Abstinence and safer sex HIV risk-reduction interventions for African American adolescents: a randomized controlled trial

Testing implementation support for evidence-based programs in community settings: a replication cluster-randomized trial of Getting To Outcomes®

Background

Community organizations can have difficulty implementing evidence-based prevention programs. More research is needed on implementation support interventions designed to help these organizations implement programs with quality.

Methods

Preparing to Run Effective Programs (PREP) is a randomized controlled trial testing Getting To Outcomes (GTO), a 2-year implementation support intervention. It compares 15 Boys and Girls Club sites implementing CHOICE (control group), a five-session evidence-based alcohol and drug prevention program, with 14 similar sites implementing CHOICE supported by GTO (intervention group). PREP replicates a previous GTO study that had the same design, but featured a teen pregnancy prevention program instead. All sites received typical CHOICE training. Fourteen intervention sites received GTO manuals, training, and onsite technical assistance to help practitioners complete implementation best practices specified by GTO (i.e., GTO steps). During the first year, technical assistance providers helped the intervention group adopt, plan, and deliver CHOICE. Then, this group was trained on evaluation and quality improvement steps of GTO using feedback reports summarizing their own data, which yielded revised plans for subsequent implementation of CHOICE. This paper presents results regarding GTO’s impact on CHOICE fidelity (adherence, quality of delivery, dosage) and the proximal outcomes of the youth participants (aged 10–14)—attitudes and intentions regarding cigarettes, alcohol, and marijuana use. Fidelity was assessed at all sites by observer ratings and attendance logs. Proximal outcomes were assessed via survey at baseline, 3, and 6 months.

Results

After 1 year, fidelity and proximal outcomes were similar between Intervention and control groups. After 2 years (which included GTO quality improvement activities that took place between years 1 and 2), intervention sites had higher ratings of CHOICE adherence and quality of delivery (dosage remained similar). Proximal outcomes did not differ between groups in either year, although there was universally high endorsement of prosocial responses to those outcomes from the start.

Conclusions

Findings suggest that systematic implementation support provided by GTO can help community organizations achieve better fidelity. Findings replicate the implementation results from a previous GTO study using the same design, but with a different evidence-based program and different fidelity measures. Although proximal outcomes did not change, in large part due to ceiling effects, the implementation findings suggest GTO can support a variety of programs.

Trial registration

This project is registered at ClinicalTrials.gov with number NCT02135991. The trial was first registered on May 12, 2014.

Health-Promotion Intervention Increases Self-Reported Physical Activity in Sub-Saharan African University Students: A Randomized Controlled Pilot Study

To evaluate the efficacy of a health-promotion intervention in increasing self-reported physical activity among university students in Sub-Saharan Africa. Randomly selected second-year students at a university in South Africa were randomized to an intervention based on social cognitive theory: health-promotion, targeting physical activity and fruit, vegetable, and fat consumption; or HIV risk-reduction, targeting sexual-risk behaviors. Participants completed assessments via audio computer-assisted self-interviewing pre-intervention and 6 and 12 months post-intervention. A total of 176 were randomized with 171 (97.2%) retained 12 months post-intervention. Generalized-estimating-equations analyses indicated that the health-promotion-intervention participants were more likely to meet physical-activity guidelines than were control participants, post-intervention, adjusting for pre-intervention physical activity (odds ratio [OR] = 3.35; 95% CI: 1.33-8.41). Health-promotion participants reported a greater number of days they did vigorous-intensity (risk ratio [RR] = 2.01; 95% CI: 1.43-2.83) and moderate-intensity (RR = 1.40; 95% CI: 1.01-1.95) aerobic activity, but not strength-building activity (RR = 1.37; 95% CI: 0.091-2.07). The intervention reduced self-reported servings of fried foods (mean difference = -0.31; 95% CI: -0.60, -0.02). The findings suggest that theory-based, contextually appropriate interventions may increase physical activity among university students in Sub-Saharan Africa.

A Cluster-Randomized Trial of Getting To Outcomes' Impact on Sexual Health Outcomes in Community-Based Settings

The USA has high teen pregnancy rates compared to other developed nations. Many community-based organizations need assistance conducting evidence-based teen pregnancy prevention programs (EBPs) appropriately. This study evaluated the impact of an implementation support intervention called Getting To Outcomes (GTO) designed to help such organizations. This cluster randomized controlled trial compared 16 Boys and Girls Clubs (BGCs) implementing a teen pregnancy prevention EBP called Making Proud Choices for two years, with 16 BGCs implementing MPC augmented with GTO training, tools, and technical assistance. Participating middle school youth were compared on proximal outcomes (knowledge, attitudes, and intentions about sex and condoms from baseline to post) and sexual behaviors (frequency of sex and condom use, from baseline to 6-month follow-up). In year 1, there were no significant effects of GTO for any proximal outcome. After GTO-stimulated quality improvement in year 2, the GTO group improved significantly more on condom attitudes and use intentions. Frequency of sex and condom use did not differ between the two groups in either year; however, base rates of these behaviors in the sample were very low. Findings suggest that in typical community-based settings, detailed manuals and training common to structured EBPs may be sufficient to yield some improvement in key proximal outcomes, but that more systematic implementation support is needed to achieve greater improvement in these outcomes. Using GTO with many communities, as currently supported by various federal agencies, could yield public health impact via improvements in condom attitudes and use intentions.

Abstinence Funding Was Not Associated With Reductions In HIV Risk Behavior In Sub-Saharan Africa

The President's Emergency Plan for AIDS Relief (PEPFAR) has been the largest funder of abstinence and faithfulness programming in sub-Saharan Africa, with a cumulative investment of over US $1.4 billion in the period 2004-13. We examined whether PEPFAR funding for abstinence and faithfulness programs, which aimed to reduce the risk of HIV transmission, was associated with a relative change in five outcomes indicative of high-risk sexual behavior: number of sexual partners in the past twelve months for men and for women, age at first sexual intercourse for men and for women, and teenage pregnancies. Using nationally representative surveys from twenty-two sub-Saharan African countries, we compared trends between people living in countries that received PEPFAR abstinence and faithfulness funding and those living in countries that did not in the period 1998-2013. We found no evidence to suggest that PEPFAR funding was associated with population-level reductions in any of the five outcomes. These results suggest that alternative funding priorities for HIV prevention may yield greater health benefits.

Predictors and psychological pathways for binge drinking among South African men

OBJECTIVE

To develop targeted interventions for high-risk drinkers among South African men, we assessed whether sociodemographic factors and history of childhood sexual abuse predicted binge drinking at six-month follow-up assessment and their psychological pathways according to the extended Theory of Reasoned Action (TRA).

DESIGN

Survey responses with a sample of 1181 South African men from randomly selected neighbourhoods in Eastern Cape Province were collected at baseline and six-month follow-up. Multiple logistic regression analysis examined the baseline predictors of binge drinking. Serial multiple mediation analysis examined the psychological pathways.

MAIN OUTCOME MEASUREMENTS

Binge drinking at six-month follow-up.

RESULTS

Age (OR = 1.03, 95% CI: 1.01, 1.05), religious participation (OR = .73, CI: .65, .82) and history of childhood sexual abuse (OR = 1.82, CI: 1.32, 2.51) were significant predictors of binge drinking. Predictions of religious participation and history of childhood sexual abuse were partially mediated through attitude, subjective norm, descriptive norm and intention to binge drinking.

CONCLUSION

South African men with childhood sexual abuse experience and low religious participation were at higher risk for binge drinking. The extended TRA model explains the associations of these factors to binge drinking and can contribute to the design and evaluation of interventions.

Preliminary Impacts of an HIV-Prevention Program Targeting Out-of-School Youth in Postconflict Liberia

Adolescents in Sub-Saharan Africa account for greater HIV/STI (human immuno defiency virus/sexually transmitted infection) burdens and difficult-to-reach populations. This study implemented a community-based HIV/STI program to reach at-risk youth aged 15 to 17 years in postconflict Liberia. Using a randomized controlled trial, community youths were assigned to an adapted version of an effective HIV/STI program, Making Proud Choices, or attention-matched comparison curriculum, General Health Program. Both programs were of similar doses, reach and coverage, and administered in classroom settings by trained health educators. The findings suggest that the adapted HIV/STI program had positive effects on knowledge, sexual refusal and condom use self-efficacy, condom negotiation self-efficacy, positive condom attitudes, parental communication about sex, and negative condom attitudes over time. Culturally adapted community-based, behavioral-driven programs can positively affect mediators of sexual behaviors in at-risk adolescents in postconflict settings. This is the first published report of an evidence-based HIV/STI program on sexual risk-taking behaviors of community youths in Liberia.

Comparison of comprehensive and abstinence-only sexuality education in young African American adolescents

The purpose of this study was to identify predictors of sexual behavior and condom use in African American adolescents, as well as to evaluate the effectiveness of comprehensive sexuality and abstinence-only education to reduce adolescent sexual behavior and increase condom use. Participants included 450 adolescents aged 12-14 years in the southern United States. Regression analyses showed favorable attitudes toward sexual behavior and social norms significantly predicted recent sexual behavior, and favorable attitudes toward condoms significantly predicted condom usage. Self-efficacy was not found to be predictive of adolescents' sexual behavior or condom use. There were no significant differences in recent sexual behavior based on type of sexuality education. Adolescents who received abstinence-only education had reduced favorable attitudes toward condom use, and were more likely to have unprotected sex than the comparison group. Findings suggest that adolescents who receive abstinence-only education are at greater risk of engaging in unprotected sex.

Improving -Omics-Based Research and Precision Health in Minority Populations: Recommendations for Nurse Scientists

PURPOSE

The purpose of this article is to provide an overview of the role of nurse scientists in -omics-based research and to promote discussion around the conduct of -omics-based nursing research in minority communities. Nurses are advocates, educators, practitioners, scientists, and researchers, and are crucial to the design and successful implementation of -omics studies, particularly including minority communities. The contribution of nursing in this area of research is crucial to reducing health disparities.

METHODS

In this article, challenges in the conduct of -omics-based research in minority communities are discussed, and recommendations for improving diversity among nurse scientists, study participants, and utilization of training and continuing education programs in -omics are provided.

FINDINGS AND CONCLUSIONS

Many opportunities exist for nurses to increase their knowledge in -omics and to continue to build the ranks of nurse scientists as leaders in -omics-based research. In order to work successfully with communities of color, nurse scientists must advocate for participation in the Precision Medicine Initiative, improve representation of nurse faculty of color, and increase utilization of training programs in -omics and lead such initiatives.

CLINICAL RELEVANCE

All nursing care has the potential to be affected by the era of -omics and precision health. By taking an inclusive approach to diversity in nursing and -omics research, nurses will be well placed to be leaders in reducing health disparities through research, practice, and education.

Devaluation of Safe Sex by Delay or Uncertainty: A Within-Subjects Study of Mechanisms Underlying Sexual Risk Behavior

The value of safe sex may be discounted based on contextual factors associated with an opportunity for sex. College students in a within-subjects study selected hypothetical sexual partners from a set of pictures and classified them based on attractiveness and estimated chance of having an sexually transmitted infection (STI). In the Sexual Delay Discounting (SDD) task, participants rated their likelihood (0-100 %) of waiting for some period of time (e.g., 3 h) to have protected sex with their selected partners, when they could have immediate sex without protection. In the Sexual Probability Discounting (SPD) task, participants rated their likelihood of having protected sex if the opportunity was uncertain (e.g., 50 %), when they could have unprotected sex for sure (100 %). All participants included in the final analyses were aware of and had a positive attitude towards protection against STIs as they were likely to have immediate (or certain) protected sex. Results from 432 delay data in the SDD task and 488 probability data in the SPD task showed that participants' preference for safe sex systematically decreased as the delay to and odds against having safe sex increased. However, this preference was altered by the participants' perception of their partner's attractiveness and STI risk.

The Sooner, the Worse? Association between Earlier Age of Sexual Initiation and Worse Adolescent Health and Well-being Outcomes

This cross-sectional study assesses the association between age of sexual initiation during adolescence and a selection of well-being outcomes regarding that first relationship. High-school adolescents from El Salvador (2,686) and from Peru (3,399) replied to a paper-pencil questionnaire. Those who were sexually initiated replied to several questions regarding their age at sexual initiation, condom use, satisfaction and reasons/circumstances for that sexual relationship. Approximately 19% of participants were sexually initiated (n = 1,179). After retaining participants with valid responses and with sexual initiation ages between 13 and 17, the final sample for this paper consisted of 996 sexually initiated participants (526 Salvadorians and 470 Peruvians). Multiple logistic regression analyses showed that those who initiated sex at earlier ages had worse outcomes compared to those who initiated at older ages. Specifically, they had lower odds of having used a condom, of having good memories of that experience and of having had that first relationship because they were in love. Conversely, they had higher odds of having had that first sexual relationship as a result of peer pressure (“Most of my friends already had sex”), because of partner pressure (“I was afraid to lose him/her,” “My partner told me he/she would leave me” or “I did not know how to say no to a person who insisted”), or as a consequence of different forms of impaired autonomy (“I was under the influence of alcohol or drugs” or “As a consequence of seeing sexual images”). Results show that sex at earlier ages is associated with worse adolescent health and well-being outcomes.

Go Grrrls: A Randomized Controlled Trial of a Gender-Specific Intervention to Reduce Sexual Risk Factors in Middle School Females

PURPOSE

Adolescent females continue to face health consequences associated with risky sexual behaviors such as unintended pregnancies and sexually transmitted diseases. The purpose of this study was to investigate the efficacy of a gender-specific intervention targeted to early adolescent females.

METHOD

This study used an intent to treat randomized clinical trial comparing a broad-based female empowerment curriculum with a dose-matched science and technology female leadership curriculum. The sample ( N = 801) was recruited from schools and was implemented in community-based settings mostly in an after school context. Assessments were conducted at baseline, postintervention, 6-, and 18-month follow-up time periods.

RESULTS

Both groups in the study obtained good implementation and engagement. The average attendance rate was 81% of program sessions. There were significant differences between the two groups favoring the intervention group on measures of sexually transmitted disease knowledge and condom technical skills. On a measure of condom self-efficacy, there was a significant trend. At the postassessment, there was a significant difference on the intentions to reduce sexual risk behaviors. Both the intervention and control groups made gains on the self-assertive behavior scale.

CONCLUSIONS

Gender-specific programs for early adolescent females can help reduce indicators that are related to sexual risk reduction. More long-term follow-up is needed to assess impact on sexual behaviors. Efforts directed at a younger population of females should continue to be researched for potential in reducing sexual risks.

Randomized controlled trial of abstinence and safer sex intervention for adolescents in Singapore: 6-month follow-up

We assessed the efficacy of an individual-based behavioral intervention on sexually transmitted infections' (STI) risk-reduction behaviors in Singapore. A randomized controlled trial of a behavioral intervention compared to usual care was conducted on sexually active heterosexual adolescents aged 16-19 years attending the only public STI clinic. The intervention included two on-site skills-based sessions targeting individual, relational and environmental influences on sexual behaviors, followed by online support. Participants were assessed at baseline and 6-month follow-up. Primary outcomes were self-reported abstinence, number of partners and consistent condom use for vaginal sex. We recruited 337 adolescents to the intervention and 351 to usual care (controls). Fifty-nine percent of intervention participants and 53% of controls completed follow-up. Young men [adjusted risk ratio (RR) 2.03; 95% CI, 1.25-3.30], but not young women, in the intervention were more likely than controls to report secondary abstinence. More non-abstinent young women in the intervention than controls kept to one partner (adjusted RR, 1.25; 95% CI, 1.04-1.50) compared to no differences in young men. There was no intervention effect on consistent condom use in both genders. Skill-based intervention can promote abstinence in young men and keeping to one partner in young women in a clinic setting.

Association between Socio-Ecological Risk Factor Clustering and Mental, Emotional, and Behavioral Problems in Hispanic Adolescents

Compared to non-Hispanic whites, Hispanic adolescents in the U.S. report higher rates of several mental, emotional, and behavioral (MEB) problems such as substance use, sexual risk behaviors, and internalizing and externalizing problems. There is evidence of common pathways in the development of MEB problems with certain subgroups of Hispanic adolescents being at greater risk. In the present article, we report analysis of baseline data for 959 Hispanic adolescents who participated in one of two randomized controlled trials evaluating a family-based preventive intervention. Utilizing latent class analysis, we identified subgroups of Hispanic adolescents based on socio-ecological risk and protective factors (e.g., parent-adolescent communication, parental involvement in school). Three distinct socio-ecological risk subgroups (high, medium, and low risk) were identified and exhibited significant differences from each other across a majority of socio-ecological risk and protective factors. Adolescents in higher socio-ecological risk subgroups reported greater MEB problems across all outcomes. Individual comparisons revealed significant differences between the low socio-ecological risk group and both the medium and high socio-ecological risk group in lifetime alcohol use, smoking, and sex, as well as internalizing and externalizing problems. Implications for intervention include focusing on specific risk subgroups and targeting shared risk and protective factors rather than specific MEB outcomes.

NATIVE-It's Your Game: Adapting a Technology-Based Sexual Health Curriculum for American Indian and Alaska Native youth

Sexually transmitted infection (STI) and birth rates among American Indian/Alaska Native (AI/AN) youth indicate a need for effective middle school HIV/STI and pregnancy prevention curricula to delay, or mitigate, the consequences of early sexual activity. While effective curricula exist, there is a dearth of curricula with content salient to AI/AN youth. Further, there is a lack of sexual health curricula that take advantage of the motivational appeal, reach, and fidelity of communication technology for this population, who are sophisticated technology users. We describe the adaptation process used to develop Native It's Your Game, a stand-alone 13-lesson Internet-based sexual health life-skills curriculum adapted from an existing promising sexual health curriculum, It's Your Game-Tech (IYG-Tech). The adaptation included three phases: (1) pre-adaptation needs assessment and IYG-Tech usability testing; (2) adaptation, including design document development, prototype programming, and alpha testing; and (3) post-adaption usability testing. Laboratory- and school-based tests with AI/AN middle school youth demonstrated high ratings on usability parameters. Youth rated the Native IYG lessons favorably in meeting the needs of AI/AN youth (54-86 % agreement across lessons) and in comparison to other learning channels (57-100 %) and rated the lessons as helpful in making better health choices (73-100 %). Tribal stakeholders rated Native IYG favorably, and suggested it was culturally appropriate for AI/AN youth and suitable for implementation in tribal settings. Further efficacy testing is indicated for Native IYG, as a potential strategy to deliver HIV/STI and pregnancy prevention to traditionally underserved AI/AN middle school youth.

Childhood Sexual Abuse and Sociodemographic Factors Prospectively Associated with Intimate Partner Violence Perpetration Among South African Heterosexual Men

BACKGROUND

Intimate partner violence directed at women by men continues to be a global concern. However, little is known about the factors associated with perpetrating intimate partner violence among heterosexual men.

PURPOSE

History of childhood sexual abuse and other sociodemographic variables were examined as potential factors associated with severe intimate partner violence perpetration toward women in a sample of heterosexual men in South Africa.

METHODS

Longitudinal logistic generalized estimating equations examined associations of childhood sexual abuse and sociodemographic variables at baseline with intimate partner violence perpetration at subsequent time points.

RESULTS

Among participants with a steady female partner, 21.81 % (190/ 871) reported perpetrating intimate partner violence in the past year at baseline. Having a history of childhood sexual abuse (p < .001), binge drinking (p = .002), being employed (p = .050), and more difficulty controlling sexual impulses in order to use a condom (p = .006) at baseline were associated with self-reported intimate partner violence perpetration in the past year at subsequent time points.

CONCLUSIONS

With high levels of recent severe physical and/or sexual intimate partner violence perpetration in South Africa, comprehensive interventions are urgently needed. To more fully address gender-based violence, it is important to address associated factors, including exposure to childhood sexual abuse that could impact behavior later in life and that have long-lasting and deleterious effects on men and their female partners.

Sub-Saharan African University Students' Beliefs about Abstinence, Condom Use, and Limiting the Number of Sexual Partners

Given the high risk of HIV infection among university students in sub-Saharan Africa, there is a need for culturally appropriate risk-reduction interventions specifically targeting this population. Efforts to reduce the risk require an understanding of the modifiable antecedents of sexual-risk behaviors. We report the results of a semi-structured elicitation survey based on the reasoned action approach to identify behavioral, normative, and control beliefs regarding abstinence, condom use, and limiting sexual partners. Two coders classified into 64 belief categories the written responses of 96 sub-Saharan African university students. Most students believed each behavior could reduce risk of HIV infection. The students reported that peer pressure and being in a risky environment made it harder to practice abstinence. Good communication made it easier to use condoms and to limit partners; however, unstable relationships made practicing these protective behaviors harder. The identified beliefs help to inform the development of theory-based HIV risk-reduction interventions.

Conducting rigorous research with subgroups of at-risk youth: lessons learned from a teen pregnancy prevention project in Alaska

In 2010, Alaska Department of Health and Social Services (DHSS) received federal funding to test an evidence-based teen pregnancy prevention program. The grant required a major modification to an existing program and a randomized control trial (RCT) to test its effectiveness. As the major modifications, Alaska used peer educators instead of adults to deliver the program to youth aged 14-19 instead of the original curriculum intended age range of 12-14. Cultural and approach adaptations were included as well. After 4 years of implementation and data collection, the sample was too small to provide statistically significant results. The lack of findings gave no information about the modification, nor any explanation of how the curriculum was received, or reasons for the small sample. This paper reports on a case study follow-up to the RCT to better understand outcome and implementation results. For this study, researchers reviewed project documents and interviewed peer educators, state and local staff, and evaluators. Three themes emerged from the data: (a) the professional growth of peer educators and development of peer education, (b) difficulties resulting from curriculum content, especially for subpopulations of sexually active youth, youth identified as lesbian, gay, bisexual, transgender, queer, intersex and/or asexual, pregnant, and parenting youth and (c) the appropriateness of an RCT with subpopulations of at-risk youth. Three recommendations emerged from the case study. First, including as many stakeholders as possible in the program and evaluation design phases is essential, and must be supported by appropriate funding streams and training. Second, there must be recognition of the multiple small subpopulations found in Alaska when adapting programs designed for a larger and more homogeneous population. Third, RCTs may not be appropriate for all population subgroups.

Adapting an HIV Risk Reduction Curriculum: Processes and Outcomes

Becoming a Responsible Teen (BART) is a community-based, HIV risk reduction curriculum shown to increase safer sex behaviors among African American adolescents. However, BART does not address common barriers to sexual health care access, which may limit program efficacy. We used a community-engaged adaptation process to maximize program relevance and health outcomes by incorporating a broad ecological perspective. Adolescent and staff advisory boards at a community-based organization recommended modifications (e.g., delete references to Kwanzaa, update language, localize incentives) and supported inclusion of critical on-site health services, such as sexually transmitted infection testing and condom provision. We conducted a trial of adapted BART (one session/week for 8 weeks) with 36 adolescents at two community organizations (mean age = 15.5 years, 52% female; 61% reported previous sexual intercourse). Most received on-site sexually transmitted infection testing (61%) and condoms (70%). Adolescents demonstrated significant improvements in self-efficacy for safer sexual practices (p < .02), AIDS risk knowledge (p < .001), condom knowledge (p < .001), and condom attitudes (p < .04). Adolescents and staff were satisfied with the revised curriculum and found on-site services acceptable. Based on improvements in constructs influencing behavior and the successful delivery of services essential for optimal health, future studies to assess efficacy and sustainability of the adapted curriculum appear warranted.

The Application of the Theory of Reasoned Action and Planned Behavior to Prevention Science in Counseling Psychology

The theory of reasoned action and planned behavior (TRA/PB) is a model of behavior change that has been extensively studied in the health sciences but has had limited exposure in the counseling psychology literature. The model offers counseling psychologists a framework to conceptualize prevention research and practice. The model is important to consider since the training of counseling psychologists is heavily dominated by theories of psychotherapy that emphasize remediation rather than prevention. This article discusses a brief history and explanation of TRA/PB along with relevant research, limitations, and multicultural considerations. Elicitation research, an important component of the model, receives emphasis because it solicits population-specific cognitions and social influences relevant to targeted behaviors, thus strengthening prevention interventions. An example demonstrates how TRA/PB can be used as a theoretical framework to support prevention research. Recommendations for prevention training of counseling psychologists are presented.

Short-Term Impact of a Teen Pregnancy-Prevention Intervention Implemented in Group Homes

PURPOSE

Youth living in group home settings are at significantly greater risk for sexual risk behaviors; however, there are no sexual health programs designed specifically for these youth. The study's purpose was to assess the effectiveness of a teen pregnancy-prevention program for youth living in group home foster care settings and other out-of-home placements.

METHODS

The study design was a cluster randomized controlled trial involving youth (N = 1,037) recruited from 44 residential group homes located in California, Maryland, and Oklahoma. Within each state, youth (mean age = 16.2 years; 82% male; 37% Hispanic, 20% African-American, 20% white, and 17% multiracial) in half the group homes were randomly assigned to the intervention group (n = 40 clusters) and the other half were randomly assigned to a control group that offered "usual care" (n = 40 clusters). The intervention (i.e., Power Through Choices [PTC]) was a 10-session, age-appropriate, and medically accurate sexual health education program.

RESULTS

Compared to the control group, youth in the PTC intervention showed significantly greater improvements (p < .05) from preintervention to postintervention in all three knowledge areas, one of two attitude areas, all three self-efficacy areas, and two of three behavioral intention areas.

CONCLUSIONS

This is the first published randomized controlled trial of a teen pregnancy-prevention program designed for youth living in foster care settings and other out-of-home placements. The numerous significant improvements in short-term outcomes are encouraging and provide preliminary evidence that the PTC program is an effective pregnancy-prevention program.

Improving Adolescent Sexual and Reproductive Health: A Systematic Review of Potential Interventions

Adolescents have special sexual and reproductive health needs (whether or not they are sexually active or married). This review assesses the impact of interventions to improve adolescent sexual and reproductive health (including the interventions to prevent female genital mutilation/cutting [FGM/C]) and to prevent intimate violence. Our review findings suggest that sexual and reproductive health education, counseling, and contraceptive provision are effective in increasing sexual knowledge, contraceptive use, and decreasing adolescent pregnancy. Among interventions to prevent FGM/C, community mobilization and female empowerment strategies have the potential to raise awareness of the adverse health consequences of FGM/C and reduce its prevalence; however, there is a need to conduct methodologically rigorous intervention evaluations. There was limited and inconclusive evidence for the effectiveness of interventions to prevent intimate partner violence. Further studies with rigorous designs, longer term follow-up, and standardized and validated measurement instruments are required to maximize comparability of results. Future efforts should be directed toward scaling-up evidence-based interventions to improve adolescent sexual and reproductive health in low- and middle-income countries, sustain the impacts over time, and ensure equitable outcomes.

Sexually Transmitted Diseases and Managed Care: An Inquiry and Review of Issues Affecting Service Delivery

To understand the potential role of managed care organizations (MCOs) in prevention and control of sexually transmitted diseases (STDs), we conducted a systematic review of articles on STDs and managed care and sought qualitative information from MCOs on STD-related activities. The review focused on prevention, risk assessment, patient education, counseling, screening, and costs of care, but revealed relatively few published articles. Barriers to STD service delivery included competing priorities, lack of time or supporting organizational structures, and differing mandates of health departments and MCOs. Facilitators included collaboration between health departments and MCOs, regulatory and performance incentives, buy-in from key stakeholders, availability of infrastructure to support data collection, and inclusion of chlamydia screening in the Health Employer Data and Information Set to monitor plan performance. Because of the shift of STD service delivery from the public to private sector, incentives need to maximize interest and cooperation of patients, clinicians, and MCOs in STD prevention.

The STD and HIV Epidemics in African American Youth: Reconceptualizing Approaches to Risk Reduction

Sexually transmitted infections, including human immunodeficiency virus (HIV), disproportionately affect African American adolescents and young adults. Many of our current strategies and approaches have been inadequate in the promotion of risk reduction among youth and need to be reconceptualized. This article identifies issues that may guide researchers to better address the risks faced by African American youth. Some of these issues include tailoring of intervention messages and programs, timing of intervention delivery, consideration of contextual factors that influence risk behaviors, and increasing the breadth of our intervention focus. Discussions of how these strategies and approaches may enhance intervention effectiveness are highlighted.

Relationship Status, Psychological Orientation, and Sexual Risk Taking in a Heterosexual African American College Sample

The present study examined relationship status, psychological orientation toward sexual risk taking, and other characteristics as potential correlates of risky sexual behavior in a sample of 223 heterosexual African American college students. Risky sexual behavior was investigated as a multinomial variable (i.e., abstinence, consistent condom use, inconsistent condom use, or noncondom use) to determine whether differentiation of levels of risky sexual behavior yielded meaningful psychological or demographic patterns. The hypotheses were (a) students who are in a long-term relationship are more likely to engage in risky sexual behavior, and (b) students who report inconsistent condom use differ from those who report noncondom use on demographic and psychological variables. The first hypothesis was partially supported. The second hypothesis was supported. The findings suggest that HIV/AIDS interventions need to take into consideration different levels of sexual risk taking with regard to condom use behavior among African American college students.

Welfare, Liberty, and Security for All? U.S. Sex Education Policy and the 1996 Title V Section 510 of the Social Security Act

When adolescents delay (meaning they wait until after middle school) engaging in sexual intercourse, they use condoms at higher rates and have fewer sexual partners than those who have sex earlier, thus resulting in a lower risk for unintended pregnancies and sexually transmitted infections. The 1996 Section 510 of Title V of the Social Security Act (often referred to as A-H) is a policy that promotes abstinence-only-until-marriage education (AOE) within public schools. Using Stone's (2012) policy analysis framework, this article explores how A-H limits welfare, liberty, and security among adolescents due to the poor empirical outcomes of AOE policy. We recommend incorporating theory-informed comprehensive sex education in addition to theory-informed abstinence education that utilizes Fishbein and Ajzen's (2010) reasoned action model within schools in order to begin to address adolescent welfare, liberty, and security.

Is Abstinence Education Theory Based? The Underlying Logic of Abstinence Education Programs in Texas

Authors examined the logic (or the implicit theory) underlying 16 abstinence-only-until-marriage programs in Texas (50% of all programs funded under the federal welfare reform legislation during 2001 and 2002). Defined as a set of propositions regarding the relationship between program activities and their intended outcomes, program staff's implicit theories were summarized and compared to (a) data from studies on adolescent sexual behavior, (b) a theory-based model of youth abstinent behavior, and (c) preliminary findings from the national evaluation of Title V programs. Authors interviewed 62 program directors and instructors and employed selected principles of grounded theory to analyze interview data. Findings indicated that abstinence education staff could clearly articulate the logic guiding program activity choices. Comparisons between interviewdata and a theory-based model of adolescent sexual behavior revealed striking similarities. Implications of these findings for conceptualizing and evaluating abstinence-only-until-marriage (or similar) programs are examined.

Self-Esteem and Theoretical Mediators of Safer Sex Among African American Female Adolescents: Implications for Sexual Risk Reduction Interventions

Theories of health behavior posit that change is accomplished by modifying factors deemed as mediators. A set of mediators from several theoretical models used in sexual risk reduction programs was assessed among a sample of 522 African American female adolescents. The goal was to determine whether self-esteem was associated with sexually transmitted disease (STD), pregnancy, and the set of theoretical mediators controlling for covariates. Bivariate analyses showed no relationship between self-esteem and STD or pregnancy; multivariate regression analysis revealed a significant relation between self-esteem and the set of mediators. Girls higher in self-esteem were more likely to hold positive condom attitudes, felt more efficacious in negotiating condom use, had more frequent communication with sex partners and parents, perceived fewer barriers to using condoms, and were less fearful of negotiating condom use. Self-esteem should be considered when designing and evaluating sexual risk reduction programs for this population.

Evaluation of Statewide Teen Pregnancy Prevention Initiatives: Challenges, Methods, and Lessons Learned

Evaluation of community-based, teen pregnancy prevention initiatives is complex. This article describes the challenges encountered and solutions derived while creating a comprehensive evaluation of teen pregnancy prevention initiatives across 46 counties in a southeastern state. Background information on the evaluation and highlights of the data collection constructs, methods, and tools are provided. In particular, the efforts to appropriately scope the evaluation activities and the use of qualitative and quantitative methods are discussed. In addition, the key lessons learned from the evaluation are presented. This article's discussion of contextual influences and evaluation planning and implementation efforts may benefit program practitioners and evaluators in their future evaluation activities.

Mediation Analysis of the Efficacy of the Eban HIV/STD Risk-Reduction Intervention for African American HIV Serodiscordant Couples

Targeting couples is a promising behavioral HIV risk-reduction strategy, but the mechanisms underlying the effects of such interventions are unknown. We report secondary analyses testing whether Social-Cognitive-Theory variables mediated the Eban HIV-risk-reduction intervention's effects on condom-use outcomes. In a multisite randomized controlled trial conducted in four US cities, 535 African American HIV-serodiscordant couples were randomized to the Eban HIV risk-reduction intervention or attention-matched control intervention. Outcomes were proportion condom-protected sex, consistent condom use, and frequency of unprotected sex measured pre-, immediately post-, and 6 and 12 months post-intervention. Potential mediators included Social-Cognitive-Theory variables: outcome expectancies and self-efficacy. Mediation analyses using the product-of-coefficients approach in a generalized-estimating-equations framework revealed that condom-use outcome expectancy, partner-reaction outcome expectancy, intention, self-efficacy, and safer-sex communication improved post-intervention and mediated intervention-induced improvements in condom-use outcomes. These findings underscore the importance of targeting outcome expectancies, self-efficacy, and safer-sex communication in couples-level HIV risk-reduction interventions.

Can implementation support help community-based settings better deliver evidence-based sexual health promotion programs? A randomized trial of Getting To Outcomes®

BACKGROUND

Research is needed to evaluate the impact of implementation support interventions over and above typical efforts by community settings to deploy evidence-based prevention programs.

METHODS

Enhancing Quality Interventions Promoting Healthy Sexuality is a randomized controlled trial testing Getting To Outcomes (GTO), a 2-year implementation support intervention. It compares 16 Boys and Girls Club sites implementing Making Proud Choices (MPC, control group), a structured teen pregnancy prevention evidence-based program with 16 similar sites implementing MPC augmented with GTO (intervention group). All sites received training and manuals typical for MPC. GTO has its own manuals, training, and onsite technical assistance (TA) to help practitioners complete key programming practices specified by GTO. During the first year, TA providers helped the intervention group adopt, plan, and deliver MPC. This group then received training on the evaluation and quality improvement steps of GTO, including feedback reports summarizing their data, which were used in a TA-facilitated quality improvement process that yielded revised plans for the second MPC implementation. This paper presents results regarding GTO's impact on performance of the sites (i.e., how well key programming practices were carried out), fidelity of MPC implementation, and the relationship between amount of TA support, performance, and fidelity. Performance was measured using ratings made from a standardized, structured interview conducted with participating staff at all 32 Boys and Girls Clubs sites after the first and second years of MPC implementation. Multiple elements of fidelity (adherence, classroom delivery, dosage) were assessed at all sites by observer ratings and attendance logs.

RESULTS

After 2 years, the intervention sites had higher ratings of performance, adherence, and classroom delivery (dosage remained similar). Higher performance predicted greater adherence in both years.

CONCLUSIONS

These findings suggest that in typical community-based settings, manuals and training common to structured EBPs may be sufficient to yield low levels of performance and moderate levels of fidelity but that systematic implementation support is needed to achieve high levels of performance and fidelity.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT01818791.

Deliberative Discussion Focus Groups

This article discusses a new approach for the conduct of focus groups in health research. Identifying ways to educate and inform participants about the topic of interest prior to the focus group discussion can promote more quality data from informed opinions. Data on this deliberative discussion approach are provided from research within three federally funded studies. As healthcare continues to improve from scientific and technological advancements, educating the research participants prior to data collection about these complexities is essential to gather quality data.

Sibling teenage pregnancy and clinic-referred girls' condom use: The protective role of maternal monitoring

Younger sisters of teenage parents have elevated rates of engaging in unprotected sex. This may result from changes in parenting behavior after a sibling becomes pregnant or impregnates a partner, and be particularly pronounced for girls seeking mental health treatment. The current study examines condom use over time in 211 African-American girls recruited from outpatient psychiatric clinics. Findings indicate that having a sibling with a teenage pregnancy history predicts less consistent condom use two years later. After accounting for earlier condom use and mental health problems, maternal monitoring moderates condom use such that for girls with a sibling with a pregnancy history, more vigilant maternal monitoring is associated with increased condom use, while for girls with no sibling pregnancy history, maternal monitoring is unrelated to adolescents' condom use two years later. Findings suggest that targeted interventions to increase maternal monitoring of high-risk teens may be beneficial for girls with a sibling history of teenage pregnancy.

Familias Unidas for high risk adolescents: Study design of a cultural adaptation and randomized controlled trial of a U.S. drug and sexual risk behavior intervention in Ecuador

BACKGROUND

Developing, testing and implementing evidence-based prevention interventions are important in decreasing substance use and sexual risk behavior among adolescents. This process requires research expertise, infrastructure, resources and decades of research testing, which might not always be feasible for low resource countries. Adapting and testing interventions proven to be efficacious in similar cultures might circumvent the time and costs of implementing evidence-based interventions in new settings. This paper describes the two-phase study, including training and development of the research infrastructure in the Ecuadorian university necessary to implement a randomized controlled trial.

METHODS/DESIGN

Familias Unidas is a multilevel parent-centered intervention designed in the U.S. to prevent drug use and sexual risk behaviors in Hispanic adolescents. The current study consisted of Phase 1 feasibility study (n=38) which adapted the intervention and study procedures within a single-site school setting in an area with a high prevalence of drug use and unprotected sexual behavior among adolescents in Ecuador, and Phase 2 randomized controlled trial of the adapted intervention in two public high schools with a target population of families with adolescents from 12 to 14 years old.

DISCUSSION

The trial is currently in Phase 2. Study recruitment was completed with 239 parent-youth dyads enrolling. The intervention phase and the first follow-up assessment have been completed. The second and third follow-up assessments will be completed in 2016. This project has the potential of benefitting a large population of families in areas of Ecuador that are disproportionally affected by drug trafficking and its consequences.

TRIAL REGISTRATION

MSP-DIS-2015-0055-0, Ministry of Public Health (MSP), Quito, Ecuador.

Perceived Discrimination, Peer Influence and Sexual Behaviors in Mexican American Preadolescents

Both discrimination and sexual health disparities have significant negative health implications for Latina/o preadolescent youth, including negative mental health outcomes, STIs/HIV, unintended pregnancy, and ongoing poverty. Studying these links within this population, therefore, has significant public health relevance, both in terms of promoting sexual health in general as well as serving the specific needs of Latina/o youth. This study explored the relationship between perceived discrimination, peer influence and sexual behaviors among 438 Mexican American preadolescents in the Southwest United States (55.3 % male). Additionally, this study examined whether psychological distress, substance use, and sexual motives mediated and whether gender moderated these relations. A multiple-group path analysis of the analytical model was performed to examine the hypothesized relations between perceived discrimination, peer influence, psychological distress, substance use, sexual motives and sexual behaviors. The findings indicated that perceived discrimination was directly linked to sexual behaviors among participants and indirectly linked via substance use. The findings also indicated that peer influence was indirectly linked to sexual behaviors via substance use among participants and via sexual motives among boys. This study underscores the importance of substance use in the perceived discrimination, peer influence and sexual behavior link in Mexican American preadolescents. Additionally, it highlights the importance of sexual motives in the link between peer influence and sexual behaviors of Mexican American boys.

Brief Behavioral Intervention to Improve Adolescent Sexual Health: A Feasibility Study in the Emergency Department

OBJECTIVE

Although emergency department (ED) visits offer an opportunity to deliver brief behavioral interventions to improve health, provision of ED-based interventions targeting adolescent sexual health is uncommon. The objectives for this study were to evaluate the feasibility and preliminary effects of a novel sexual health service intervention for adolescents.

METHODS

In this cross-sectional feasibility study, sexually active patients aged 14 to 19 years presenting to a Midwestern pediatric ED were recruited to receive an intervention to improve sexual health. The intervention, based on motivational interviewing (MI), included agenda setting, exploration of behaviors, a decisional balance exercise, tailored feedback, and provision of personalized health services (including condoms, prescription for emergency contraception, urine testing for Chlamydia trachomatis and Neisseria gonorrheae, and referral to the hospital-affiliated adolescent clinic). Data were collected before and after intervention administration and at a 3-month follow-up telephone interview. Surveys assessed sexual risk behaviors, satisfaction with the intervention, health care use, and demographics. Feasibility criteria were (1) subject-rated interventionist fidelity to MI principles (Likert scale 1 [strongly agree] to 4 [strongly disagree]), (2) subject satisfaction (Likert scale 1 [not at all] to 5 [very]), and (3) session duration (minutes, recorded by the interventionist). A secondary outcome was the proportion of subjects who completed at least 1 health service. Services provided at the adolescent clinic were determined by an electronic medical record review. Comparisons of responses between sex subgroups were analyzed using Χ test.

RESULTS

From August to November 2012, 69 adolescents were approached, 66 (96%) completed the screening survey, and 24 (37%) reported previous sexual activity. Of those, 20 (83%) agreed to participate. The mean (SD) age was 16.2 (1.4) years; 60% were female. Most (78%) reported that the interventionist maintained high fidelity to MI principles and most (80%) were very satisfied with the intervention. Mean (SD) intervention length was 15.7 (2.2) minutes. Most subjects (65%) accepted 1 or more health services, including 42% who completed clinic follow-up. In the ED or the referral clinic, the following services were provided to the subjects: condoms (n = 11), emergency contraception prescription (n = 5), C. trachomatis/N. gonorrheae testing (n = 4), hormonal birth control provision (n = 2), and human immunodeficiency virus testing (n = 3). Fifteen subjects (75%) were reached for the 3-month follow-up, and condom use was maintained by 67% of those reporting sexual activity.

CONCLUSIONS

This study demonstrated the feasibility and potential utility of an MI-based service navigation intervention to connect youth with point-of-care services as well as resources for ongoing sexual health needs.

Comparing School-Based Teen Pregnancy Prevention Programming: Mixed Outcomes in an At-Risk State

BACKGROUND

The purpose of this study is to compare the effectiveness of a national comprehensive teen pregnancy prevention (TPP) intervention to a national abstinence-only TPP intervention on middle school students' knowledge, attitudes, and behaviors related to teen sexual behaviors in a state with high teen birth rates.

METHODS

Pre- and post-intervention data were collected annually (2005-2010) from seventh-grade students to evaluate school-based TPP programs that implemented a comprehensive (N = 3244) or abstinence-only (N = 3172) intervention. Chi-square and t tests, logistic regressions, and hierarchical multiple regressions examined relationships between sexuality-related behavioral intentions, knowledge, and attitudes.

RESULTS

Students in both interventions reported significant (p < .05) improvements post-intervention. Youth in the comprehensive TPP intervention were more likely (p < .05) to have significantly improved their attitudes (odds ratios [ORs] = 1.35, 1.83, 1.23) and behavior regarding abstinence decisions in the past 3 months (OR = 1.39). The interventions' improvements in attitudes were more explanatory for behavioral intentions for students in the abstinence-only intervention than for students in the comprehensive TPP intervention.

CONCLUSIONS

The mixed results suggest the comprehensive TPP intervention was only slightly more effective than the abstinence intervention, but that changing student attitudes and perceptions may be a key component of more effective TPP interventions.

Mediation of an efficacious HIV risk reduction intervention for South African men

"Men, Together Making a Difference!" is an HIV/STD risk-reduction intervention that significantly increased self-reported consistent condom use during vaginal intercourse compared with a health-promotion attention-control intervention among men (N = 1181) in Eastern Cape Province, South Africa. The present analyses were designed to identify mediators of the intervention's efficacy. The potential mediators were Social Cognitive Theory (SCT) constructs that the intervention targeted, including several aspects of condom-use self-efficacy, outcome expectancies, and knowledge. Mediation was assessed using a product-of-coefficients approach where an α path (the intervention's effect on the potential mediator) and a β path (the potential mediator's effect on the outcome of interest, adjusting for intervention) were estimated independently in a generalized estimating equations framework. Condom-use negotiation self-efficacy, technical-skill self-efficacy, and impulse-control self-efficacy were significant mediators. Although not mediators, descriptive norm and expected friends' approval of condom use predicted subsequent self-reported condom use, whereas the expected approval of sexual partner did not. The present results suggest that HIV/STD risk-reduction interventions that draw upon SCT and that address self-efficacy to negotiate condom use, to apply condoms correctly, and to exercise sufficient control when sexually aroused to use condoms may contribute to efforts to reduce sexual risk behavior among South African men. Future research must examine whether approaches that build normative support for condom use among men's friends are also efficacious.

Efficacy of a Brief Intervention to Reduce Substance Use and Human Immunodeficiency Virus Infection Risk Among Latino Youth

PURPOSE

Familias Unidas is an efficacious and effective family-based intervention for preventing and reducing substance use and unsafe sexual behaviors among Latino youth. To facilitate its dissemination, Familias Unidas was shortened from a 12-week intervention to a 6-week intervention and evaluated. We hypothesized that brief Familias Unidas would be efficacious in reducing substance use and unsafe sexual behaviors relative to a comparison condition.

METHODS

We randomized 160 ninth-grade Latino adolescents and their families to brief Familias Unidas or a community practice control condition. Adolescents were surveyed at baseline and 6, 12, and 24 months after baseline.

RESULTS

At 24 months, youth randomized to brief Familias Unidas had a significantly lower sexual initiation rate (34.0%) relative to control (55.0%), p = .02. Brief Familias Unidas also increased positive parenting. Moderation analyses revealed that brief Familias Unidas was significantly associated with decreased substance use initiation among girls (30.4% vs. 64.0%, respectively; p = .02), but not boys (28.0% vs. 26.7%, respectively; p = .91). Brief Familias Unidas was also significantly associated with reduced unsafe sex among adolescents aged 15 years or less (p < .001), but not among older adolescents (p = .37). Moderating effects were also found for family-level variables.

CONCLUSIONS

Brief Familias Unidas was efficacious in reducing sex initiation and improving positive parenting. Moderation analyses suggested that brief Familias Unidas was efficacious in reducing substance use initiation and unsafe sex for certain Hispanic adolescent subgroups, highlighting the importance of conducting moderation analyses, and of targeting interventions for specific subgroups.

An Interactive Website to Reduce Sexual Risk Behavior: Process Evaluation of TeensTalkHealth

Background

Different theoretical frameworks support the use of interactive websites to promote sexual health. Although several Web-based interventions have been developed to address sexual risk taking among young people, no evaluated interventions have attempted to foster behavior change through moderated interaction among a virtual network of adolescents (who remain anonymous to one another) and health professionals.

Objective

The objective was to conduct a summative process evaluation of TeensTalkHealth, an interactive sexual health website designed to promote condom use and other healthy decision making in the context of romantic and sexual relationships.

Methods

Evaluation data were obtained from 147 adolescents who participated in a feasibility and acceptability study. Video vignettes, teen-friendly articles, and other content served as conversation catalysts between adolescents and health educators on message boards.

Results

Adolescents’ perceptions that the website encouraged condom use across a variety of relationship situations were very high. Almost 60% (54/92, 59%) of intervention participants completed two-thirds or more of requested tasks across the 4-month intervention. Adolescents reported high levels of comfort, perceived privacy, ease of website access and use, and perceived credibility of health educators. Potential strategies to enhance engagement and completion of intervention tasks during future implementations of TeensTalkHealth are discussed, including tailoring of content, periodic website chats with health educators and anonymous peers, and greater incorporation of features from popular social networking websites.

Conclusions

TeensTalkHealth is a feasible, acceptable, and promising approach to complement and enhance existing services for youth.

Group Interventions for Patients with Cancer and HIV Disease: Part III. Moderating Variables and Mechanisms of Action

Growing evidence supports the value of group interventions for individuals who are at risk for or have developed cancer or HIV disease. However, information is more limited concerning how these services can be delivered in an optimal manner, and what processes contribute to their benefits. Parts I and II of this review examined the efficacy of different interventions for individuals at different phases of illness, ranging from primary prevention to late-stage disease, in both psychosocial and biological domains. The current paper examines some of the factors other than phase of illness that might influence group treatment effects (e.g., intervention parameters, participant characteristics), and explores mechanisms of action.

Group Interventions for Patients with Cancer and HIV Disease: Part I: Effects on Psychosocial and Functional Outcomes at Different Phases of Illness

Group interventions for individuals facing cancer or HIV disease have drawn considerable attention among researchers and clinicians over the past 20 years. There is growing evidence that group services may be helpful, but which interventions are most effective for participants at which phases in the trajectory of disease has been less clear. Moreover, professionals working in different intervention settings (e.g., primary prevention vs. clinical care) and different disease sites (cancer vs. HIV disease) often have little awareness of relevant advances in other fields. Efforts to integrate findings in the literature may accelerate research and advance the standard of clinical care. The current article, the first in a series of four special reports, critically evaluates the efficacy of group interventions led by professional or trained facilitators for individuals confronted by cancer or HIV, across the spectrum of illness from elevated risk through advanced disease. We examine psychosocial and functional outcomes for different interventions directed toward different patient subgroups, trace common themes, highlight limitations, and offer recommendations for further research.

Mediation and moderation of an efficacious theory-based abstinence-only intervention for African American adolescents

OBJECTIVE

This secondary data analysis sought to determine what mediated reductions in self-reported sexual initiation over the 24-month postintervention period in early adolescents who received "Promoting Health among Teens," a theory-based, abstinence-only intervention (Jemmott, Jemmott, & Fong, 2010).

METHOD

African American Grade 6 and 7 students at inner-city public middle schools were randomized to 1 of 5 interventions grounded in social-cognitive theory and the theory of reasoned action: 8-hr abstinence-only targeting reduced sexual intercourse; 8-hr safer-sex-only targeting increased condom use; 8-hr and 12-hr comprehensive interventions targeting sexual intercourse and condom use; 8-hr control intervention targeting physical activity and diet. Primary outcome was self-report of vaginal intercourse by 24 months postintervention. Potential mediators, assessed immediately postintervention, were theory-of-reasoned-action variables, including behavioral beliefs about positive consequences of abstinence and negative consequences of sex, intention to have sex, normative beliefs about sex, and HIV and sexually transmitted infection (STI) knowledge. We tested single and serial mediation models using the product-of-coefficients approach.

RESULTS

Of 509 students reporting never having vaginal intercourse at baseline (324 girls and 185 boys; mean age = 11.8 years, SD = 0.8), 500 or 98.2% were included in serial mediation analyses. Consistent with the theory of reasoned action, the abstinence-only intervention increased positive behavioral beliefs about abstinence, which reduced intention to have sex, which in turn reduced sexual initiation. Negative behavioral beliefs about sex, normative beliefs about sex, and HIV/STI knowledge were not mediators.

CONCLUSIONS

Abstinence-only interventions should stress the gains to be realized from abstinence rather than the deleterious consequences of sexual involvement.

Knowledge and Attitudes of Doctors Toward People Living With HIV/AIDS in Saudi Arabia

OBJECTIVES

Reports showed that Saudi Arabia has low prevalence of HIV/AIDS despite increasing influx of foreign nationals from countries with high risk of HIV. Knowledge and stigmatizing attitudes of health care workers contribute to difficulties of people living with HIV/AIDS (PLWHA) accessing prevention, care, and treatment services. Nothing is known about stigma and discrimination about PLWHA in Saudi Arabia.

DESIGN

We assessed knowledge of Saudi Arabian doctors about HIV and their attitudes toward PLWHA using a cross-sectional study design.

METHOD

In this study, 1483 doctors completed a self-administered questionnaire.

RESULT

Knowledge scores and stigma index were computed from responses to relevant statements in the questionnaire. Stigmatizing attitudes of contact, reproductive rights, blaming, and judgmental were identified. HIV knowledge was a significant predictor of high stigma. Doctors' year of medical practice, status/specialty, and location of practice in Saudi Arabia were major predictors of HIV knowledge.

CONCLUSIONS

Evidence of poor knowledge of HIV suggests the need for further training of health workers on HIV transmission mode.

On the Efficacy and Mediation of a One-on-One HIV Risk-Reduction Intervention for African American Men Who Have Sex with Men: A Randomized Controlled Trial

We examined the efficacy and mediation of Being Responsible for Ourselves (BRO), an HIV/STI risk-reduction intervention for African American men who have sex with men (MSM), the population with the highest HIV-diagnosis rate in the US. We randomized African American MSM to one of two interventions: BRO HIV/STI risk-reduction, targeting condom use; or attention-matched control, targeting physical activity and healthy diet. The interventions were based on social cognitive theory, the reasoned-action approach, and qualitative research. Men reporting anal intercourse with other men in the past 90 days were eligible and completed pre-intervention, immediately post-intervention, and 6 and 12 months post-intervention surveys. Of 595 participants, 503 (85 %) completed the 12-month follow-up. Generalized-estimating-equations analysis indicated that, compared with the attention-matched control intervention, the BRO intervention did not increase consistent condom use averaged over the 6- and 12-month follow-ups, which was the primary outcome. Although BRO did not affect the proportion of condom-protected intercourse acts, unprotected sexual intercourse, multiple partners, or insertive anal intercourse, it did reduce receptive anal intercourse compared with the control, a behavior linked to incident HIV infection. Mediation analysis using the product-of-coefficients approach revealed that although BRO increased seven of nine theoretical constructs it was designed to affect, it increased only one of three theoretical constructs that predicted consistent condom use: condom-use impulse-control self-efficacy. Thus, BRO indirectly increased consistent condom use through condom-use impulse-control self-efficacy. In conclusion, although BRO increased several theoretical constructs, most of those constructs did not predict consistent condom use; hence, the intervention did not increase it. Theoretical constructs that interventions should target to increase African American MSM’s condom use are discussed.

Translating primary into 'positive' prevention for adolescents in Eastern Africa

There is an urgent need to develop positive prevention interventions for adolescents living with HIV in high endemic regions. Adapting existing evidence-based interventions for resource-constrained settings is effective when the intervention's theoretical core elements are preserved while achieving cultural relevance. We describe the process of adapting a primary prevention to a secondary/positive prevention programme for adolescents living with HIV in Kenya and Uganda. The systematic adaptation was guided by the Centers for Diseases Control's map for the adaptation process, describing an iterative process. The procedure included: assessing the target positive prevention group's needs (safer sex; fertility-related issues), identifying the potential interventions through a literature review, conducting qualitative adaptation research to identify areas for adaptation by ensuring cultural relevance (revising the intervention logic by adding topics such as adherence; HIV-related stigma; HIV-disclosure; safer sex), pilot-testing the adapted programme and conducting a process evaluation of its first implementation. Areas added onto the original intervention's logic framework, based on social cognitive theory, the theories of reasoned action and planned behaviour were information and skills building on sexual relationships and protection behaviour, prevention of vertical HIV transmission, contraception, HIV-disclosure, HIV-related stigma, HIV-treatment and adherence. The process evaluation using mixed methods showed that we delivered a feasible and acceptable intervention for HIV-positive adolescents aged 13-17 years. The systematic approach adopted facilitated the development of a contextualized and developmentally appropriate (i.e. age-specific) intervention for adolescents living with HIV.

Self-Efficacy for Sexual Risk Reduction and Partner HIV Status as Correlates of Sexual Risk Behavior Among HIV-Positive Adolescent Girls and Women

Little is known about the correlates of sexual risk behavior among HIV-positive adolescent girls and women in the United States. This study investigates two potential factors related to unprotected vaginal and anal intercourse (UVAI) that have yet to be thoroughly studied in this group: self-efficacy for sexual risk reduction and partner HIV status. Data was analyzed from 331 HIV-positive adolescent girls and women between 12 and 24 years old who reported vaginal and/or anal intercourse with a male partner in the past 3 months at fifteen sites across the United States. Results show that overall self-efficacy (B=-0.15, p=0.01), self-efficacy to discuss safe sex with one's partner (B=-0.14, p=0.01), and self-efficacy to refuse unsafe sex (B=-0.21, p=0.01) are related to UVAI episodes. Participants with only HIV-positive partners or with both HIV-positive and HIV-negative partners showed a trend towards higher percentages of UVAI episodes compared to participants with only HIV-negative partners (F(2, 319)=2.80, p=0.06). These findings point to the importance of including self-efficacy and partner HIV status in risk-reduction research and interventions developed for HIV-positive adolescent girls and young women.