JOURNAL OF APPLIED BEHAVIOR ANALYSIS 1990, 239 275-284 NUMBER 3 (FALL 1990)

AN ANALYSIS OF AND INTERVENTION IN THE

SEXUAL TRANSMISSION OF DISEASE
Luis MONTESINOS, LAWRENCE E. FIusci-, BRANION F. GREENE, AND
MICHELLE HAMILTON
SOUTHERN ILLINOIS UNIVERSITY-CARBONDALE

Sexually transmitted diseases are a serious threat to the public health. Indeed, when an individual
seeks medical treatment for a sexually transmitted disease, health authorities frequently attempt to
identify, procure, and treat that individual's sexual contact(s). We conducted a comparative analysis
of three alternative approaches to tracing the sexual partners of individuals diagnosed as having a
sexually transmitted disease. The first approach involved counseling individuals (n = 27) infected
with either gonorrhea or nongonococcal urethritis and exhorting them to procure their sexual partners
for treatment. In addition to counseling, the second and third approaches involved distributing
'occasion cards" for patients to use when informing sexual contacts of the need for treatment.
Moreover, in the second approach, the counselor (a nurse or physician) informed infected patients
(n = 19) that they and their partners could waive the $3 clinic fee contingent upon the partners
seeking treatment within 1 week. In the third approach, the counselor asked infected persons (n
= 19) to accept a follow-up telephone contact if their sexual partners failed to seek treatment within
1 week. The third approach was most effective. Ninety percent of the partners identified through
this approach sought treatment, versus only about 60% of the partners in the other two conditions.
The third approach was also the least expensive, costing about $2.95 to procure each partner for
treatment.
DESCRIPTORS: health-related behaviors, sexual behavior, medical compliance, community
behavior analysis, contact tracing

The incidence of sexually transmitted disease PID is a particularly serious malady attributable to
(STD) has increased dramatically worldwide. Even NGU and gonorrhea in about 50% and 25% of
exciusive of acquired immune deficiency syndrome the cases, respectively. After just one case of PID,
(AIDS), STDs are the most prevalent infectious the risk of infertility increases seven-fold. Should a
disease in this country (Felman, 1983; World pregnancy occur, it is more likely to be ectopic
Health Organization, 1981, 1983). The Centers (outside of uterus), inevitably terminating in a fetal
for Disease Control estimate that each year 8 to 10 death (Handsfield, 1985). Also, both gonorrhea
million Americans suffer from an STD other than and NGU are transmitted to infants during deliv-
AIDS (Kroger & Weisner, 1981; National Institute ery.
of Allergy and Infectious Diseases, 1979). These diseases burden the nation's economy. In
The two most prevalent, STDs, gonorrhea and just 1 year, $770 million was spent to manage
nongonococcal urethritis (NGU), present serious gonorrhea (Weisner, 1980). Such costs are trivial,
health complications such as epididymitis in men however, compared to the costs incurred when STDs
and cervicitis, salpingitis, and pelvic inflammatory are not diagnosed and treated early. For example,
disease (PID) in women (Felman, 1983; National the health costs and losses in wages attributable to
Institute of Allergy and Infectious Diseases, 1980). PID totaled more than $2.6 billion in 1984 and
are expected to exceed $3.5 billion by 1990 (Wash-
We would like to thank Sam McVay, Tommie Perkins,
Robin Dittmer, Sylvia Chalem, Jan Radlke, and A. K. Par- ington, Arno, & Brooks, 1986).
mar. Although containment of gonorrhea and NGU
Copies of all protocols and materials used in this study, is a priority for the public health systems in many
as well as reprints, may be obtained by writing Brandon F. countries, this task is complicated by an especially
Greene, Behavior Analysis & Therapy Program, Rehabili-
tation Institute, Southern Illinois University, Carbondale, Il- insidious characteristic of both diseases: They may
linois 62901. remain asymptomatic for a period during which
275
276 LUIS MONTESINOS et al.
infected individuals may unwittingly infect others. thorities assumed responsibility for notifying these
In fact, evidence indicates that NGU among fe- contacts. In the motivational interview, patients
males is asymptomatic in a majority of cases (Fel- themselves were asked to inform partners of the
man, 1983; Sanders, Harrison, & Washington, need to seek treatment. The comparison between
1986). If the transmission of these diseases is to these approaches was based on reinfection rates for
be curtailed, upon discovery of an infected indi- the originally treated patient. The assumption was
vidual it is imperative to identify and treat that that these patients would continue sexual relations
individual's sexual contact(s). These sexual contact with the same contacts and become reinfected unless
partners should be treated epidemiologically, that those contacts were treated. A statistically signifi-
is, regardless of whether symptoms or pathology is cant difference in reinfections only among males
evident in the sexual contact (U.S. Department of favored the motivational interview.
Health and Human Services, 1982; Washington, Atwater (1974) reported an increase in clinic
1984; Weinstein, 1984). attendance associated with a change from a tracing
Laws in each of the United States require public approach similar to the epidemiological interview
health agencies to attempt to trace contacts of pa- to one similar to the motivational interview. Pot-
tients diagnosed as having gonorrhea or syphilis. terat and Rothenberg (1977) reported an equiva-
However, tracing has not been required for cases lent number of contacts seeking treatment under
of NGU. This is attributable to some peculiarities two tracing conditions. One involved a 15- to 20-
historically associated with its diagnosis. Specifi- min interview in which a counselor attempted to
cally, although there is an affirmative basis for the solicit the names of contacts from infected patients;
diagnosis of gonorrhea (i.e., available to the phy- the other involved a shorter interview (5 min) dur-
sician are several techniques to detect gonococci), ing which a "contact slip" (of unspecified content)
until recently, a specific infecting organism had not was handed to the patients to give to their contacts.
been isolated in the case of NGU. Thus, its di- Judson and Wolf (1978) gave gonorrhea patients
agnosis was a matter of inference when gonorrhea- a "contact card" that exhorted them to bring their
like symptoms were evident in the absence of partners for treatment and assured them that the
gonococci; hence, the term nongonococcal urethri- patient's identity would not be revealed. This ap-
tis. Only recently has an infecting organism, CGla- proach produced as many contacts as the more
mydia trachomatis, been isolated in about 50% labor-intensive and costly approach in which the
of NGU cases (National Institute of Allergy and health authorities themselves assumed responsibil-
Infectious Diseases, 1980). The laboratory tech- ity for contacting patients.
nology for culturing Chlamydia is quite expensive Applied behavioral studies of prompts and in-
and not presently available or affordable at every centives to promote cooperation with medical reg-
cdinic. imens may be germane to developing effective con-
As a consequence, studies of methods for con- tact tracing programs. For example, in a study of
ducting contact tracing have been limited to cases parents seeking dental care for their children, mul-
of gonorrhea and syphilis. Most studies were con- tiple preappointment prompts (involving an ap-
ducted at public health or STD clinics in the course pointment card and two telephone calls) produced
of fulfilling legal obligations and often lacked pre- high levels of appointment keeping (Reiss & Bailey,
cise measurement and/or appropriate controls for 1982). An incentive, consisting of a coupon for $5
threats to internal validity. For example, Jamison or an equivalent gift item, also effectively promoted
and Mueller (1979) compared two approaches in- appointment keeping but was more costly to ad-
volving either an "epidemiological interview" or a minister. Rice and Lutzker (1984) reported that
"motivational interview" with the infected patient. incentives, in the form of reduced or waived fees
In the epidemiological interview, patients were asked for service, resulted in high levels of appointment
to identify sexual contacts. However, health au- keeping among parents of children scheduled for
 SEXUAL TRANSMISSION OF DISEASE 277

follow-up care at a family practice clinic. A con- that their partner(s) were not university students.
dition in which parents received an appointment (Tracing such partners was neither possible nor
card was not effective. permitted at the health service.) Eligible subjects
These studies suggest that a combination of (n = 65) were categorized as original patients and
prompts and/or incentives may contribute to an were individuals (a) whose stated reason for seeking
effective program for tracing sexual contacts. How- treatment was either the presence of symptoms or
ever, contact tracing presents some challenging vari- the fact that a health authority had notified the
ations on the problem of appointment keeping. student of the need for treatment upon discovering
First, health authorities do not have direct access (e.g., during a gynecological examination) a posi-
to the target subject (i.e., the sexual contact) who tive culture for gonorrhea and (b) who reported
needs to make and keep a medical appointment. having at least one sexual partner during the pre-
Thus, all contingencies must be mediated by the vious 6 weeks who also was a student at the uni-
infected patient who initially receives treatment. versity. (The 6-week interval was a standard rec-
Second, even if the patient identifies sexual contacts ommended by authorities at the health service.)
by name, health authorities are not obligated legally Five of these original patients had been identified
to conduct tracing in cases of NGU. Some health previously as the sexual partners of other original
authorities may even regard direct communication patients. We treated them as original patients (i.e.,
with an NGU contact as an intrusion. Finally, the included them in contact tracing) because they iden-
precise measurement of the impact of contact trac- tified additional individuals with whom they had
ing programs depends upon the willingness of in- had sexual contact during the previous 6 weeks.
fected patients to provide names of contacts. With- The 65 original patients consisted of 17 females
out such identifying information, it is not possible and 48 males; most (80%) were between 18 and
to attribute mere increases in clinic attendance to 23 years of age. Their stated reasons for seeking
a tracing program mediated by the infected patient. medical treatment were the presence of symptoms
We studied three approaches to contact tracing (n = 51), a prompt by a sexual partner (n = 8),
at a university clinic. These approaches involved or notification from the university health service (n
combinations of prompts, incentives, and varying = 4) or other health authority (n = 2) of a positive
degrees of participation by the patients themselves. culture.
Experimental Procedures
METHOD Counseling only. Four female nurses and two
male physicians (one was the second author) con-
Subjects and Setting ducted counseling sessions. Physicians conducted
We conducted the study at the health service of counseling in their offices; nurses accompanied the
a large midwestern university. The study was re- patient to a private area set aside for this purpose.
viewed and approved by the university's Commit- Typically, counseling immediately followed the
tee for Research Involving Human Subjects. Six physical examination and diagnosis of the STD. In
fiull-time physicians, 20 nurses, and approximately a few cases, counseling followed the discovery of a
six student workers staffed the service between 8:00 positive culture for gonorrhea. Cultures were pre-
a.m. and 4:30 p.m., Monday through Friday. Ser- pared within 48 hr of the initial examination. The
vices were provided by appointment or emergency. health service immediately contacted these patients
Each visit cost $3. and arranged an appointment for treatment and
We selected subjects from 117 students diag- counseling at the patient's earliest convenience.
nosed with gonorrhea or NGU. Two refused to Counselors followed a written protocol that
participate in the contact tracing program. Fifty prompted them to ascertain the patient's reason for
were excluded from the study when they reported seeking treatment (e.g., noticed symptoms), inform
278 LUIS MONTESINOS et al.
the patient of the nature and treatment of the STD, contact him or her (the original patient) by tele-
obtain the names of sexual partners during the phone to ask if the partner(s) had been notified.
previous 6 weeks, ask the patients to procure their Patients were asked to consent to this call, to specify
partners for treatment, assure the patient of the suitable times of the day to receive it, and were
confidentiality of all information obtained both told the name of the specific individual who would
during the examination and counseling session, and call them. Nineteen original patients participated
to assure him or her that the health service would in this condition. (Two of these refused to be called,
not contact the partner(s). Twenty-seven original but their partners arrived for treatment within 5
patients participated. days.)
Counseling, occasion cards, and incentive. Pa-
tients assigned to this condition received the coun- Experimental Design
seling described above. In addition, counselors told The counseling-only condition lasted for 6 months
patients that if they successfully recruited their part- (July through December 1984). Counseling/cards/
ners for treatment at the health service, then the incentives and counseling/cards/follow-up condi-
health service would waive the $3 charge for the tions were implemented concurrently during the
visit for both the patient and partner. Counselors next 6 months (January through June 1985). Dur-
then presented original patients with a selection of ing this latter period, subjects were assigned to these
three cards that could be accepted in any quantity two conditions randomly. That is, protocols ap-
or combination. The three cards, attractively de- propriate to each condition in equal numbers were
signed as occasion cards (in the Hallmark and Skin- provided each counselor. Thus, for any particular
nerian traditions), differed primarily in the nature patient, the counselor simply removed the next
and font (e.g., cursive vs. block lettering) of the protocol from the randomly ordered set and con-
opening messages in order to reflect possible vari- ducted the intervention accordingly.
ations in the relationship between original patients
and partners. Thus, one card represented a "caring Integrity of Interventions
lover," another an "anonymous lover," and another Precautions were taken to ensure that the pro-
a "matter-of-fact lover." For example, the message cedures appropriate to each condition were fol-
on the "caring lover" card (depicted in Figure 1) lowed. Specifically, the protocols were color-coded.
began, "This is not easy to say, but because I care In addition, we conducted a meeting at the start
about you . . ."; the anonymous lover card began, of the study to discuss its purpose with counselors
"We don't know each other well but...." The and to emphasize the importance of adhering to
inside of each card described the particular STD in experimental procedures. Just prior to beginning
question (either gonorrhea or NGU) and exhorted the counseling/cards/incentives and counseling/
the recipient to seek treatment (without specifying cards/follow-up conditions, we held a brief (15-
where). Counselors suggested to the patients that to 20-min) training session with each counselor
the cards could be used in preparing to speak to during which we role-played the part of a minimally
partners or simply could be given to partners. Nine- responsive patient so that the counselor could prac-
teen original patients participated in this condition. tice providing reassurance while firmly soliciting the
Counseling, occasion cards, and follow-up desired information. We continued to meet with
telephone call. Patients were counseled and given counselors approximately every 2 weeks to review
the occasion cards as in the former condition. How- the results of contact tracing efforts and to consider
ever, no financial incentive was offered. Rather, any problems that arose. In addition, the senior
counselors told each patient that if the partncr(s) author collected completed protocols each day and
did not arrive at the health service within 5 working was available to address any issues.
days, then a professional (of the same sex as the Finally, during the experimental phase a ques-
patient) affiliated with the health service would tionnaire was attached to each counseling protocol.
 SEXUAL TRANSMISSION OF DISEASE 279
- - -
= - --

Jihis is not easy to say, but

because care about you..IN

* teta you that X have been trete for a

must
Sexuaay Transmittd Dise. 1st meqns that
you ned tttoo even fWough waaaithwe
nagmpka. Ms iese may show no signs for a
long tiom and your body can be harmed before it ever
does show stgns. Thereore,,i is importnt for you
to get medica atention as soon as you cqn.
What is important to me is our relationship and
your wetfare,

PHease get tretnt. fold _

_- _ _ _ _

I was diagnosed as having the condition below. The

doctor- gave me this information to pass to you so that
you understand how important it is for you to seek treatment.

Gonorrhea is an infection of the cervix or the urethra and

may produce discharge in persons of eitherr sex. There is a
carrier state which may be comletely without' syptOs.
Gonorrhea is usually treated with. a single dose of penicillin
although this is often followd with tettacyline. D oabamay.
nxnduce pevic inlnntar. MiAMA*Lagi tIbAfalendaIti
especially Important phat sQxpa na'irenr he t~eatd regxardless of
sgIgests
whether ~amt¶Ii;al ~lnatloni L-ty. All persons
who have gonorrhea need a repeat cultU *- week after completing
treatment to ensure that the organism is eradicated.
IF YOU ARE AN SIU` STUDENT PLEASE PRESENT THIS CARD TO YOUR
PHYSICIAN AT THE HEALTH SERVICE.
Figure 1. Illustration of the occasion card for the "caring lover." Upper panel is the outside face; middle panel is the
inside top half; lower panel is the inside lower half.

The questions probed whether patients had received it in a box near the exit of the health service. Fifty-
information appropriate to each condition (e.g., $3 five percent of the patients responded, at least par-
waiver vs. the telephone call). Counselors asked tially, to the questionnaire; 21% of the patients (in
patients to complete the questionnaire and to drop nearly equal distribution across conditions) an-
280 LUIS MONTESINOS et al.

swered the question pertaining to the integrity of RESULTS

the particular counseling condition. All but 2 pa-
tients (one in each experimental condition) indi- Partners Seeking Treatment
cated that they were told and understood the terms The upper panel of Figure 2 presents the per-
of the particular condition. centage of STD patients who acknowledged that a
university student had been a sexual partner within
Measurement the preceding 6 weeks and who provided the names
Identified partners seeking treatment. We as- of these partners. A significant difference, x2( 1, 46)
certained the percentage of original patients who = 6.79, p < .01, was found between the per-
were willing to provide the name(s) of sexual con- centages of patients who identified their partners
tacts by reviewing the completed counseling pro- during counseling only (70%) versus each of the
tocols. We maintained a list of these identified two experimental phases (100% in both condi-
partners to determine whether they arrived for treat- tions). Among original patients who provided names
ment within 1 month of the original patient's treat- of university students, an average of 1.2 partners
ment and, if so, whether they stated that their visit per patient were identified during counseling only,
was prompted by an original patient. (Thus, al- 1.3 in counseling/cards/incentive, and 1.1 in
though the patient was encouraged to have the counseling/cards/follow-up conditions. Fifteen
partner seek treatment within 5 days, a partner original patients selected the "matter-of-fact" oc-
who sought treatment within 1 month was regarded casion card (8 in the counseling/cards/incentive;
as a successful instance of tracing, provided that 7 in the counseling/cards/follow-up condition).
the partner stated the visit had been prompted by Nineteen selected the "caring lover" card (9 and
the original patient.) 10 in the counseling/cards/incentive and counsel-
There were only two instances in which the orig- ing/cards/follow-up conditions, respectively) and
inal patient could not identify a partner by fill 2 selected the "anonymous lover" card (1 in each
name. In both cases the apparent partners reported condition). Two patients in the counseling/cards/
their visits had been prompted by an original pa- follow-up condition declined to take any card.
tient. In one case that partner provided the full The lower panel of Figure 2 indicates that 56%
name of the original patient. the second case, of the identified partners sought treatment during
In
the original patient gave the partner's first name. counseling only; 62% and 90% sought treatment
A person by that name arrived during the week during the counseling/cards/incentive and coun-
following the treatment of the original patient. Both seling/cards/follow-up conditions, respectively. The
cases were scored as successful instances of tracing. superiority of the lattermost approach was signifi-
Cost analysis. We calculated the costs for ma- cant in comparison both to counseling only, X2(1,
terials, incentives, counseling time (of nurses and 43) = 6.01,p < .025, and the approach involving
doctors), and time involved in telephone contacts. incentives, X2(1, 44) = 4.40, p < .05. During
These costs were then expressed as a cost per patient the counseling/cards/follow-up condition, it was
counseled and as a cost per partner successfully necessary to call only 2 of the original patients.
procured for treatment.
Patient satisfaction. The questionnaires used Cost Analysis
to ascertain treatment integrity induded several Table 1 provides an itemization of costs asso-
questions to assess patient satisfaction. Patients were ciated with each condition, induding costs for ma-
asked to rate (on a 5-point scale) whether they were terials, incentives, and time expended by a graduate
comfortable during counseling and whether the na- assistant in making follow-up telephone calls. The
ture of the diagnosis, means for preventing rein- costs of time expended in counseling were deter-
fection, and the importance of procuring partners mined separately for nurses and physicians on the
were explained adequately. basis of their respective mean salaries. These costs
 SEXUAL TRANSMISSION OF DISEASE 281

Percentage of Original Patients Providing Partners' Names

100
100 -

us

w 80- 70
.m" m

c
0
60-
ID
a 40-
ca
C 20=

Counseling Counseling/Card Counseling/Card

Only Incentive Follow-Up

Percentage of Identified Partners Seeking Treatment

100- Iff
90
Ct
'I

4-A
80 -
62 _
c) 60 -
04
Co"

Cu 40 -
am
C.w
I."
43) 20 -
0-1
Counseling Counseling/Card Counseling/Card
Only Incentive Follow-Up
CONTACT TRACING CONDITION
Figure 2. Upper panel: The percentage of original patients who reported having university students as partners and
who provided partners' names during counseling only, counseling/cards/incentive and counseling/cards/follow-up condi-
tions. Lower panel: The percentage of students who were identified as partners by original patients and were successfully
traced for medical treatment during counseling only, counseling/cards/incentive and counseling/cards/follow-up conditions.
282 LUIS MONTESINOS et al.
Table 1
Analysis of Costs Per Patient Counseled and Per Partner Traced

Counseling/cards
Item Counseling only incentive Cards/follow-up

Protocols $0.02 $ 0.02 $0.02

Cards 0.06 0.06
Counseling Time
M.D. ($0.49/min) 2.45 2.94 2.94
(5 min) (6 min) (6 min)
Nurse ($0.19/min) 1.71 1.52 1.90
(9 min) (8 min) (10 min)
Incentives 4.26
Follow-up call 0.04
Total mean costs
Per patient counseled
M.D. 2.47 7.28 3.06
Nurse 1.73 5.86 2.02
Per partner traced
M.D. $4.41 11.74 3.40
Nurse 3.08 9.45 2.24

were totaled and averaged across all original pa- DISCUSSION

tients to derive a mean cost per patient counseled
during each condition. These means were then di- Of the approaches to contact tracing examined
vided by the proportion of partners successfully in this study, the most effective involved the coun-
traced during each condition (i.e., .56, counseling selor arranging to reestablish contact by telephone
only; .62, counseling/cards/incentives; .90, coun- with original presenting patients if their identified
seling/cards/follow-up) to derive a mean cost per partners did not promptly seek treatment. In all
partner traced. It is evident from Table 1 that it but two cases, it was not necessary to make the
was not expensive to provide counseling. Counsel- follow-up telephone call. Apparently, simply mak-
ing only cost as little as $1.73 per patient. However, ing the arrangements for a contingent call was suf-
when considering the costs per partner traced, the ficient to encourage these patients to prompt their
procedures involving a follow-up telephone call were partners to seek treatment.
not only more effective, they were more cost effi- In comparison, counseling procedures alone were
cient. Indeed, when implemented by a nurse, the associated with moderate effects. We intended for
cost was only $2.24 per partner traced. counseling only to represent the practices at the
health service at the time the study began. That is,
Patient Satisfaction personnel at the health service reported that they
Patients responded affirmatively (by indicating discussed the nature and treatment of the STD with
either "agree" or "strongly agree") when asked original patients and exhorted them to procure their
whether they were comfortable talking to the coun- partners for treatment. However, from our discus-
selor (88% of the respondents), the diagnosis had sion with health service personnel prior to the study,
been adequately explained (93%), the means for it was apparent that the counseling provided during
reinfection had been discussed (90%), and the im- the study was more extensive than preexisting prac-
portance ofprocuring partners had been understood tices. For instance, prior to the study, patients were
(97%). not encouraged to divulge the identities of partners
 SEXUAL TRANSMISSION OF DISEASE 283

for the purpose of evaluating the impact of coun- ditions. Moreover, we noted that counselors were
seling itself. Thus, it is likely that the systematized more successful at soliciting the names of partners
counseling procedures in this study were more po- subsequent to implementing the two variations on
tent than the preexisting counseling procedures. counseling. This may have been attributable to the
Because of its encouraging results, the tracing training sessions undertaken in preparation for these
approach involving cards and a follow-up telephone two conditions. In addition, the population itself
call has been continued at the health service. The (i.e., university students) is a relatively homoge-
approach involving monetary incentives was dis- neous one, although it should be noted that it
continued. Perhaps a larger incentive could achieve represents the age group at greatest risk for STD,
larger effects. However, the incentive in this study especially NGU. In fact, at student health clinics
($3 fee waiver) was already more costly, but less 85% of urethritis is attributable to NGU (World
effective, than the approach involving a follow-up Health Organization, 1981). However, the partic-
telephone call. It is doubtful that many incentives ular methods involved in this study have not been
could produce comparable effects at comparable applied and tested in community-based STD clin-
costs vis-a-vis the approach involving the follow- ics. Such application could be important even for
up telephone call. Moreover, the follow-up tele- the university population, given that a significant
phone call procedure allows health professionals to portion of the initial pool of students who sought
maintain contact with original patients-perhaps treatment for STD had nonstudents for sexual part-
the only ongoing link to a pool of infected and ners.
untreated individuals. In conducting the study we began to appreciate
Inasmuch as the occasion cards were just one the implications that a successful contact tracing
part of two contact tracing approaches, the indi- may have in containing the problem of STDs, in-
vidual effects of the specific card chosen cannot be duding AIDS. For example, one aspect of the study
determined. The indusion of a card in the coun- that was extensively debated among the health-care
seling/cards/incentive condition did not produce providers at the dinic pertained to soliciting the
statistically significant increases over counseling only identity of sexual contacts. This was a particularly
in the percentage of partners who sought treatment. sensitive issue in cases of NGU because, at the time
Nevertheless, there may have been some effect of of our study, the reporting of NGU was not man-
the cards in interaction with the approach involving datory in any state. Some health-care providers
a telephone follow-up. That is, each card provided argued their responsibilities ended with the treat-
a script written from the point of view of the patient ment of the original patient, despite the fact that
communicating with the partner and thereby may a small amount of "behavioral treatment" could
have made it easier for patients to approach their ultimately protect the health of many other persons,
sexual contacts or, at least, to pass the card to them. induding the original patient (by reducing the
Whether such prompts are more apt to produce probability of reinfection).
the intended effect than prompts that simply exhort The issue is equally sensitive for STD patients
the patient to procure the partner(s) for treatment themselves, especially AIDS victims. Such persons
(e.g., Atwater, 1974) is equivocal. In any case, the may be concerned that any exposure of identities
cost of the cards was negligible. Because written could compromise their civil rights (Osborne, 1988).
informational material is often standard fare at health In our study, patients trusted us not to notify their
clinics, there is probably no practical reason to iso- sexual contacts directly. It is undear, in the case of
late the effects of a card experimentally or to limit AIDS, whether such assurances could either be ex-
the distribution of cards in practice. tended by health authorities or confidently accepted
The generality of our findings is limited by sev- by patients themselves. Perhaps this concern could
eral factors. For example, the counseling only con- be resolved by having patients or their represen-
dition was not concurrent with the other two con- tatives participate substantially in the management
284 LUIS MONTESINOS et al.
of the health care system (Greene & Neistat, 1983). preliminary report. American Journal of Public Health,
If so, such a blending of behavioral and medical 67, 174-176.
Reiss, M. L., & Bailey, J. B. (1982). Visiting the dentist:
technologies with regard for civil liberties may con- A behavioral community analysis of participation in a
tribute significantly to the development of an ef- dental health screening and referral program. Journal of
fective and socially acceptable system through which Applied Behavior Analysis, 15, 353-362.
Rice, J. M., & Lutzker, J. R. (1984). Reducing noncom-
the negative impact of STDs and other infectious pliance to follow-up appointment keeping at a family
diseases can be better addressed. practice center. Journal of Applied Behavior Analysis,
17, 303-311.
Sanders, L. L., Harrison, H. R., & Washington, A. E. (1986).
Treatment of sexually transmitted Chlamydia infections.
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