A quarter century of HIV prevention intervention efforts among children and adolescents across the globe

In 1988 a group of pediatricians, developmental, clinical, child and social psychologists, anthropologists and health educators began researching in Baltimore, Maryland, on an Human Immunodefiency Virus (HIV) prevention intervention, Focus on Youth (FOY). Over the next 25 years, the questions being addressed by FOY reflected those of the global HIV research experience. During the first phase, the questions being addressed by the broader research community included: Can HIV risk behaviors be purposefully impacted by behavioral interventions? If so, how do successful interventions differ from those that are not effective? Are theory-based interventions more likely to be effective than information-only-based interventions? Can theories be translated into culturally and developmentally appropriate interventions including those that are appropriate for children and adolescents? Should parents be involved – and if so, how? During its next phase, the FOY team increasingly became concerned with a disturbing reality. A large number of interventions had been developed and some had been shown to have evidence of impact. But virtually all of these interventions had been conducted in the USA or Europe. The questions facing researchers included: With the global burden of HIV disproportionately impacting low- and middle-income countries (LMIC), especially those in southern Africa, the Caribbean and parts of Asia, what is known about the effectiveness of western-based interventions in these culturally, racially and economically disparate settings? With the exciting proliferation of interventions, federal agencies in the USA and international agencies including Joint United Nations Programme on HIV/AIDS realized the importance of assessing the research portfolio and developing metrics of effectiveness. The questions during this phase included: What is an “effective” intervention? How are effective interventions implemented in a new setting? This phase merged with the next phase as researchers and public health workers realized that the dissemination to a new community of an intervention developed and found to be effective in one community requires change. The central questions during this time included: What changes or kinds of changes can be made to an intervention without undermining its effectiveness? What aspects of an intervention cannot be changed without potentially undermining its effectiveness? What constitutes a “change”? Who should be involved in this decision-making? These efforts culminated in our current phase, one focused on implementation. We must learn more about the factors that allow an intervention to survive and thrive and selectively target these critical factors. The main objective of this paper is to review our experiences and lessons learned in developing, implementing and evaluating FOY in a wide range of socio-cultural settings over the past quarter of century.

Comparing data collected by computerized and written surveys for adolescence health research

BACKGROUND

This study assessed whether data-collection formats, computerized versus paper-and-pencil, affect response patterns and descriptive statistics for adolescent health assessment surveys. Youth were assessed as part of a health risk reduction program.

METHODS

Baseline data from 1131 youth were analyzed. Participants completed the questionnaire either by computer (n = 390) or by paper-and-pencil (n = 741).

RESULTS

The rate of returned surveys meeting inclusion requirements was 90.6% and did not differ by methods. However, the computerized method resulted in significantly less incompleteness but more identical responses. Multiple regression indicated that the survey methods did not contribute to problematic responses. The two survey methods yielded similar scale internal reliability and descriptive statistics for behavioral and psychological outcomes, although the computerized method elicited higher reports of some risk items such as carrying a knife, beating up a person, selling drugs, and delivering drugs.

CONCLUSIONS

Overall, the survey method did not produce a significant difference in outcomes. This provides support for program personnel selecting survey methods based on study goals with confidence that the method of administration will not have a significant impact on the outcome.

Trial of an urban adolescent sexual risk-reduction intervention for rural youth: a promising but imperfect fit

PURPOSE

The purpose of this study was to assess the effectiveness of Focus on Kids (FOK), a sexual risk reduction intervention, shown to be effective among urban, African-American adolescents living in communities with high rates of sexually transmitted diseases, in reducing sexual risk behaviors among rural, white adolescents living in communities with low rates of sexually transmitted diseases. The subjects were 1,131 youth ages 12 to 16 years from 12 rural counties in West Virginia.

METHOD

The study was a randomized, controlled, longitudinal trial of a theory-based prevention intervention. Outcomes included self-reported sexual behaviors and perceptions assessed at baseline and at 3, 6, and 9 months after intervention.

RESULTS

At baseline, 21% of youth were sexually experienced; 80% reported using a condom at last episode of intercourse. Rates of behaviors did not differ based on intervention assignment (FOK vs control group) after adjusting for baseline differences at any follow-up period among the full cohort or among the subset of youth who completed the intervention curriculum to which they were assigned. Perceptions of risk and protective behaviors were positively influenced by FOK at 3, 6, and 9 months in a fashion consistent with the guiding model of behavioral change and the FOK curriculum.

CONCLUSIONS

Consistent with previous studies of FOK in high-risk urban areas, some perceptions were positively altered by FOK in these rural areas, although many of these changes did not persist through 9 months of follow-up. In contrast to previous studies, self-reported sexual risk behaviors did not decrease among FOK youth. FOK was not associated with any increases in sexual risk behaviors.

Substance use among rural adolescent virgins as a predictor of sexual initiation

Longitudinal data from 746 virgins (310 males) aged 12 to 16 years were analyzed to assess the relationship between baseline substance use and sexual initiation 3, 6, and 9 months later. Compared to virgins with no substance use, virgins who had used three or more substances were three times more likely to initiate sex over the ensuing 9 months. The use of alcohol, tobacco, and marijuana and the use of more than three substances are highly specific for predicting sexual initiation.

The complex business of adapting effective interventions to new populations: an urban to rural transfer

PURPOSE

To assess the effectiveness of a relatively unaltered version of a sexual risk reduction intervention previously shown to be effective among urban youth, "Original Focus on Kids" (OFOK), compared with a version modified for West Virginia (WVFOK) and a control condition (training in environmental conservation), in altering protective sexual behaviors and perceptions among rural, Appalachian youth.

SUBJECTS

Nine hundred ninety-nine youth aged 12 to 16 years from 12 rural counties in West Virginia.

METHOD

Randomized, controlled, longitudinal trial of a theory-based prevention intervention. Outcomes were self-reported sexual behaviors and perceptions assessed at baseline, 3, 6, and 9 months postintervention.

RESULTS

Both WVFOK and OFOK positively affected perceptions of abstinence but not behaviors. OFOK significantly enhanced some perceptions of condom use compared with both control youth and WVFOK youth, but again, not behaviors.

CONCLUSIONS

Overall, neither version was as effective as FOK had been in the original urban setting. The less altered version (OFOK) was more effective, especially with regard to condom-use perceptions, in this new population and cultural setting than the more culturally altered version (WVFOK). In several of the implementation settings, neither version was delivered as intended by the researchers because of logistic issues. Although many of these changes were seemingly minor, such deviations may have significant impact on intervention effect.

HIV/STD risk behaviors and perceptions among rural-to-urban migrants in China

Data from 2,153 sexually active rural-to-urban migrants in China were analyzed to examine the relationship between the movement of rural-to-urban migration and increased HIV/STD (sexually transmitted disease) risk and the applicability of constructs of a Western-based theory of behavioral change to the study population. Measurements included migrant mobility, sexual risk, and the seven constructs of the protection motivation theory (PMT). Data in the current study suggest that high mobility among rural-to-urban migrants was associated with increased sexual risk. The PMT constructs are applicable in identifying perceptions and attitudes associated with sexual risk behaviors in this culturally distinct population. Increased sexual risk was associated with increased perceptions of extrinsic rewards, intrinsic rewards, and response cost. Also consistent with PMT, increased sexual risk was associated with perceptions of decreased severity, vulnerability, response efficacy, and self-efficacy. After controlling for a number of key confounding factors, all seven PMT constructs were associated with sexual risk in the manner posited by the theory. The association between mobility and sexual risk underscores the importance of effective HIV/STD prevention efforts among this vulnerable population. The social cognitive theories including the PMT may form a logical base for prevention intervention programs targeting rural-to-urban migrants in China.