infection will be necessary. Therefore, rather than using the lack of adoption of behavioral interventions as a reason to dismiss such interventions as impractical, the of adoption itself should be explored to identify ways that may lead to improvement.

The purpose of this chapter is to describe the process by which identified model behavioral interventions and best practices are disseminated and ultimately adopted by providers of STI/HIV prevention services. In this process, a number of phases are recognized: 1) identification of interventions with proven efficacy; 2) replication and demonstration; 3) dissemination and scale-up; 4) adaptation; and 5) maintenance. Each of these phases will be examined in detail below, along with an appraisal of how an efficacy-focused linear dissemination process versus a circular effectiveness-focused approach may impact the adoption of the intervention at the provider level and thus the potential benefits of behavior change in the at-risk population. Two (related) case studies will be used to illustrate the process (see text box).

The goal of public health is to promote the health of all persons for the good of the entire population. While this is a straightforward intention, in practice, public health regularly raises ethical dilemmas that result primarily from conflicts between individual interests and community interests. With respect to sexual health, ethical public health practice is made all the more challenging by the private nature of sexual behavior, and by the social stigma associated with many sexual practices and sexually transmitted diseases (STDs).

This chapter provides an overview of the ethical topics that arise in STD prevention and control, in order both to heighten awareness and understanding of these issues and to provide readers with some guidance for articulating and exploring these issues. We examine the ethics of STD prevention and control in both public health practice and in the delivery of health care. Here, we circumscribe public health practice as the set of activities intended to improve the health of a specific community or population by preventing or controlling disease (1–3). We define delivery of health care as the provision of preventive and treatment services to individuals, including the use of screening and diagnostic tests and the implementation of vaccination programs (4,5).

Policy making in public health is a multidisciplinary activity that has a major impact on how public health problems are addressed. While most assume that relevant science should form the basic foundation for development of public health policy, the way that connection is bridged and how the science is interpreted are frequently influenced by the political arena within which they exist. STD prevention and reproductive health are not immune to this reality.

This chapter will first describe and define the core functions of public health, which provide a critical context for policy making. The basis and specific domains of policy making and how they relate to preventing STDs will be explored, using case study examples to highlight specific points. The interface of science and policy making and the political arena within which they function will also be woven into the discussion.