Abstract
Scenarios simulating real-world risk situations have proven effective for substance use intervention methods and could potentially prove useful as an HIV-prevention method. This study explored qualitatively the development and use of such “in-the-moment” methods. We interviewed 97 moderate-drinking women (50 % Caucasian) after participation in an experiment requiring that they project themselves into a risky-sex scenario. Most participants (58 %) reported experiencing the scenario as a reflective tool characterized by two primary themes: (1) increased awareness of risk and (2) contemplation of behavior change. Findings suggest that “in-the-moment” methods depicting real-world risk situations and providing opportunities to reflect about behavioral choices and subsequent outcomes could prove a useful adjunct to HIV/AIDS-prevention interventions. Such methods could potentially augment existing prevention protocols.
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Notes
It is important to note that not all risky sexual encounters that result in unprotected intercourse can be characterized as heat of the moment situations. This may be especially true for economically disadvantaged women of color with primary partners whom they feel pressured to please because of gendered power dynamics and economic factors. Under such circumstances, heat of the moment factors presumably are less influential in determining sexual safety outcomes. However, among women who are less disadvantaged educationally and economically and who are actively seeking casual dating and sex experiences, structural factors are less likely to be the sole determinant of such decisions. Among participants in our samples (moderately heavy drinkers between 21 and 30 years of age, who are inconsistent condom users, who currently are sexually active, and who currently do not have a primary exclusive partner), focus groups with ethnically diverse women and ethnically diverse men have revealed that the “we should have used a condom, but did not” encounters prototypically are associated with substance use and high sexual arousal and are attributed to heat of the moment factors. In fact, among the condom use resistance strategies men report, aiming to get the woman so aroused that she will forego condom consideration is a common tactic (Davis et al., in press).
The following points are useful in placing our choice of target dosage in perspective for readers unfamiliar with alcohol research methods. First, experimental evidence (e.g., see meta-analysis by Rehm et al., 2012) and illustrative multiple-dose experiments (e.g., George et al., 2009) has clearly established that alcohol exerts a causal impact on sexual risk taking and that this effect appears to become evident at a BAC of about .05 and becomes stronger as the BAC rises to .10 (the highest level tested to date under controlled experimentation). As a comparison point, recall that nationally .08 is the legal limit for driving, thus indicating that BACs at and above this level are universally understood to impair judgment. Second, experimental studies conducted in the field have shown that drinkers in bars express greater risky sex intent at BACs above .08 (MacDonald et al., 2000, Study 2). Third, non-experimental survey data—which are largely retrospective and essentially address the question “does alcohol’s established causal impact manifest in the real-world and what context factors moderate it”—have provided support (albeit inconsistent) for alcohol generating increasing riskier judgments at BAC’s at this level and above (e.g., see review by George & Stoner, 2000; Hendershot & George, 2007).
For readers unfamiliar with alcohol research methods, it is also important to note that the comparison condition here was not a placebo condition (where participants expect to receive alcoholic drinks, but actually receive non-alcoholic drinks); but was instead a standard no-alcohol control condition (where participants expect to receive non-alcoholic drinks, and actually receive non-alcoholic drinks). That is, participants in the control condition were not led to “expect” that their drinks contained alcohol. Instead, they underwent a standard no-alcohol control condition, in which participants are told that they would be treated identically as participants in the alcohol condition, except that their drinks will contain only juice –that is, no alcohol. Extensive research has shown that a placebo condition is an appropriate comparison control condition for low dosage alcohol conditions (e.g., see review by George, Gilmore, & Stappenbeck, 2012). However, placebo conditions are not viable as an experimental control condition when it is being compared to a high dosage alcohol condition, as was the case in this project. Specifically, it is not possible to credibly convince someone they have received a very high dosage of alcohol, in the face of consuming drinks devoid of alcohol.
Generally, participants are very successful at this projection protocol. We know this from the following sources: (1) In numerous published studies (both experimental and qualitative) from our labs using projection protocols involving sexual assault resistance (rather than sexual risk), the evidence for successful projection is highly robust based on post experimental ratings of “realism” and “typical of real life” and post-experimental interviews (Masters et al., 2006) in which participants describe the success of their projection experience. (2) In a method paper by an independent research team, successful projection was also evident in protocols involving sexual assault resistance (Noel et al., 2008). (3) In projection protocols involving sexual risk (as is the case here), there are now more than half a dozen studies published from our labs and the evidence for successful projection is highly robust based on post experimental ratings of “realism” and “typical of real life.” (4) In three published studies from our labs involving sexual risk, evidence of successful projection was not limited to self-report, but was augmented by physiological indicators of sexual-genital response (e.g., George et al., 2009). In those studies, both subjective and physiological indicators of sexual arousal showed that participants had projected successfully and, accordingly, exhibited moderate to high levels of arousal. (5) On the crucial underlying issue of external validity or correspondence between projection protocol behavior and real-world behavior, we have found that indeed participants’ behavior in the lab correlates with past behavior in life and with intended future behavior in life (Kajumulo et al., 2009; Norris et al., 2010). (6) Finally, on a more general point about the correspondence between lab and real-world data, the truism that laboratory behavior has low external validity has been largely vanquished empirically, best exemplified by an extensive analysis of effects sizes from over 38 lab-vs.-field study pairs across a wide range of behaviors (Anderson, Lindsay, & Bushman, 1999).
Although more women in the experimental condition reported changes over and above the women in the control group, t(51) = 10.7, p < .0001.
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Andrasik, M.P., Otto, J.M., Nguyen, H.V. et al. The Potential of Alcohol “Heat-of-the-Moment” Scenarios in HIV Prevention: A Qualitative Study Exploring Intervention Implications. Arch Sex Behav 42, 1487–1499 (2013). https://doi.org/10.1007/s10508-013-0125-x
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DOI: https://doi.org/10.1007/s10508-013-0125-x