1. Love, sex, and Choices- Soap Opera Video Episodes Streamed to Smartphones in a Randomized Controlled Trial to Reduce HIV Sex Risk in Young Urban African American/Black Women
Rachel Jones, PhD, RN, FAAN, Northeastern University
Donald R Hoover, PhD, MPH, Rutgers, University
Lorraine Lacroix, MPH, Northeastern University

2. This research was supported by:
National Institute of Nursing Research R01NR10860
National Library of Medicine G08 LM008349
Healthcare Foundation of New Jersey

3. HIV/AIDS in Women IN THE UNITED STATES

4. In 2009, the majority of diagnosed HIV infections among females aged 13 years or older were attributed to heterosexual contact for all age groups. However, the percentages attributed to heterosexual contact decreased as age group increased. An estimated 17.9% of diagnosed HIV infections among females aged 45 years and older were attributed to injection drug use, compared with 9.6% in females aged 13–19 years, 10.0% in females aged 20–24 years, 13.0% in women aged years, and 15.9% in women aged years. The following 40 states have had laws or regulations requiring confidential name-based HIV infection reporting since at least January 2006: Alabama, Alaska, Arizona, Arkansas, Colorado, Connecticut, Florida, Georgia, Idaho, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Michigan, Minnesota, Mississippi, Missouri, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, West Virginia, Wisconsin, and Wyoming. The 5 U.S. dependent areas include American Samoa, Guam, the Northern Mariana Islands, Puerto Rico and the U.S. Virgin Islands.
Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data have been estimated. Estimated numbers resulted from statistical adjustment that accounted for reporting delays and missing risk-factor information, but not for incomplete reporting.
Heterosexual contact is with a person known to have, or to be at high risk for, HIV infection.

6. Formative Studies
Women had unprotected sex with partners they believed engaged in HIV risk behaviors
Jones, 2006; Jones & Gulick, 2009
Patterns of Unprotected Sex Among Women
Importance of unprotected sex to win and hold onto a man and to show trust
Jones & Oliver, 2007

7. Theoretical Framework TO Soap Opera Development
Sex Scripts Power as Knowing Participation in Change ®

8. Framework
Sex scripts: socially shared meanings about sex behavior (Simon & Gagnon, 1989)
Power as Knowing Participation in Change® (Barrett, 2010)
being aware of what one is chooses to do
feeling the freedom to act intentionally
being involved in creating the changes that one intends
People participate in change, but not always in a knowing manner
Jones, 2006; Jones & Oliver, 2007

9. Why soap operas ?

10. Entertainment-Education
Soap Operas
Singhal, Cody, Rogers, Santelli, 2004
Stories grounded in urban women’s own experiences
Women identify with the heroines’ process of change
Messages to reduce HIV risk are designed to fulfill familiar relationship needs

11. Pilot Study on Handheld Computers
A Story about Toni, Mike, and Valerie
43 minute pilot video available at:
Jones, 2008; Jones & Oliver 2007

12. The intervention: Love, Sex, and Choices (LS&C)
Twelve, minute episodes; Written & scripted by study team, professional filmmaker(Alan Roth), and actors

13. Study Design and Expected Outcome
1:1 randomized controlled trial (RCT)
Comparing LS&C to 12-week HIV prevention intervention of text messages
Both groups used study-provided smartphones Jones & Lacroix, 2012
Expected Outcome
Video intervention participants have less unprotected vaginal and anal sex with high risk partners at 3 months (T2) and at 6 months (T3) than the comparison text message group

14. Sex Risk Measured by VEE
Unprotected anal and vaginal sex using the vaginal episode equivalent (VEE)* with high risk partners
∑ (#UV) i + 2 (#UA)i )= sex risk
the sum of the # of unprotected vaginal sex acts + 2 x the number of unprotected anal sex acts, where i is the # of high risk partners in the past 3 months
*Susser, Desvarieux, & Wittkowski (1998), Reporting sexual risk behavior for HIV: A practical risk index and a method for improving indices. American Journal of Public Health, 88,

15. Participants and Settings
18 to 29 year old women
Inclusion criteria:
Had unprotected vaginal / anal sex with men they believed had sex with other women/men, and/or injected drugs -past 3 months
Recruited in Newark, Jersey City, East Orange, & Irvington, NJ from:
Public housing, STD Clinics, Community Center, Storefront, Food Pantry
Screening, Baseline, and Post-Intervention Interviews conducted with Audio Computer Assisted Self-Interview (ACASI)

16. Interventions Sent weekly for 12 wks √ Study provided smartphones
Video LS&C
(n=117)
Written messages
(n=121)
Sent weekly for 12 wks √
Study provided smartphones
Sent weekly to phone with link to open intervention
F/u contact if missed weekly s
Can watch/read current & previous episodes /messages 24/7
Track Frequency
Track viewing time
Responds on the phone with reason for re-watching
Responds on the phone with answers about content

17. Data Analysis
Outcome = VEE with high risk partners at T2 (3 mo), and T3 (6 mo)
Due to skewness (VEE +0.5) was log transformed
Repeated measures mixed linear models that adjusted for baseline behavior were fit

18. Results

19. Results: Participant Flow
505 screened
-295 eligible, consented, randomized
-57 lost to f/u, most due to lost cell phones
238 completed T2 and T3 post-intervention interviews
-117 in Video Group
-121 in Text Group

20. Table 1. Baseline Equality of Video and Text Arms
Variable
Text (n=121)
Video (n=117)
Mean ± std-dev or %
Age (years)
22.0 ± 3.4
22.1 ± 3.6
Age at first sexual intercourse (years)
14.4 ± 1.8
14.5 ± 2.2
Highest grade completed
12.2 ± 1.7
12.22 ± 1.7
African American/Black
90.1%
86.32%
Employment outside home
36.4%
40.2%
Study Site
Community center
Public Housing
Food Pantry
Storefront
STD Clinics
14.1%
30.6%
19.0%
22.3%
18.8%
30.8%
10.3%
17.1%
23.1%
Used Alcohol before /during sex
81.8%
75.2%
Injected drugs
2.5
3.4
Any unprotected vaginal sex with a high risk partner
99.2%
Any unprotected anal sex with a high risk partner
40.5%
47.9%
Sexual Pressure Score
25.5 ± 15.3
29.7 ± 16.3
Sensation Seeking Score
13.6 ± 6.9
15.1 ± 7.5
High Risk Sex Scripts Score
5.1± 5.9
6.6 ± 7.4
Any Male partner had sex with other women
100%
Any Male partner had sex with men
29.8%
41.9%
Any Male partner injected drugs
25.6%
31.6%
* Note- The intervention groups did not differ on any of these variables at p < 0.05 by exact test or Wicoxon test

21. Summary of Baseline Findings
Almost half had unprotected anal sex in the prior 3 months with high risk partners.
Half (n=121, 51%) had 3 or more partners
A surprising number knew/ suspected their partners had sex with men –42 % Video vs 30% of Text arm, P =0.06.
Over half the sample (56.7%) had first coitus at ≤ 14 years old.

22. Table 2. Pre and Post Intervention VEE Change
Geometric Mean
Of VEE Acts
Point Estimate ± Standard Error
Text Arm
Video Arm
At baseline1
21.32 ± 2.83
22.20 ± 3.01
Follow Up
At T2 (3 months)1
6.55 ± 1.02
5.70 ± 0.84
At T3 (6 months) 1
5.93 ± 0.91
4.85 ± 0.73
P > 0.20 from Wilcoxon test for difference in VEE between Video Arm and Text Arm at each of the three time points
BUT NOTE THE DRAMATIC DECLINE IN VEE FOR BOTH GROUPS FROM BASELINE TO T2 and T3. ALL DECLINES AT P < 0.001

23. Table 3 Associations of Variables with VEE behavior Change 1
Characteristic2
Association With Ratio of the Post to Pre intervention VEE Behavior3
Point Estimate
( ±SE) P
Video (Vs Text).
0.81
±0.13
0.21
Visit 3 (Vs Visit 2)
0.88
±0.08
0.17
High Risk Sex Script/ Log Unit
0.87
0.10
Study Site4
Community center
Public Housing
Food Pantry
Storefront
STD clinics
1.48
2.10
1.73
1.74
Baseline
±0.39
±0.48
±0.50
±0.45 NA
.03 -OVERALL4
0.12
0.002
0.06
0.03
1. From Mixed Model Linear Regression on log transformed VEE at T2 and T3 with log baseline VEE as a covariate. Video Vs. Text and time points T2 Vs. T3 are forced into the model, otherwise only variables with P < 0.20 in Adjusted Models are included. Pre-intervention baseline VEE is included in all models.
2. NOTE – Age, Age at First Sex, Ethnicity, Work Outside of Home, Education, Sexual Pressure Score, Sensation Seeking Score, and Any Male Partner had sex with Men did not meet the P < 0.20 Selection criteria
3. From exponentiation of parameter estimates from mixed linear regression models with Log transformed VEE at post intervention Visits 2 and 3 as outcomes.
4. Overall P-value for study site association with post intervention behavior was 0.03 in the multivariate model

24. Summary of Main Findings
Sex risk behavior declined by 19% more in the soap opera video group than the HIV prevention text group. Difference was not statistically significant (p=0.21).
VEE risk behavior was ~12% lower at T3 (6 Mo) than T2 (3 Mo) in both groups, this difference between time points was not statistically significant (p = 0.17)
Greater risk post-baseline reduction of VEE at STD clinic sites than in storefront or public housing.

25. Evaluation of Love, Sex, and Choices Videos By Participants
Women were enthusiastic about the videos.
All but 4 of 117 thought the stories were realistic
All but 8 could relate to the characters
90 % thought their friends might like to watch
All but one wanted the stories to continue

26. Evaluation of Smartphone by 117 Video Participants
Using cell phone for the project was easy (n = 113, 96.6%)
Using the cell phone maintained privacy (n =113, 96.6%)
Wanted to continue watching with the phone (n =107, 91.4%)
Jones & Lacroix (2012)

27. Discussion, Implications

28. High risk behavior at baseline
Post-intervention sex risk VEE behavior was reduced (p < 0.001) in both groups.
While reduction was 19% more in the video group, this difference was not statistically significant.
Both groups received s, calls, smartphones, high level of involvement /attention
Greater VEE reduction at STD clinic sites than public housing or storefront: further study needed
The stories held participants’ attention
Participants identified with characters & stories and wanted to continue watching

29. Conclusion
This is the first study to evaluate streaming weekly videos to smartphones to promote health.
We believe that Love, Sex, and Choices was highly effective in reducing HIV risk behavior and the comparison group also received a viable HIV prevention intervention.
A streamed video intervention
can be widely distributed and accessed 24/7
Allows usage to be tracked, providing measures of treatment fidelity

30. Gratefully Acknowledge
The National Institute of Nursing Research (NINR) supported this work (RO1-NRO10864).
Technical support at Rutgers Newark Computing Services
Alan Roth, filmmaker, Martinique L. Moore, Assistant Director
The cast of Love, Sex and Choices; Starring: Toni:Yasmine Weaver, Diamond:Tationna Bosier,
Valerie: Leeann Hellijas, Keyanna: Darnell Rhea Williams, Mike: Laurence Covington,
Dante: Omar Golden, James: Jaylen Sansom
Rutgers University College of Nursing and the Educational Opportunity Fund (EOF) research assistants whose dedication made this work possible: Yvesnallie Antoine, Magnolita Bonheur, Essence Burrows, Fernandine Charles, Lin Chen, Geraldine Dufort, Catherine Lora, Judeline Marcellus, Sandra Rios, Tatiana Saavedra, Griselda Sanchez, and Mireille Zuniga;
Thank you to the site recruiters, and to: Carol Tyler, the late Kevin Burnett, Brenda Davis, MS, LCSW, and Grace Malley, at Jersey City Public Housing; Honorable Mayor Wayne Smith of Irvington Township; Dorothy Wojcik, Program Manager, Jersey City Preventive Medicine Clinic; Ms. Verna Sims, Director at Mary McLeod Bethune Life Center; Rochelle D. Williams-Evans, RN, MS, Director/Health Officer, East Orange Department of Health & Human Services;
And with gratitude to the women who participated in this study.

31. Jones, R. & Lacroix, L.J. (2012). Using Smartphones to View Weekly Soap Opera Videos in a Randomized Controlled Trial to Reduce HIV Risk in Young Adult, Urban African American/Black Women. DOI /s AIDS & Behavior, 16, 1341–1358. 
Jones, R. (2012). Handheld computers to run ACASI to assess HIV risk and deliver tailored soap opera video feedback: Acceptability among young adult urban women. DOI: /j.jana Journal of the Association of Nurses in AIDS Care, 23 (3).
Jones, R. & Gulick, E. (2009).The Sexual Pressure Scale for Women-Revised. Research in Nursing and Health. 32, 71–85
Jones, R. (2008). Soap opera video on handheld computers to reduce urban women’s HIV risk. AIDS and Behavior, 12, 876–884
Jones, R. & Oliver, M. J. (2007). Young urban women’s patterns of unprotected sex with men engaging in HIV risk behaviors. AIDS and Behavior, 11 (6),
Jones, R. (2006). Reliability and validity of the Sexual Pressure Scale. Research in Nursing and Health, 29,
  Jones, R. (2006) Sex Scripts and power: A framework to explain urban women’s HIV sexual risk with male partners. Nursing Clinics of North America, 41,
 Jones, R. (2004). Relationships of sexual imposition, dyadic trust, and sensation seeking with sexual risk behaviors in young urban women. Research in Nursing and Health, 27,
Jones, R. (2003). Survey data collection using Audio Computer Assisted Self-Interview. Western Journal of Nursing Research, 25,

32. Many Thanks to the XIX International AIDS Conference
Rachel Jones, PhD, RN, FAAN