Sexual risk among African American girls seeking psychiatric care: A social-personal framework

The Role of Family Factors in the Outcomes of Court-Involved Youth

Court-involved youth (CIY) comprise a significant portion of the U.S. population and have a high prevalence of psychiatric illness and substance use. Youth delinquency has also been associated with family variables and parenting practices. However, it is not known which family factors are most relevant to behavioral outcomes in CIY mandated to outpatient mental health treatment. Self-report measures from 163 CIY (M = 15.19 years; 58.3% male) starting psychiatric care in two U.S. cities were utilized in a cross-sectional analysis to examine the association of parental monitoring and family functioning with the severity and variety of delinquent acts. Results demonstrate that parental monitoring is significantly associated with the delinquent behavior of CIY in mental health treatment, beyond that of psychiatric symptoms and substance use. Improved understanding of influential family factors can enhance tailoring of existing interventions to ensure that they are relevant to the needs of CIY, especially those in psychiatric treatment.

Family Functioning in Hispanic Parents of Adolescents: Who Benefits Most from a Family-Based HIV and Substance Use Preventive Intervention?

To understand which families are likely to benefit most from resource-intensive family-based, evidence-based interventions (EBIs), we must examine the key, modifiable determinant of family functioning. The purpose of this study was to (1) identify whether there are subgroups of Hispanic parents that differ meaningfully based on their family functioning at baseline, (2) test whether the Familias Unidas preventive intervention was differentially effective across the baseline family functioning subgroups, and (3) understand the mechanisms of intervention effectiveness within each baseline family functioning subgroup. On a pooled data set of 4 completed efficacy and effectiveness trials of Familias Unidas (n = 1445 low-income, Hispanic immigrant origin, parents and their adolescent between the ages of 12-17), we conducted a series of secondary data analyses. Latent profile analyses revealed four significantly different profiles: (1) low family functioning (n = 210, 14.55%), (2) low-to-moderate family functioning (n = 554, 38.39%), (3) moderate-to-high family functioning (n = 490, 33.96%), and (4) high family functioning (n = 189, 13.10%). A structural equation modeling approach found there were significant differences in intervention effectiveness between the subgroups. The low family functioning subgroup experienced gains in family functioning, and in turn, lower levels of adolescent substance use, internalizing, and externalizing symptoms. The high family functioning subgroup showed significant direct effects of the intervention on adolescent substance use, internalizing, and externalizing symptoms, but no indirect effects through improvements in family functioning. Implications for screening, targeting, and adapting interventions are discussed.

Preliminary effectiveness and implementation outcomes of the IMARA-South Africa sexual health intervention on adolescent girls and young women: A pilot randomized trial

Family-based interventions may help reduce the risk of HIV and other sexually transmitted infections (STI) among adolescent girls and young women (AGYW) in sub-Saharan Africa but few have been tested. We examined the preliminary effectiveness and implementation outcomes of Informed, Motivated, Aware, and Responsible Adolescents and Adults-South Africa (IMARA-SA), an evidence-based intervention for South African AGYW (15-19 years) and their female caregivers. We piloted IMARA-SA in the Western Cape using an individually randomized experimental design and average follow-up at 11 months. Primary outcomes were HIV Testing and Counselling (HTC) uptake, STI incidence (gonorrhea, chlamydia), and pre-exposure prophylaxis (PrEP) uptake. Secondary outcomes were self-reported sexual risk behavior (condom use at last sex, consistency of condom use, substance use during sex, and number of sexual partners) and PrEP adherence. We examined four implementation outcomes: reach, feasibility, acceptability, and fidelity. Data from 59 AGYW (mean = 17.2 years) were analyzed at baseline (n = 29 from IMARA-SA, 30 from a health promotion control group). At follow-up, 51 (86%) completed surveys and 39 (66%) presented for HTC, STI testing, and/or PrEP. Compared to controls, fewer IMARA-SA participants tested positive for an STI (22% versus 38%), more IMARA-SA participants took up PrEP (68% versus 45%), and four of five secondary outcomes favored the IMARA-SA group at follow-up. These differences did not reach statistical significance. HTC uptake at follow-up was 100% in both groups. All AGYW-FC dyads agreed to participate in the study (reach). In the IMARA-SA group, 76% of dyads completed the intervention (feasibility), and over 76% of acceptability ratings from AGYW and their FC had the highest Likert rating. Fidelity of intervention delivery was 95%. IMARA-SA is a promising strategy for reducing HIV/STI risk among South African AGYW. We found strong evidence of reach, feasibility, acceptability, and fidelity. A fully powered randomized controlled trial is warranted. Trial registration: Clinical trials.gov registration number: NCT05504954.

Family-Related Factors and HIV-Related Outcomes Among Black Young Men Who Have Sex with Men in Mississippi

Given their disproportionate HIV incidence, there is a critical need to identify factors related to HIV risk among Black young men who have sex with men (YMSM) in the southeastern United States. This study investigated the association of family factors and HIV-related outcomes among Black YMSM in Mississippi ages 14-20 (n = 72). Multivariable regression models evaluated associations of family factors and outcomes. Greater parent/child communication about sex was associated with fewer lifetime male sex partners and lower odds of lifetime anal sex. Greater parental monitoring was associated with greater likelihood of future condom use. Sexual orientation disclosure was associated with more lifetime male sex partners. Parental monitoring and parent/child communication about sex were protective, suggesting that family-based interventions are promising for HIV prevention among Black YMSM in Mississippi. Results also indicated that YMSM who are "out" to family are important to reach, and families could be useful in encouraging healthy behaviors.

Sexual Communication between Adolescent Partners: A Scoping Review and Directions for Future Research

Sexual communication between adolescent partners is an important component of sexual health and wellbeing. Over 40 years of research on adolescent sexual communication has yielded rich information, yet there remain gaps in our understanding of the communication process. The purpose of this scoping review was to synthesize the body of research on adolescent sexual communication to identify how communication has been conceptualized, how researchers have measured communication, and what theoretical frameworks have been applied across the literature. We identified 198 assessments of sexual communication across 119 quantitative studies. This work included 127,489 adolescents (M_age = 15.97) from 15 countries (81.5% U.S.-based). Most studies relied on self-reports (93.4%) and surveyed only one member of a couple (97.5%). The definition of sexual communication was highly varied across the literature: in half of assessments (52.0%) sexual communication was operationalized as a behavior-the verbal or nonverbal exchange of messages about sex-whereas the remaining half of assessments captured social-cognitive aspects of communication (e.g., communication self-efficacy, fear/anxiety). There was also a tendency for investigators to create their own idiosyncratic instruments: half of studies (48.9%) used instruments created by the research team with limited or no discussion of reliability/validity. Regarding the topic of communication, a third of assessments (33.8%) focused exclusively on condom communication and another quarter (24.0%) focused on other safer-sex issues (e.g., STDs, abstinence). Notably absent were studies focused on communication surrounding consent or sexual pleasure. Also absent was a guiding conceptual model or theory that could unify this body of work. Overall, results highlight gaps and inconsistencies in how partner sexual communication has been conceptualized, measured, and theorized about in previous work. We provide several recommendations for future theory-building efforts as well as rigorous, multimethod empirical investigations of adolescent sexual communication that would further our understanding of this important aspect of adolescent sexual wellbeing.

Perceptions of Sexual Risk and HIV/STI Prevention Among Black Adolescent Girls in a Detention Center: an Investigation of the Role of Parents and Peers

Black American adolescent girls constitute approximately one third of the US youth legal system population. Their overrepresentation in the youth punishment system is an indicator of significant physical, sexual, and/or behavioral health needs. Since less is known about perceptions of HIV/STI risk among Black girls with juvenile justice histories, we used intersectionality theory to explore the following: (1) how a sample of Black girls in detention endorse their perceptions of sexual safety given the multiple intersections of their race, gender, and SES and (2) how their endorsements align with interlocking systems of social inequality for system-involved Black at the social structural level. We examined relational and behavioral factors associated perceived HIV/STI risk. Among a sample of 188 Black girls (ages 13-17 years), we examined parent and partner sexual communication, fear of condom negotiation, a positive STI test, and partner risk profile as significant correlates. Major findings indicated that greater partner communication was associated with higher perceived HIV/STI risk, whereas having had a risky sexual partner, fear of condom negotiation, and having had a positive STI test were correlated with lower perceived risk. The significant factors identified in this study can be the focus of STI prevention and intervention programs for Black girls with youth punishment histories.

An individually randomized controlled trial of a mother-daughter HIV/STI prevention program for adolescent girls and young women in South Africa: IMARA-SA study protocol

BACKGROUND

South Africa has the world's largest HIV epidemic, but South African adolescent girls and young women (AGYW) acquire HIV at twice the rate of and seroconvert on average 5-7 years earlier than their male peers. Female caregivers (FC) are an untapped resource for HIV/STI prevention in South Africa and offer a novel opportunity to strengthen AGYW prevention efforts. This study will evaluate the effectiveness and cost-effectiveness of an evidence-based mother-daughter HIV/STI prevention program tested in the United States and adapted for South Africa, Informed Motivated Aware and Responsible Adolescents and Adults (IMARA), to decrease STI incident infections and increase HIV testing and counseling (HTC) and PrEP uptake in AGYW.

METHODS

This is a 2-arm individually randomized controlled trial comparing IMARA to a family-based control program matched in time and intensity with 525 15-19-year-old Black South African AGYW and their FC-dyads in Cape Town's informal communities. AGYW will complete baseline, 6-, and 12-month assessments. Following randomization, AGYW-FC dyads will participate in a 2-day group workshop (total 10 h) that includes joint and separate mother and daughter activities. Primary outcomes are AGYW STI incidence, HTC uptake, and PrEP uptake at 6 months. Secondary outcomes are AGYW STI incidence, HTC uptake, and PrEP uptake at 12 months, sexual behavior (e.g., condom use, number of partners), HIV incidence, and ART/PrEP adherence and intervention cost-effectiveness. AGYW who test positive for a STI will receive free treatment at the study site. HIV positive participants will be referred to ART clinics.

DISCUSSION

Primary prevention remains the most viable strategy to stem new STI and HIV transmissions. HIV and STI disparities go beyond individual level factors, and prevention packages that include supportive relationships (e.g., FC) may produce greater reductions in HIV-risk, improve HTC and PrEP uptake, and increase linkage, retention, and adherence to care. Reducing new HIV and STI infections among South African AGYW is global public health priority.

TRIAL REGISTRATION

ClinicalTrials.gov Number NCT04758390 , accepted 02/16/2021.

IMARA: A mother-daughter group randomized controlled trial to reduce sexually transmitted infections in Black/African-American adolescents

Black/African-American girls are infected with sexually transmitted infections (STIs) at higher rates than their White counterparts. This study tested the efficacy of IMARA, a mother-daughter psychosocial STI/HIV prevention program, on adolescent Black/African-American girls’ incident STIs at 12 months in a 2-arm group randomized controlled trial. Black/African-American girls 14–18 years old and their primary female caregiver were eligible for the study. Girls provided urine samples to test for N. gonorrhoeae, C. trachomatis, and T. vaginalis infection at baseline and 12-months. Mother-daughter dyads were randomly assigned to IMARA (n = 118) or a time-matched health promotion control program (n = 81). Retention at 12-months was 86% with no difference across arms. Both interventions were delivered over two consecutive Saturdays totaling 12 hours. Girls who received IMARA were 43% less likely to contract a new STI in the 12-month post-intervention period compared with those in the health promotion control program (p = .011). A secondary follow-up intent-to-treat analysis provided additional support for the protective effect of IMARA, albeit with a similar magnitude of 37% (p = .014). Findings provide early evidence for IMARA’s efficacy, such that IMARA protected against STIs at 12-months among adolescent Black/African-American girls. Future research should examine the mechanisms associated with reduced STIs.

Developmental Trajectories of Adolescent Girls' Borderline Personality Symptoms and Sexual Risk Behaviors

Adolescence is a developmental period during which youth tend to initiate sexual behavior, which may include sexual risk behavior. Symptoms of borderline personality disorder (BPD) are associated with increased rates of risky behaviors. However, little is known about longitudinal associations between BPD symptoms and sexual risk behaviors during adolescence. This study examines developmental trajectories of adolescent girls' BPD symptoms and sexual risk behaviors in a community sample of Black and White girls from the Pittsburgh Girls Study (n = 1620). Dual trajectory modeling provided insights into the temporal precedence and co-development of BPD symptoms and sexual risk behaviors from ages 14 to 18. In order to examine the unique association between BPD symptoms and sexual risk behaviors, analyses controlled for symptoms of depression and conduct disorder, as well as race, sexual orientation, and pubertal development. Girls with more BPD symptoms at age 14 showed steeper growth over time in sexual risk behaviors from ages 14 to 18. Additionally, adolescents who showed steeper increases in BPD symptoms over time also showed steeper increases in sexual risk behaviors across adolescence. Notably, however, sexual risk behavior at age 14 was not significantly associated with longitudinal trajectories of BPD symptoms. Results suggest that adolescent girls with early symptoms of BPD are at heightened risk for the development of sexual risk behaviors during adolescence, while the reverse association does not hold. Implications for adolescent development and sexual risk behavior are discussed.

Changes in externalizing and internalizing symptoms among African American female adolescents over 1 year following a mother-daughter sexual health intervention

OBJECTIVE

African American female adolescents face disparities compared with White peers in the interrelated areas of mental health symptoms and sexually transmitted infection (STI) acquisition. IMARA (Informed, Motivated, Aware and Responsible about AIDS) is a group-based mother-daughter intervention addressing these factors among African American teenagers. Previous work demonstrated that female adolescents who received IMARA were 43% less likely than controls to evidence a new STI at 1 year. This report aimed to provide the 1st test of IMARA on externalizing and internalizing symptoms and an exploratory analysis of whether symptom improvements were associated with the protective effect of treatment against future STIs.

METHOD

Female African Americans aged 14-18 years (M = 16; N = 199) were randomly assigned to IMARA or a health promotion control group matched for time and structure. They completed the Youth Self-Report of externalizing and internalizing symptoms at baseline and at 6 and 12 months and were tested for STIs at baseline and 12 months; positive cases were treated. Hierarchical linear modeling tested symptom change over time, including the moderating effects of baseline symptoms.

RESULTS

Among participants who entered with high versus lower externalizing symptoms, those who received IMARA showed a slightly greater decrease in externalizing scores relative to the control (p = .035). For these youth, symptom improvements appeared to be associated with IMARA's protective effect against new STIs. Treatment was not associated with internalizing symptom change (p > .05).

CONCLUSION

IMARA shows promise in modestly reducing self-reported externalizing symptoms, although only for participants with high scores at baseline. The possibility that externalizing symptom improvement is linked with reduced STI acquisition warrants future examination. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Utilizing a Life Course Approach to Examine HIV Risk for Black Adolescent Girls and Young Adult Women in the United States: A Systematic Review of Recent Literature

Objective

Black female youth have been disproportionately burdened by the HIV epidemic. Emerging literature suggests that individual and social-structural factors may uniquely increase HIV risk within this population during key developmental periods, namely adolescence (ages 10-17 years) and emerging adulthood (ages 18-25 years). Few studies, however, have compared drivers of risk within and between these key developmental periods. Therefore, we conducted a systematic review of recent literature to characterize and identify important gaps in our understanding of the individual, psychosocial, and social-structural determinants of HIV risk among Black adolescent girls and emerging adult women.

Design

Using a replicable strategy, we searched electronic databases for articles and abstracts published between October 1, 2017 and September 30, 2019 in which the primary focus was on HIV prevention among Black adolescent girls and emerging adults in the United States.

Results

In total, 21 studies met the inclusion criteria. Most of the studies on Black adolescent girls assessed family functioning, parental monitoring, and parent-adolescent communication as determinants of HIV-related behaviors. However, equivalent studies were lacking for Black emerging adult women. Moreover, few studies assessed neighborhood characteristics, social networks, or other community-level factors as determinants of HIV-related behaviors, which are known drivers of HIV disparities.

Conclusions

Our findings highlighted several gaps in the literature, including failure to recognize the ethnic and cultural differences among Black women that may contribute to behavioral differences within this population and insufficient acknowledgment of the role of HIV protective factors (eg, resilience and community assets). Implications and future directions are discussed.

Pathways from witnessing community violence to mental health problems among South African adolescents

BACKGROUND

The intersection of violence exposure and mental health problems is a public health crisis for South African (SA) adolescents. Understanding the impact of community violence on adolescent mental health can inform future interventions.

OBJECTIVES

To assess pathways between community violence exposure and internalising and externalising problems in SA adolescents receiving mental healthcare, and the roles of parent and peer relationships in these associations.

METHODS

Participants (N=120 parent-adolescent pairs) were recruited from four mental health clinics in Western Cape Province to participate in a pilot test of a family-based HIV prevention study. Adolescents reported on their exposure to community violence, parental attachment, peer support of risk behaviour, and mental health. Parents reported on adolescents' internalising and externalising mental health problems. Participants received transport money (ZAR30 = USD3) and a shopping voucher or cash (ZAR50 = USD5) for their time.

RESULTS

Adolescents were 12 - 18 years old (mean (standard deviation) 14.39 (1.82) years), 53% were male, and 67% and 33% reported black African and mixed-race ethnicity, respectively. Parents were 94% female and reported an average monthly income of ZAR3 973 (USD397). Boys reported significantly higher rates of witnessing community violence than girls. Among boys, significant paths emerged from community violence and low parent attachment to externalising symptoms and from community violence to peer support of risky behaviour. For girls, the only significant path was from low parent attachment to peer support of risky behaviour.

CONCLUSIONS

This cross-sectional study sheds new light on the possible pathways from witnessing community violence to mental health problems among SA adolescents. Identifying factors that drive and mitigate psychological distress in the context of persistent community violence is critical to SA's future and can inform the selection and delivery of appropriate and targeted evidence-based interventions.