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. 2019 Aug 12;60(6):1159–1168. doi: 10.1093/geront/gnz098

A Web-Based HIV/STD Prevention Intervention for Divorced or Separated Older Women

Patricia Flynn Weitzman 1,✉, Yi Zhou 1, Laura Kogelman 2, Sarah Mack 1, Jie Yang Sharir 1, Sara Romero Vicente 1, Sue E Levkoff 1,3
Editor: Suzanne Meeks
PMCID: PMC7427482  PMID: 31403668

Abstract

Background and Objective

Sexually transmitted diseases (STDs) are increasing among older adults concomitant with a rise in divorce after the age of 50 years. The objective of this study was to examine the effectiveness of a web-based human immunodeficiency virus (HIV)/STD risk reduction intervention for divorced and separated women aged more than 50 years.

Research Design and Methods

Two hundred nineteen divorced or separated women, aged 50 years and older, participated in 60-day randomized pre–post control group study. Recruitment occurred via health agencies in Boston and Columbia, SC, and Craigslist advertisements placed in Boston, Columbia, Charleston, New York City, Washington DC, Baltimore, Chicago, Atlanta, Orlando, and Miami.

Results

Intervention group reported greater intention to practice safe sex compared to the control group (B = .55, p = .03). Intention to practice safe sex differed by perceived stress (B = .15, p = .005), with no difference between control and intervention groups for those with low levels of stress. For high levels of stress, intervention group reported greater intention to practice safe sex compared to controls. Sexual risk was reduced by 6.10 points (SD: 1.10), and self-efficacy for sexual discussion was increased by 2.65 points (SD: 0.56) in the intervention group.

Discussion and Implications

A web-based intervention represents a promising tool to reduce HIV/STD risk among older women. Offering HIV/STD education in the context of other topics of interest to at-risk older women, such as divorce, may solve the problem of at-risk older women not seeking out prevention information due to lack of awareness of their heightened risk.

Keywords: Sexual health, Dating, Positive psychology

The Centers for Disease Control and Prevention (2018a) notes a trend of increasing rates of sexually transmitted diseases (STDs) among older adults in the United States, particularly among those in ethnic minority groups (Centers for Disease Control and Prevention, 2018b). Between 2010 and 2014, Chlamydia, syphilis, and gonorrhea increased by 52%, 65%, and 90%, respectively, among American adults aged 65 years and older (Centers for Disease Control and Prevention, 2018a). Adults, aged 50 years and older, accounted for 17% of new human immunodeficiency virus (HIV) infection diagnoses in 2015 in the United States. (Centers for Disease Control and Prevention, 2018b). In the United States and elsewhere, older adults are typically diagnosed with HIV at a later stage when the disease is harder to treat (Centers for Disease Control and Prevention, 2018c; Hu et al., 2019; Mugavero, Castellano, Edelman, & Hicks, 2007; Wilton et al., 2019). A late diagnosis, combined with the presence of age-related comorbid conditions, makes the consequences of HIV more severe for older adults (United States Department of Health and Human Services, 2019). Unfortunately, acquired immune deficiency syndrome (AIDS) policies in the United States, as well as globally, often overlook HIV prevention and treatment needs of older adults (see The United States President’s Emergency Plan for AIDS Relief, 2019).

Older American women who become infected with an STD, including HIV, typically do so through heterosexual contact (Centers for Disease Control and Prevention, 2018d). Not surprisingly, older women who are divorced or widowed are at increased risk for HIV/STD infection compared to married older women (Cardoso et al., 2013). Indeed, divorce after the age of 50 years, also known as “gray divorce,” is more common among the current generation of older American women, that is, “baby boomers” born between 1946 and 1964, than in previous generations, which means more older women are dating than ever before (Brown, Lin, Wright, & Hammersmith, 2015). These older women are less likely to be aware of their HIV risk compared to younger adults due, at least in part, to the fact that they became sexually active before the HIV infection and AIDS(HIV/AIDS) crisis (Centers for Disease Control and Prevention, 2018b). Women are more easily infected with an STD than men, and older women especially so due to postmenopausal physiological changes (National Institute on Aging, 2018). Thus, older women who are dating are at double jeopardy for contracting an STD compared to men and younger women. An American Association of Retired Persons study found only 20% of older adults who are dating use condoms regularly (Fisher et al., 2010). Research suggests doctors may be uncomfortable raising the issue of HIV/STD prevention with their older women patients, and older women may be uncomfortable initiating these conversations with their doctors (Cardoso et al., 2013; Grant & Ragsdale, 2008). Indeed, older women may feel heightened stigma around HIV, which reduces the likelihood that they will seek out accurate information or the skills needed to reduce their risk (Durvasula, 2014). Furthermore, even if older women are aware of their need to practice safe sex, the older men they date may resist condom use (National Survey of Sexual Health and Behavior, 2019), which highlights the particular importance of concrete communication skills for negotiating condom use in risk reduction education for older women (Morton, Kim, & Treise, 2011).

Providing targeted safe sex education via the web can overcome access, stigma, and communication barriers that may uniquely affect older women. Nearly 70% of people aged more than 50 years in the United States, including minority seniors, use the internet (Zickuhr & Madden, 2016). Unfortunately, few websites offer concrete, age-specific HIV/STD prevention information for older adults. For example, several reliable health websites, such as National Institute on Aging, American Association of Retired Persons, Mayo Clinic, and Womenshealth.gov include information on HIV/AIDS in older adults, but the focus is largely on risk awareness and encouraging active sex lives, while often overlooking critical details on how to practice safe sex, especially key behavioral and communication skills that older women need for successful condom use. Ageisnotacondom.org promotes safe sex specifically among older adults. Although the site has valuable information about HIV prevention, it is designed for both older men and women, and as such, offers little concrete information to address unique challenges older women may face around negotiating safe sex, for example, an older male partner refuses to use a condom on the grounds that an older woman cannot get pregnant. Also, the website focuses almost exclusively on prevention of HIV.

As advantageous as the web may be for delivering safe sex education to older women who are dating, there is a complicating factor: because many older women are unaware of their risk, they are not going to deliberately seek out HIV/STD prevention information on the internet. Divorce, by contrast, is a frequently searched term on the internet (Google, 2017). Thus, given the rise in gray divorce, which represents a risk factor for HIV/STDs in older women, in this initial effort to deliver safe sex information to at-risk older women, we created Divorceafter50.com: an HIV/STD risk reduction web intervention for culturally diverse older women who are divorced or separated. Our primary outcome of interest was intention to practice safe sex. The site featured information about divorce recovery, dating, and building new relationships designed for culturally diverse older women. Embedded within it was age-specific, concrete safe sex education. The comprehensive site included evidence-based HIV/STD prevention information, including how to practice safe sex and communicate with sex partners about condoms; video interviews with women’s health, relationship, and dating experts; videos of culturally diverse older women discussing real-life safe sex challenges and solutions; an online community of older divorced women for sharing ideas and support; blog posts from health, financial, and legal experts; an “ask the expert” section in which women could write in questions to our team of experts; and related E-mails and text messages highlighting evidence-based activities to promote happiness and resilience. Building emotional resilience, in particular, may aid in divorce recovery and the adoption of safe sex behaviors (Sbarra, Smith, & Mehl, 2012; Wong Yuen, & Tang, 2015), yet rarely is a focal point of safe sex education.

This study evaluated the impact of Divorceafter50.com on older women’s intentions to practice safe sex.

Theoretical Bases

The Modified AIDS Risk Reduction Model (M-ARRM) (Miller, Exner, Williams, & Ehrhardt, 2000) posits that women’s adoption and maintenance of safe sex is a process involving five stages: (a) behavior labeling, (b) prioritizing, (c) commitment to change, (d) enactment, and (e) maintenance. Each stage takes into account the social context of women’s lives, particularly stress burden, and highlights specific strategies, such as negotiation and communication training, that aid in the acquisition of the behavior in a given stage. Our web intervention addressed M-ARRM stages 1–3 with written content providing basic HIV/STD education that we specifically framed to (a) heighten HIV risk perception in order to encourage the prioritization of safe sex, and (b) encourage women to see themselves as capable of implementing safe sex, that is, to promote safe sex self-efficacy. To address stages 4–5, we included (a) mobile access which would allow women to view the site as needed, including when they were out on a date, (b) video interviews with experts who offered multiple ways for older women to bring up safe sex with potential partners and ways to bring up the conversation with their health care professionals, (c) video interviews of older women discussing their own safe sex “success stories,” and (d) an online community which allowed women to support each other around the adoption and maintenance of safe sex behaviors.

The intervention was also informed by Social Cognitive Theory (Bandura, 1994), which posits that safe sex self-efficacy, that is, confidence in one’s ability to implement safe sex behaviors, is key to adopting safe sex behaviors. As such, the M-ARRM asserts self-efficacy is the primary capability that allows women to move from stage to stage (Miller et al., 2000). Methods for promoting self-efficacy include peer modeling and social persuasion (Bandura, 1994). On the website, peer modeling was offered via videos of older women discussing safe sex successes. Social persuasion occurred through these same videos as well as videos and articles from health experts and through contact with other older women through the online community.

Hypotheses

We evaluated the impact of Divorceafter50.com on older women’s intention to practice safe sex. Our primary hypothesis was that exposure to the intervention, via either computer or smartphone, would result in increased intention to engage in safe sex behaviors compared to controls. Our secondary hypothesis was that the impact of intervention on the primary outcome would be (a) mediated through key factors, including increased safe sex self-efficacy, increased HIV transmission knowledge, reduced sexual risks, and increased positive affect and (b) moderated by perceived stress and years since divorce/separation.

Methods

Power Analysis

A priori power analysis for a multiple regression with 16 predictors of intention to practice safe sex was conducted in GPower 3.1.3 to determine a sufficient sample size using an alpha of .05, a power of .80, and a moderate effect size of Cohen’s f2 of .15. On the basis of the aforementioned assumptions, the desired minimum total sample size was 160.

As indicated later, our actual sample size was 219 women.

Recruitment

The New England Internal Review Board approved the study protocol and materials. Inclusion criteria included women aged 50 years and older, divorced or separated, who are dating or thinking of dating in the near future, HIV negative, own a computer and a smartphone, and for whom English is their primary language. Exclusion criteria included currently married, HIV positive, participating in another research study, and do not own both computer and smartphone.

We distributed advertisements for the study through collaborating health and social service agencies in Boston and Columbia, SC, and through Craigslist in the following locations: the greater Boston area, Charleston and Columbia, SC, New York City, Washington, DC, Baltimore, MD, greater Chicago area, Atlanta, GA, and Orlando and Miami, FL.

Procedures

A pre–post control group study design was used to evaluate intervention effectiveness at increasing the intention to engage in safe sex behaviors. We focused on intention, rather than self-reported safe sex behaviors, for the following reasons: Safe sex intention is positively correlated with condom use, and frequently used as a proxy for actual behavior (Albarracín, Durantini, & Earl, 2006; Turchik & Gidycz, 2012). For individuals who are not yet dating/sexually active, new to dating, and/or for whom safe sex is a new idea, it could take longer than the 60-day study period for safe sex behaviors to be enacted (stage 4 of the M-ARRM). Indeed, how long it takes a divorced or separated older woman, on average, to start dating and/or implement new safe sex skills is not known, and is likely to be affected by numerous individual, social, and environmental factors (Edgar, Noar, & Freimuth, 2008). We included perceived stress burden as a potential moderating variable for two reasons. First, the intervention targeted emotional resilience and happiness building through texts/E-mails. Increased feelings of emotional resilience and positive affect are associated with reductions in perceived stress (Folkman & Maskowitz, 2000; Lyubomirsky, 2008). Second, reductions in perceived stress can facilitate the prioritizing of safe sex behaviors as per stage 2 of the M-ARRM (Miller et al., 2000). Finally, we also included time since divorce/separation as a moderator as it seemed possible that the greater the length of time since divorce/separation, the more likely a woman may have become sensitized to the issue of safe sex through dating or other experiences.

We aimed to make the Divorceafter50.com appropriate for culturally diverse women. Accordingly, we depicted culturally diverse women on the site, and engaged health experts with specific knowledge and expertise on minority women’s health to aid in developing and reviewing our content. We also used “plain-language,” for example, approximately eighth grade level, to ensure accessibility to women with varying literacy levels (see Quesenberry, 2017). In implementing the study, we recruited participants from American cities with relatively large ethnic minority populations to help ensure the inclusion of minority women. Nevertheless, our participants were primarily Caucasian (see Limitations section for discussion of possible reasons for this, along with ways to ensure that culturally diverse women access our website in the future).

We used Qualtrics software to implement the study. When interested individuals contacted us, we E-mailed a link to complete online eligibility screening that was set up within Qualtrics. If an individual self-screened as eligible, Qualtrics software automatically brought that individual to another page to review the consent form. If the individual consented to the study (by clicking a box online), the software program automatically E-mailed a copy of the signed informed consent to her and then linked her to the baseline surveys. (If an individual did not sign the consent, she was thanked for her time and was automatically exited from the program.) After each participant had completed the baseline surveys within Qualtrics, the Qualtrics Randomizer feature randomly assigned that participant to either the intervention group or the control group. Intervention group participants were further randomized by the Qualtrics Randomizer into computer or smartphone groups for viewing the website. (The consent form informed participants that they were required to use only their assigned device for viewing the website throughout the trial.) At the study conclusion, Qualtrics software automatically E-mailed each participant a link to retake the surveys that she had taken at baseline. The link led the participant either to the “intervention block” of surveys or to the “control block” of surveys, depending upon their group assignment. The intervention block included some open-ended questions about satisfaction with the website. Otherwise, the two survey blocks were identical to each other and to those administered at baseline. (See surveys later.)

During the study, intervention group participants were then given access to Divorceafter50.com for a 60-day period, which they were to view either by computer or smartphone according to their assignment. Intervention group participants were given a unique login for viewing the site, which allowed the research team to track time spent on the website, and determine if participants were using their assigned device. Intervention participants received twice-weekly E-mail/texts with specific evidence-based activities for promoting happiness and resilience drawn from the literature on positive psychology (see Lyubomirsky, 2008). These texts were developed by the team, and refined in formative focus groups with older women. The following is a text message example: <Keep a “gratitude journal”> At least once a week, think about three to five things for which you are currently grateful, and write them in your journal. Be Well!—The Divorce After 50 Team, www.divorceafter50.com.

Control group participants were E-mailed written materials with HIV/STD and safe sex education for older adults drawn from Centers for Disease Control and Prevention and National Institute on Aging websites (Centers for Disease Control and Prevention, 2018c; National Institute on Aging, 2018). The document was seven pages, large print, including graphics, and written in plain language by a health communications expert on the study team. Control group participants also received twice-weekly evidence-based health education E-mails on general health topics relevant to older women, for example, heart health, exercise, healthy eating. Following is an example of an E-mail sent to control group participants: Subject: Take charge of your health. Hi there! Here’s a tip for you—Physical activity can reduce menopausal symptoms like hot flashes, joint pain, and sleep problems. Be Well,—The Divorce After50 Team.

At baseline (T1) and 60 days (T2), the following surveys were administered: For intention to practice safe sex, we used a three-item intention to engage in safe sex practices instrument, which we had used in the pilot phase of the study and which has been used with at-risk male and female populations (Fisher, Willcutts, Misovich, & Weinstein, 1998; Mausbach, Semple, Strathdee, & Patterson, 2009). As the study did not evaluate actual safe sex behavior, that is, enactment, we considered intention to practice to be a proxy for this stage of the M-ARRM. Because a primary goal of the intervention was to increase HIV/STD prevention knowledge and, especially, HIV/STD risk awareness, we administered the 38-item Sexual Risks Scale (modified) (DeHart & Birkimer, 1997); the 15-item HIV/AIDS Knowledge and Attitudes Survey (Diclemente, Zorn, & Temoshok, 1986; Li et al., 2004); and the 13-item modified HIV Sexual Transmission and Prevention Knowledge Survey (Henderson et al., 2004). To assess safe sex self-efficacy, we administered the 8-item Self-efficacy for Sexual Discussion Scale (Lux & Petosa, 1994). The M-ARRM posits that stress burden may affect the prioritization of safe sex. We, therefore, administered the 10-item Perceived Stress Scale (Cohen & Williamson, 1988). Finally, research shows that chronic stress burden may be mitigated by experiences of positive affect (Folkman & Maskowitz, 2000), which we attempted to boost via targeted positive psychology E-mails/texts. Accordingly, we measured positive affect using the 4-item General Happiness Scale (Lyubomirsky & Lepper, 1999).

A general demographic information form (age, ethnicity, education, income, time since divorce or separation) and the Center for Epidemiologic Studies Depression Scale (CES-D) were administered at baseline (only) to all participants (Radloff, 1977). The latter was included as a control variable to account for the possibility that the presence of depression might impede intervention uptake and efficacy. Individuals who scored above 16 on the CES-D were retained in the study, but contacted by a licensed mental health professional, who offered referral. CES-D scores were the only survey results that were viewed by the team prior to the conclusion of the study.

All participants were compensated $30 for completing the baseline surveys, and $30 for completing them again at 60 days. Compensation occurred at 60 days and was provided in Amazon.com points. Intervention group participants were paid $1.00 for every 5 min of time on the website and were required to spend 5 min per week more than 60 days; maximum time compensated per week was equal to $5.00 for 25 min of activity. Individuals in the smartphone subgroup also received 25 cents reimbursement for each text they received.

Data Analysis

Quantitative data were obtained from the surveys and entered into SAS 9.4 (SAS Institute, Cary, NC). Descriptive statistics, including frequencies for categorical data, and means and standard deviations for continuous data were calculated. The primary hypothesis was tested through a series of multiple linear regression models. Tests for normality, multicollinearity, and heteroscedasticity were performed to assess violations of analytic assumptions. The first regression model included four demographic variables (age, ethnicity, depression, and income), location of recruitment, and the intervention variable as predictors of participants’ intentions to practice safe sex (measured as the difference between T1 and T2 responses). Next two interaction models were estimated to examine if the relationship between being in the intervention group or the control group and intentions to practice safe sex differed by (a) stress and (b) time since most recent divorce or separation (measured as years). Next, we used the Sobel test to see if changes in intention to practice safe sex were mediated by changes (T2 − T1) in (a) HIV/AIDS Knowledge and Attitudes, (b) HIV Sexual Transmission and Prevention Knowledge, (c) Sexual Risks Scale, (d) Self-efficacy for Sexual Discussion, and (e) General Happiness. These analyses allowed us to examine if the intervention resulted in a change that ultimately influenced the outcome.

Results

Participant Characteristics

Overall, 451 women initiated the online survey through Qualtrics, and 331 were eligible for the study. Of these, 219 participants completed both the pre-test and the final post-test surveys (Figure 1). There were 123 participants in the control group and 96 participants in the intervention group, with 34 accessing the intervention via smartphone and 62 via computer, respectively. The mean age for study participants was 54.6 (SD = 3.6) years; 54.4 (SD = 2.9) years in control group, 54.9 (SD = 4.3) years in smartphone group, and 54.7 (SD = 4.3) years in the computer group. There was no difference in age between the intervention and control group (p = .446).

Figure 1.

Figure 1.

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Diagram of participants flow through phases of the study: a web-based HIV/STD prevention intervention Divorceafter50.Com, United States, 2017. HIV = human immunodeficiency virus; STD = sexually transmitted disease.

Table 1 presents a descriptive analysis of the categorical variables involved in this study. Approximately 80% of the participants were divorced, over three-quarters were white, all women had at least a high-school degree or equivalent, and most women had annual incomes between $10,000 and $59,000. In addition, Craigslist was the most common place that participants learned about the study.

Table 1.

Demographic and Other Baseline Characteristics of Intervention and Control Groups of Divorced or Separated Older Women: A Web-Based HIV/STD Prevention Intervention Divorceafter50.Com, United States, 2017

Variables Control Smartphone Computer
Marital status
 Divorced 88 (73.3%) 31 (91.2%) 55 (88.7%)
 Separated 32 (26.7%) 3 (8.8%) 7 (11.3%)
Race/ethnicity
 American Indian or Alaskan Native 1 (0.9%) 2 (6.2%) 3 (5.1%)
 Asian/Pacific Islander 2 (1.7%) 0 (0%) 0 (0%)
 Black or African American 7 (6.0%) 3 (9.4%) 2 (3.4%)
Hispanic 13 (11.2%) 3 (9.4%) 8 (13.5%)
 White/Caucasian 90 (77.6%) 24 (75.0%) 44 (74.6%)
 Multiple ethnicity/Other 3 (2.6%) 0 (0%) 2 (3.4%)
Educational level
 High-school degree or equivalent 39 (31.7%) 14 (41.2%) 18 (29.0%)
 Some college 38 (30.9%) 8 (23.5%) 19 (30.7%)
 College graduate 40 (32.5%) 9 (26.5%) 23 (37.1%)
 Graduate degree 6 (4.9%) 3 (8.8%) 2 (3.2%)
Years since separation/divorce
 <1 2 (1.6%) 0 (0%) 1 (1.6%)
 1–5 53 (43.1%) 18 (53.0%) 23 (37.1%)
 6–10 59 (48.0%) 15 (44.1%) 33 (53.2%)
 >10 9 (7.3%) 1 (2.9% 5 (8.1%)
Annual income
 <$10,000 14 (11.4%) 7 (20.6%) 5 (8.0%)
 $10,000–$19,000 30 (24.4%) 9 (26.5%) 17 (27.4%)
 $20,000–$39,000 36 (29.3%) 11 (32.4%) 20 (32.3%)
 $40,000–$59,000 16 (13.0%) 4 (11.7%) 8 (12.9%)
 $60,000–$79,000 10 (8.1%) 2 (5.9%) 4 (6.5%)
 $80,000–$99,000 11 (8.9%) 1 (2.9%) 8 (12.9%)
 >$100,000 6 (4.9%) 0 (0%) 0 (0%)
Recruitment source
 Craigslist.com 54 (43.9%) 14 (41.2%) 26 (41.9%)
 Friend/someone you know 29 (23.6%) 6 (17.6%) 12 (19.4%)
 Posted sign or advertisement 5 (4.1%) 3 (8.8%) 1 (1.6%)
 Facebook 23 (18.7%) 6 (17.6%) 15 (24.2%)
 Health care or social service agency 9 (7.3%) 5 (14.7%) 5 (8.1%)
 Other 3 (2.4%) 0 (0%) 3 (4.8%)
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Note: HIV = human immunodeficiency virus; STD = Sexually transmitted disease.

Intention to Practice Safe Sex

Results from the main effect multiple linear regression model reveal that, after controlling for age, ethnicity, depression, income, and recruitment location, women who participated in the intervention reported greater intention to practice safe sex, compared to women in the control group (B = .551, p =.029). In addition, the relationship between the intervention effect and intention of practicing safe sex differed by stress levels (B = .15, p = .005). That is, there were no noticeable differences between the control and intervention groups among those with low levels of stress, however, among women with the highest levels of stress, those in the intervention group reported significantly higher intention to practice safe sex compared to controls with similar levels of stress. There was no moderating effect of time, possibly because most participants were recently divorced or separated. Results from all three regression models are presented in Table 2.

Table 2.

Regression Models for Changes in Intention to Practice Safe Sex Among Intervention and Control Group of Divorced or Separated Older Women: A Web-Based HIV/STD Prevention Intervention Divorceafter50.Com, United States, 2017

Model B SE t p
Main effects only
Age .09 0.04 2.35 .02
Ethnicity
 Others .1 0.29 0.35 .73
 Ref (Caucasian) — — — —
Depression −.03 0.01 −3.17 .002
Income −.08 0.09 −0.85 .40
Location of recruitment
 Massachusetts .97 0.5 1.99 .048
 Other locations .37 0.39 0.95 .35
 Ref (South Carolina) — — — —
Group
 Intervention .55 0.25 2.2 .029
 Ref (control) — — — —
Main effects with modification effect of stress level
Stress level −.1 0.03 −2.86 .005
Group
 Intervention .78 0.27 2.88 .004
 Ref (control) — — — —
Interaction
 Stress level × intervention .15 0.05 3.08 .002
Main effects with modification effect of time since most recent divorce or separation in years
Time −.01 0.27 −0.06 .96
Group
 Intervention .54 1.11 0.49 .62
 Ref (control) — — — —
Interaction
 Time × intervention 0 0.41 0 .99
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Note: HIV = human immunodeficiency virus; STD = sexually transmitted disease.

On average, sexual risk was reduced 6.10 points (SD = 1.10) among women in the intervention group compared to almost no changes in the control group (0.07 [SD = 0.91]); 57% of the total intervention effect on intention to practice safe sex was mediated by perceived sexual risk. Self-efficacy for sexual discussion increased 2.65 points (SD = 0.56) among the intervention group compared to a 0.84 (SD = 0.38) in the control group; 21% of the total intervention effect on intentions to practice safe sex was mediated by self-efficacy for sexual discussions. The other three variables, General Happiness, HIV Sexual Transmission and Prevention Knowledge, and HIV/AIDS Knowledge did not show significant mediation effects (see Table 3). These findings suggest that the intervention increased risk perception, which is associated with prioritization stage in the M-ARRM. Also, intention to practice safe sex, here a proxy for the M-ARRM enactment stage, was increased via an increased sense of safe sex self-efficacy.

Table 3.

Summary of Sobel Tests for Mediation of Intervention Effect: A Web-Based HIV/STD Prevention Intervention Divorceafter50.Com, United States, 2017

Variables Intervention group Control group
Change between pre- and post-test SE Change between pre- and post-test SE Indirect effect of intervention mediated by variable (in each row) Proportion of total effect mediated
Sexual Risks Scale −6.10 1.10 0.07 0.91 0.084* 57.3%
Self-efficacy For Sexual discussion 2.65 0.56 0.84 0.38 0.030* 20.7%
General Happiness Scale 0.01 0.38 −0.11 0.33 0.001 0.4%
HIV Sexual Transmission and Prevention Knowledge Survey 0.90 0.21 0.75 0.17 0.003 2.0%
HIV/AIDS Knowledge Survey −1.07 0.28 −0.86 0.32 −0.007 −4.6%
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Notes: *Indirect effect statistically significant at .05 level. HIV = human immunodeficiency virus; STD = sexually transmitted disease.

The regression model did not show change in intention to be associated with time spent on website or using either computer or smartphone.

Discussion

Between 2015 and 2016, there was a 20% increase in the number of older adults diagnosed with an STD (Centers for Disease Control and Prevention, 2018a). This increase was greater than in any other age group. Moreover, thousands of adults aged more than 50 years are infected with HIV each year, often at a later stage when the disease is harder to treat. Divorce and separation are risk factors for HIV/STD infection among older women (Cardoso et al., 2013). Yet there is a lack of concrete, targeted safe sex education for this group. To the best of our knowledge, Divorce After 50 is the first online health education platform to provide targeted multimedia, interactive educational information about HIV/STD prevention for culturally diverse divorced or separated older women. An online platform for delivering evidence-based HIV/STD prevention information can overcome access barriers, and gaps in information delivered to older women by their providers, particularly sexual health and prevention information, as well as stigma and privacy barriers that stop older women from seeking safe sex information. Moreover, an online platform can create possibilities for peer connection and support around dating, divorce, and safe sex, which may have both emotional and behavioral benefits for older women. Indeed, we received unsolicited E-mails from intervention participants about the particular value the online community had for them.

Divorceafter50.com increased the intention to practice safe sex in the intervention group. The intervention appears to have done so via an increase in women’s confidence that they could manage (i.e., reduce) their own sexual risk behaviors, and through increased self-efficacy for negotiating safe sex with sexual partners. As such, the findings align with the M-ARRM, which emphasizes the centrality of risk perception and safe sex self-efficacy to the prioritization and enactment of safe sex behaviors. Our study results also align with an earlier, non-web intervention based on the M-ARRM, which found that the broad provision of several alternative risk reduction strategies was key to enactment and commitment (Ehrhardt et al., 2002).

Interestingly, our finding pertaining to stress and the intention to practice safe sex seems to stand in contrast to the M-ARRM, which posits that relief from stressors aids in the prioritization of safe sex (Dworkin, Exner, Melendez, Hoffman, & Ehrhardt, 2006; Miller et al., 2000). Among participants with high levels of stress, those in the intervention group reported significantly higher intentions to practice safe sex compared to those in the control group with similar levels of stress. One possible explanation: higher stress is related to greater anxiety or cautiousness. As such, the more compelling, dynamic information about risk as provided on the website (compared to written materials given to control group participants) may have evoked a stronger response in these individuals. Future research on how emotional states affect the impact of safe sex education and how different delivery formats could affect different individuals may strengthen the impact of risk reduction interventions.

Limitations

One limitation of the study is that the intervention targeted intent to practice safe sex, and not actual behavior related to sexual risk taking. We made this decision based on the idea that some participants may not yet be dating. We are, nonetheless, aware that evaluating the impact of the intervention on actual behavior change would provide more definitive evidence of its value. We plan to do this in the future. Another limitation relates to the relative lack of ethnic diversity in our sample. The majority of participants were white/Caucasian, despite having recruited in cities with relatively large minority populations, such as Atlanta, Washington DC, Miami. Our team mistakenly assumed that an online recruitment strategy would reach older minority women, given data that show that most minority older adults do access the internet on a regular basis (via computer or smartphone). Given among older women, African American and Latino women are at increased risk for HIV/STDs, compared to their non-Hispanic white peers (Centers for Disease Control and Prevention, 2018b), it is essential for an intervention such as this to reach minority women. We have since found a study of social media strategies, including Craigslist, for recruiting African American women into web-based health research, which showed that Craigslist on its own was relatively ineffective, and that all social media outreach needed to be buttressed by face-to-face methods (Staffelino et al., 2017). Moreover, a study on the use of social media for reaching Latino participants for health research found that both involving stakeholders in the development of the social media strategy, and involving community organizations in promoting the study, were key to recruitment success (Martinez et al., 2014). Finally, in an article about online recruitment of African American adults for health research, the authors emphasized the importance of using additional recruitment strategies to complement online recruitment, and involving community gatekeepers in the process (Watson, Robinson, Harker, & Jacob Arriola, 2016). Our future efforts to promote the website among older minority women will involve such strategies.

An additional factor that may have affected recruitment of African American women may be relatively lower rates of marriage in this group as compared to Latino women and non-Latino white women (Raley, Sweeney, & Wondra, 2015). Anecdotally, a public health scientist consultant to the project, who is an expert on ethnic disparities in HIV, suggested many African American women may not identify as divorced or separated, even after they have been in a long-term cohabiting relationship that has ended. Accordingly, renaming and/or reframing the intervention for older women who are dating may better reach at-risk minority women.

Implications

Older divorced and separated women who are dating are at increased risk for STDs and HIV. Easily accessible online platforms represent a promising tool to provide much-needed HIV/STD prevention information to this group, both here in the United States, and internationally. Given the rise of the internet and mobile health in both lower and middle income countries, online platforms, such as the one developed here, offer great potential for implementation globally. The issue of how to negotiate condom use, in particular, is relevant to women globally, particularly in African countries hit hard by HIV/AIDS (e.g., Loggerenberg et al., 2012; Schuyler et al., 2016). Although education of this type must be tailored to culture and age group, our findings suggest doing so visually, using video stories from actual women, and making those stories easily accessible via the internet, may have value for women in countries with generalized HIV/AIDS epidemics. Our study demonstrated that such a platform can successfully educate older divorced/separated women about safe sex and—importantly—raise their own risk awareness and increase their sense of safe sex self-efficacy and, in so doing, their commitment to practicing safe sex. Creating targeted and dynamic safe sex content for older women, and offering it online in order to eliminate barriers that uniquely affect this group, may help reduce the alarming rise in STDs being seen among older adults. Finally, given the intersectionality of some women’s multiple statuses, for example, being an ethnic minority, a sexual minority, and/or disabled, future interventions need to address the different impacts each of these contexts might have on risk reduction intentions and behaviors (Durvasula, 2014). Future directions include scaling up marketing strategies, organizational partnerships, and delivery models in order to benefit greater numbers of culturally diverse older women at risk.

Funding

This work was supported by the National Institutes of Health (5 R44 AG034707-03 to P. F. Weitzman).

Conflict of Interest

None reported.

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