Social Cognitive Theory can be used to address testing and screening for sexually transmitted infections (STI) in adults aged 18-30. Social Cognitive Theory (SCT) was developed by Albert Bandura in the 1960s and suggests that learning occurs in a social context with a dynamic and reciprocal interaction of the person, environment, and health behavior (LaMorte, 2018; Bandura, 1989) (See figure 1). SCT defines three factors that affects one’s behavior: Environmental factors or one’s surroundings, Cognitive factors or one’s personal beliefs, and Behavioral factors or one’s ability to perform the health behavior (Bandura, 2001).
Sixteen articles and four scholarly sources were reviewed for this literature review of which one to two constructs from each of the three aforementioned factors are analyzed and assessed for their application to STI testing in the chosen population. Each paragraph will discuss the constructs and their applicability to the adoption of STI testing drawing evidence from various peer-reviewed scientific articles.
Self-efficacy is defined as one’s perceived self-judgment of his/her ability to perform a task or carry out a health behavior (Bandura, 1990).
The role of self-efficacy has been applied to explain the initiation and maintenance of many health behaviors including alcohol consumption, physical activity, and many others (Martin-Smith, Okpo, & Bull, 2018). Many studies analyzing the frequency and utilization of STI testing examine and identify self-efficacy as a factor in uptake of STI testing (Martin-Smith, Okpo, & Bull, 2018; Jamil et al., 2015; Pham et al., 2018).
In a study examining human immunodeficiency virus (HIV) testing, self-efficacy was found to be associated with testing frequency and likelihood to self-test (Jamil et al.
, 2015). Improving gay and bisexual men’s (GBM) confidence in HIV testing by improving their knowledge and experience may lead to higher testing frequency (Jamil et al., 2015). Findings from another study examining HIV testing in GBM who have sex with other men (MSM) shows that HIV testing self-efficacy positively correlates with HIV testing behavior of MSM aged 18–24 years in Myanmar (Pham et al., 2018). This finding is in line with findings from other studies among MSM conducted in high resource settings showing that self-efficacy was positively associated with acceptance and frequency of HIV testing among adult MSM (Pham et al., 2018; Gu, Lau, Chen, Tsui, & Ling 2011).
From these study results, we can draw the conclusion that self-efficacy is an important factor in the adoption of STI testing. Although one of the most important, if not the most important construct of SCT, self-efficacy is difficult to influence and needs to have a personal or individual approach (Powell, Pattison, & Marriott, 2016). Human expectations, beliefs, emotional attitudes and cognitive competencies are developed and modified by social influences that convey information and activate emotional reactions through modeling, instruction and social persuasion (Bandura, 2001; Bandura, 1989). A role-modeling intervention could involve displaying video messages around campuses with students sharing their experiences of going for an STI test to increase self-efficacy (Martin-Smith, Okpo, & Bull, 2018). Self-efficacy should be a main target in the creation of intervention programs aiming to increase the frequency of STI testing adoption in adults aged 18-30.
Social norms are defined as what people in a group believe to be normal in the group, that is, believed to be a typical action, an appropriate action, or both (Paluck & Ball, 2010). Beliefs about what others do, and what others think we should do, maintained by social approval and disapproval, often guide a person’s actions in his/her social setting (Mackie & Moneti, 2014). Social norms play a very important role in the adoption of STI testing in adults aged 18-30 because this age group is among the most malleable to belief change, only behind teens aged 13-17 (Morris, Hong, Chiu, & Liu, 2015). Results from Project Accept, a multi-national HIV prevention trial, found that an intervention designed to increase testing in communities by changing community norms and reducing stigma resulted in a four-fold increase in testing rates compared to the control communities (Young et al., 2010). In a study examining the predictors of chlamydia testing, intention to get tested was found to correlate positively with subjective norms, moral norms, and descriptive norms (ten Hoor et al., 2016).
From these study results, we can draw the conclusion that social norms interact with other factors to produce intention to carry out or adopt a health behavior. In the chlamydia testing study, susceptibility and subjective norms were the most influential explicit determinants in getting tested, however norms can be difficult to measure and may greatly differ among cultural or age groups (ten Hoor et al., 2016). A study performed utilizing apps to survey MSM on various apps such as Grindr and Radar found that two-thirds of participants (64%) found apps to be an acceptable source for sexual health information and that one-quarter (26%) of informational chats with a health educator resulted in users requesting and being referred to local HIV/STI testing sites (Sun, Stowers, Miller, Bachmann, & Rhodes, 2015). Future STI testing interventions should utilize this technology by reducing stigma and changing the perception of social norms to reach the target population of adults aged 18-30.
Cognitive factors in Social Cognitive Theory are defined as one’s personal knowledge and beliefs about a health behavior (Bandura, 1990). The aforementioned constructs of self-efficacy and social norms are both very important determinants in adoption of a health behavior, however, these are not sufficient for behavior change or adoption on their own (Martin-Smith, Okpo, & Bull, 2018). One must have intention to change his/her behavior which stems from their cognitive processes of attitude and outcome expectations/expectancies regarding a specific health behavior (Bandura, 1989).
Attitude in SCT refers to one’s emotion or viewpoint about a health behavior (Bandura, 1989). One’s attitude toward STI testing can be formed from previous experience, knowledge/opinions, or emotions. One study examining attitudes towards sexually transmitted infection screening in young, multi-ethnic, female students found that STI screening needs to be confidential, convenient, easily accessed and offered in ways that allow them to consider themselves as candidates for such screening without fear of social stigma (Normansell, Drennan, & Oakeshott, 2015). In order for the target age group to adopt STI testing, STI testing must be perceived positively and the discovery and treatment of an STI must be perceived as beneficial (Normansell, Drennan, & Oakeshott, 2015). STI testing interventions using SCT should focus on both attitude and outcome expectations/expectancies.
Outcome expectations refers to the individual’s perception that a given behavior will lead to a certain outcome (Reineke, 2001). Outcome expectancy is the subjective value of an outcome and the subjective probability (or expectation) that a particular action will result in that outcome (Baranowski, Perry, & Parcel, 1997). When one gets tested for STIs, his/her outcome expectation is for the result to be negative. When one gets tested and the result being negative is very important to him/her, this is the outcome expectancy. Outcome expectations do not have concrete values; however, the expectation is important to define in order to assess the importance or value of this outcome (Bandura, 2001). In health behavior, attitude, like self-efficacy, is a very difficult construct to change because it is mainly drawn from personal beliefs and opinions (Bandura, 1989). Additionally, outcome expectations and outcome expectancies are very difficult to target because these may vary per individual based on multiple experiences or varied knowledge level (Fortenberry, Brizendine, Katz, & Orr, 2002).
Cognitive theorists, along with behaviorists, believe that reinforcements operate by influencing expectations regarding the health behavior rather than by influencing behavior directly (Rosenstock, Strecher, & Becker, 1994). Safer Choices, a multicomponent school-based HIV/STI and pregnancy prevention program for high-school-aged, young adults, found that 68% of students had a concrete outcome expectation (negative STI test result or not becoming pregnant) and 82% of these students said their outcome expectation was “Very Important” to them (Coyle et al., 1999). Researching this topic, no interventions targeting a change in outcome expectations/expectancies or attitude were found. With this information, an intervention should be implemented to educate adults aged 18-30 on the seriousness of becoming pregnant or the dangers of STIs. This intervention should aim to influence the population’s expectations and expectancies, possibly in conjunction with the aforementioned constructs of SCT.
Interventions to increase the adoption and frequency of STI testing in adults aged 18-30 should utilize Social Cognitive Theory to target the three factors that influence health behavior. Higher perceived testing self-efficacy was found to be associated with higher frequency and higher likelihood to get tested (Jamil et al., 2015; Pham et al., 2018; Gu, Lau, & Tsui, 2011). Results from Project Accept found that by changing community norms and reducing stigma, STI testing rates increased four-fold compared to the control communities (Young et al., 2010). Other studies analyzing chlamydia testing found that intention to get tested was found to correlate positively with more accepting subjective norms, moral norms, and descriptive norms (ten Hoor et al., 2016).
Lastly, cognitive behaviorists found that influencing expectations regarding the health behavior is more effective than influencing behavior directly (Rosenstock, Strecher, & Becker, 1994). With this information found through research, an intervention aiming to increase the adoption and frequency of STI testing in adults aged 18-30 should mainly target self-efficacy as it is the most important construct of SCT. This intervention should also utilize technology by reducing stigma and changing the perception of social norms to reach the target population. Further research should be performed to understand the importance of outcome expectations and outcome expectancies in one’s adoption of STI testing.