Effects through 24 months of an HIV/AIDS prevention intervention program based on protection motivation theory among preadolescents in the Bahamas

Maintaining Program Fidelity in a Changing World: National Implementation of a School-Based HIV Prevention Program

Large-scale, evidence-based interventions face challenges to program fidelity of implementation. We developed implementation strategies to support teachers implementing an evidence-based HIV prevention program in schools, Focus on Youth in The Caribbean (FOYC) and Caribbean Informed Parents and Children Together (CImPACT) in The Bahamas. We examined the effects of these implementation strategies on teachers' implementation in the subsequent year after the initial implementation during the COVID-19 pandemic. Data were collected from 79 Grade 6 teachers in 24 government elementary schools. Teachers completed training workshops and a pre-implementation questionnaire to record their characteristics and perceptions that might affect their program fidelity. School coordinators and peer mentors provided teachers with monitoring, feedback, and mentoring. In Year 1, teachers on average taught 79.3% of the sessions and 80.8% of core activities; teachers in Year 2 covered 84.2% of sessions and 72.9% of the core activities. Teachers with "good" or "excellent" school coordinators in the second year taught significantly more sessions on average (7.8 vs. 7.0, t = 2.04, P < 0.05) and more core activities (26.3 vs. 23.0, t = 2.41, P < 0.05) than teachers with "satisfactory" coordinators. Teachers who had a "good" or "satisfactory" mentor taught more sessions than teachers who did not have a mentor (7.9 vs. 7.3; t = 2.22; P = 0.03). Two-level mixed-effects model analysis indicated that teachers' program fidelity in Year 1, confidence in the execution of core activities, and school coordinators' performance were significantly associated with Year 2 implementation dose. Implementation of FOYC + CImPACT was significantly associated with improved student outcomes. Teachers maintained high fidelity to a comprehensive HIV prevention program over 2 years during the COVID-19 pandemic. Future program implementers should consider additional implementation support to improve the implementation of school-based programs.

Effects of Teacher Training and Continued Support on the Delivery of an Evidence-Based HIV Prevention Program: Findings From a National Implementation Study in the Bahamas

BACKGROUND

Few studies have investigated the effects of teacher training and continued support on teachers' delivery of evidence-based HIV prevention programs. We examined these factors in a national implementation study of an evidence-based HIV risk reduction intervention for adolescents in the sixth grade in the Bahamas.

METHODS

Data were collected from 126 grade 6 teachers and 3,118 students in 58 government elementary schools in the Bahamas in 2019-2021. This is a Hybrid Type III implementation study guided by the Exploration, Preparation, Implementation, Sustainment (EPIS) model. Teachers attended 2-day training workshops. Trained school coordinators and peer mentors provided biweekly monitoring and mentorship. We used mixed-effects models to assess the effects of teacher training and continued support on implementation fidelity.

RESULTS

Teachers who received training in-person or both in-person and online taught the most core activities (27.0 and 27.2 of 35), versus only online training (21.9) and no training (14.9) (F = 15.27, p < .001). Teachers with an "excellent" or "very good" school coordinator taught more core activities than those with a "satisfactory" coordinator or no coordinator (29.2 vs. 27.8 vs. 19.3 vs. 14.8, F = 29.20, p < .001). Teachers with a "very good" mentor taught more core activities and sessions than those with a "satisfactory" mentor or no mentor (30.4 vs. 25.0 vs. 23.1; F = 7.20; p < .01). Teacher training, implementation monitoring, peer mentoring, teachers' self-efficacy, and school-level support were associated with implementation fidelity, which in turn was associated with improved student outcomes (HIV/AIDS knowledge, preventive reproductive health skills, self-efficacy, and intention to use protection).

CONCLUSION

Teachers receiving in-person training and those having higher-rated school coordinator and mentor support taught a larger number of HIV prevention core activities. Effective teacher training, implementation monitoring, and peer mentoring are critical for improving implementation fidelity and student outcomes.

The Effect of an Educational Intervention Based on Protection Motivation Theory on Pregnant Women's Knowledge and Self-Protection Regarding COVID-19. An Intervention Study

Background

COVID-19 infection endangers pregnant women and newborns. Infection prevention measures are available and easy to apply, but the problem is the application continuity. Empowering pregnant women to increase their intention for self-protection is very important. This study explores the effect of educational intervention based on the Protection Motivation Theory (PMT) on pregnant women's knowledge and self-protection regarding COVID-19.

Materials and Methods

A randomized, controlled trial was conducted at the Obstetrics and Gynecology outpatient clinic at El Shatby Hospital, Alexandria governorate/Egypt, from November 2020 to May 2021. The study included a convenient sample of 163 pregnant women using the randomization block technique. A self-reported questionnaire was used for data collection. For the intervention group, the PMT-based education included need assessment, planning, implementation, and evaluation. Two months later, a reevaluation was done.

Results

ANCOVA showed a significant improvement in the intervention group's knowledge (F1 = 8.56, p < 0.001) when taking the pretest as a reference. The effect size shows that 25.8% of the intervention group's knowledge improvement and 58.80% of the difference between the two groups were due to intervention. ANCOVA showed a significant improvement in the intervention group's PMT constructs when taking the pretest or group as a reference (p <0.001). The effect size shows that 56.10% of the intervention group's total PMT constructs improvement and 89.60% of the differences between the two groups were due to the intervention.

Conclusions

PMT-based intervention is effective in improving pregnant women's knowledge and self-protection intention regarding COVID-19. PMT is recommended to tailor educational intervention for pregnant women.

Factors Affecting Preventive Behaviors for Safety and Health at Work during the COVID-19 Pandemic among Thai Construction Workers

Occupational health and safety risks are of major concerns in construction industry. The COVID-19 outbreak provides an additional risk that could drastically affect the safety risks and health of construction workers. Understanding the factors that affect the health and safety of construction workers is significant in reducing risky behaviors and enhancing worker preventive behaviors. Via integrating the Protection Motivation Theory (PMT) and the extended Theory of Planned Behavior (TPB), this study investigates the factors that affect preventive behaviors among construction workers during the COVID-19 pandemic in Bangkok, Thailand. A total of 610 Thai construction workers participated in an online questionnaire survey, which consisted of nine factors with 43 questions. Structure equation modeling (SEM) was adopted to analyze the causal relationships among the latent variable. The SEM results indicated that organizational support and knowledge about COVID-19 had significant (p < 0.0001) direct influences on perceived vulnerability and perceived severity. In addition, perceived vulnerability and perceived severity had significant direct influences on perceived behavioral control. Perceived severity had significant (p < 0.0001) direct influence on attitude towards behavior. Moreover, perceived behavioral control and attitude towards behavior had significant (p < 0.0001) direct influence on intention to follow the preventive measure. Furthermore, the intention to follow the preventive measure had significant (p < 0.0001) direct influences on the COVID-19 preventive behavior. Of note, organizational support and knowledge about COVID-19 had significant (p < 0.0001) indirect influence on COVID-19 preventive behavior. The findings of this study may assist project managers/supervisors and authorities in the construction industry in understanding the challenge during COVID-19 and possible similar epidemics in the future. In addition, conducting effective strategies would improve construction industry safety and promote preventive behaviors among construction workers.

Implementing a school-based HIV prevention program during public health emergencies: lessons learned in The Bahamas

Background

Natural disasters and public health crises can disrupt communities’ capacities to implement important public health programs. A nationwide implementation of an evidence-based HIV prevention program, Focus on Youth in The Caribbean (FOYC) and Caribbean Informed Parents and Children Together (CImPACT), in The Bahamas was disrupted by Hurricane Dorian and the COVID-19 pandemic, especially in its more remote, Family Islands. We explored the teacher- and school-level factors that affected implementation of the program in these islands during those disruptions.

Methods

Data were collected from 47 Grade 6 teachers and 984 students in 34 government elementary schools during the 2020–2021 school year. Teachers completed a pre-implementation questionnaire to record their characteristics and perceptions that might affect their implementation fidelity and an annual program training workshop. School coordinators and high-performing teachers acting as mentors received additional training to provide teachers with monitoring, feedback, and additional support. Teachers submitted data on their completion of the 9 sessions and 35 core activities of FOYC + CImPACT. The fidelity outcomes were the number of sessions and core activities taught by teachers.

Results

On average, teachers taught 60% of sessions and 53% of core activities. Teachers with “very good” school coordinators (34% of teachers) taught more activities than those with “satisfactory” (43%) or no (34%) school coordinator (27.5 vs. 16.8 vs. 14.8, F = 12.86, P < 0.001). Teachers who had attended online training or both online and in-person training taught more sessions (6.1 vs. 6.2 vs. 3.6, F = 4.76, P < 0.01) and more core activities (21.1 vs. 20.8 vs. 12.6, F = 3.35, P < 0.05) than those who received no training. Teachers’ implementation was associated with improved student outcomes (preventive reproductive health skills, self-efficacy, and intention).

Conclusions

The Hurricane Dorian and the COVID-19 pandemic greatly disrupted education in The Bahamas Family Islands and affected implementation of FOYC + CImPACT. However, we identified several strategies that supported teachers’ implementation following these events. Teacher training and implementation monitoring increased implementation fidelity despite external challenges, and students achieved the desired learning outcomes. These strategies can better support teachers’ implementation of school-based interventions during future crises.

An Integrated Approach to COVID-19 Preventive Behaviour Intentions: Protection Motivation Theory, Information Acquisition, and Trust

COVID-19 has been a global threat since November 2019 due to its high transmission rates and the issue of unwillingness to vaccinate. Effective risk management requires accurate health communication and public compliance with reccomended preventive behaviors. Therefore, we investigated predictors of COVID-19 preventive behavior intention based on Protection Motivation Theory (PMT) in addition to frequency of public's use of and trust in a group of COVID-19 related information sources. This cross-sectional study was conducted on 458 adults in Turkey with online survey. Results showed that all PMT components (except perceived susceptibility) accounted for 49% of the variance in protection motivation and there was relationship between information sources and protection motivation. Overall, our study findings suggested that being more informed and having confidence in the feasibility (self-efficacy) and effectiveness (response efficacy) of preventive behaviors may particularly help slow the disease spread.

Motivation for protection in sexual relationship during the COVID-19 quarantine: analysis of the sociodemographic variables of the Iranian population

Background

Coronavirus is an infectious disease that has affected sexual life. Sexual activity has decreased for many people, and couples' physical contact has reduced. The present study aimed to determine the sexual relationship of Iranian people and related factors during the Corona home quarantine by focusing on all constructs of the protective motivation theory.

Methods

This cross-sectional online survey was conducted on Iranian people under in-home quarantine from July to December 2020 during the Covid-19 pandemic. Seven hundred sixteen people were selected by the convenience sampling method. The data was gathered by an ad-hoc tool consisting of demographic information and sexual relationship regarding protection motivation behavior in the Covid-19 pandemic. Participants should be able to complete the online questionnaire because the questionnaires were completed online. One-way ANOVA, independent T, and Pearson correlation tests were used to analyze the data in SPSS 16 software.

Results

Findings indicate the average age of the participants was 37.78 + 8.34 years. Most of them were women (%85.1), married (%91.3) and had a university education (%90.2). In addition, %42.5% of participants had Full-time jobs and %34.2 lived in Tehran. 49.9% obtained information about corona from TV. 63.3% of the participants and their spouses did not catch Covid-19. Employment status was the only variable that was significantly different from sexual relationships regarding protection motivation (p = 0.031). Perceived response efficiency with an average of 79.12 had the highest, and perceived self-efficacy with an average of 69.92 had the lowest mean score among the areas of sexual relationship. Among the protection motivation domains of sexual behavior that all had significant correlations, there was no significant correlation between perceived severity and perceived self-efficacy (p = 0.067).

Conclusion and implication

Perceived vulnerability is associated with employment status, place of residence, and age. Sexual relationships regarding protection motivations are only associated with employment status. Overall, participants in the present study reported high levels of perceived severity, perceived vulnerability, perceived response efficiency, and perceived costs Therefore, they reported a high level of motivation for protective and preventive behaviors in their sexual relationship. Our findings suggest that future interventions should focus on general cognition by developing appropriate knowledge about the severity and vulnerability of Covid-19 and sexual behaviors, improving perceived response efficiency, and self-efficacy of protective behavior through skills training.

Screening Intention Prediction of Colorectal Cancer among Urban Chinese Based on the Protection Motivation Theory

Colorectal cancer poses a serious threat worldwide. Although early screening has been proved to be the most effective way to prevent and control colorectal cancer, the current situation of colorectal cancer screening remains not optimistic. The aim of this article is to apply the protection motivation theory (PMT) to examine the influencing factors on screening intention of colorectal cancer (CRC). This cross-sectional survey was launched in five communities in Wuhan, China. All the eligible urban Chinese were recruited and interviewed using paper-and-pencil questionnaires. The intention of colorectal cancer screening (CRCS) was measured using six PMT subconstructs, including perceived risk, perceived severity, fear arousal, response efficacy, response cost, and self-efficacy. Data on sociodemographic variables and knowledge of CRC were also collected. The structural equation modeling (SEM) method was used for data analysis. Among all the 569 respondents, 83.66% expressed willingness to participate in CRCS. Data of the research fit the proposed SEM model well (Chi-square/df = 2.04, GFI = 0.93, AGFI = 0.91, CFI = 0.91, IFI = 0.91, RMSEA = 0.04). Two subconstructs of PMT (response efficacy and self-efficacy) and CRC knowledge were directly and positively associated with screening intention. Age, social status, medical history, physical activity, and CRC knowledge were indirectly related to the screening intention through at least one of the two PMT subconstructs (response efficacy and self-efficacy). The findings of this study suggest the significance of enhancing response efficacy and self-efficacy in motivating urban Chinese adults to participate in CRC screening. Knowledge of CRC is significantly associated with screening intention. This study can provide useful information for the formulation and improvement of colorectal cancer screening strategies and plans.

The Effectiveness of Two Implementation Strategies for Improving Teachers' Delivery of an Evidenced-based HIV Prevention Program

BACKGROUND

Effective implementation strategies are needed to enhance the success of evidence-based prevention programs. The current study evaluates the effects of two implementation strategies on teachers' implementation of an evidenced-based HIV intervention.

METHODS

Using our 7-item pre-implementation school screening tool, we identified teachers who were at-risk for not implementing the Focus on Youth HIV-risk reduction intervention curriculum which targets grade six through grade 8 students. After completing a two-day curriculum workshop, 81 low- and moderate-performing teachers were randomly assigned to one of four experimental conditions and were asked to teach the two-month intervention curriculum. This optimization trial examines the impact of two implementation strategies: biweekly monitoring/feedbacks (BMF) and site-based assistance/mentorship (SAM). The primary outcome is implementation fidelity defined as number of core activities taught. Linear mixed-effects model was used to examine the association of the implementation strategies with implementation fidelity.

RESULTS

BMF and SAM were significantly associated with teachers' implementation fidelity. Teachers who received both BFM and SAM taught the greatest numbers of core activities (15 core activities on average), followed by teachers who received either BMF (6.9 activities) or SAM (7.9 activities). Teachers who did not receive BMF or SAM taught the lowest numbers (4.1 activities). Teachers' sustained implementation of FOYC in the prior school year was related to increased implementation fidelity during the optimization trial. Teachers' confidence in implementing five core activities, attitudes toward sex education in schools, and perceived principal support were significantly related to increased self-efficacy, which in turn was related to teachers' fidelity of implementation before the optimization trial.

CONCLUSION

BMF and SAM are effective in promoting teachers' implementation of youth evidence-based interventions. Researchers and future program implementers should consider teacher training, teachers' attitudes toward sex education, perceived principal support, and self-efficacy when attempting to maintain the effects of teacher-delivered interventions in schools.

Protection Motivation Theory and Rabies Protective Behaviors Among School Students in Chonburi Province, Thailand

Objectives

The aim of this study was to predict rabies protective behaviors (RPB) based on protection motivation theory (PMT) among fourth-grade students at schools in Chonburi Province, Thailand.

Methods

This cross-sectional study was conducted from December 2020 to February 2021. A multistage sampling technique was used for sample selection. The questionnaire was divided into socio-demographic data and questions related to PMT and RPB. Descriptive statistical analysis was conducted using the EpiData program and inferential statistics, and the results were tested using the partial least squares model with a significance level of less than 5%.

Results

In total, 287 subjects were included, of whom 62.4% were girls and 40.4% reported that YouTube was their favorite media platform. Most participants had good perceived vulnerability, response efficacy, and self efficacy levels related to rabies (43.9, 68.6, and 73.2%, respectively). However, 54.5% had only fair perceived severity levels related to rabies. Significant positive correlations were found between RPB and the PMT constructs related to rabies (β, 0.298; p<0.001), and the school variable (S4) was also a predictor of RPB (β, -0.228; p<0.001). Among the PMT constructs, self efficacy was the strongest predictor of RPB (β, 0.741; p<0.001).

Conclusions

PMT is a useful framework for predicting RPB. Future RPB or prevention/protection intervention studies based on PMT should focus on improving self efficacy and response efficacy, with a particular focus on teaching students not to intervene with fighting animals. The most influential PMT constructs can be used for designing tools and implementing and evaluating future educational interventions to prevent rabies in children.

Hookah is the enemy of health campaign: a campaign for prevention of hookah smoking among youth

Hookah smoking is now a serious health threat especially for adolescents. Implementation of planned interventions can help reduce hookah smoking. This study was conducted to investigate the effect of a campaign Hookah is the Enemy of Health Campaign (HEHC) based on the protection motivation theory to prevent hookah smoking among the youth in Sirjan city, in 2018. This was a pre- and post-intervention study. Participants were 280 male and female youth who were selected randomly through the health centers of Sirjan. The educational campaign was conducted during 3 months and participants were trained through interpersonal, group, organizational and community channels and mass media. Data were collected by filling out a questionnaire (containing 64 questions) by the participant before the intervention and 3 months after. Data were analyzed by descriptive statistics (frequency and percentage), chi-square and Wilcoxon signed-rank test by SPSS20 software. The prevalence of hookah smoking was 44.3% in the target group. There was a significant change in the mean scores of knowledge and perceived susceptibility, perceived severity, response efficiency, self-efficacy, rewards, fear and protection motivation after the HEHC (p < 0.05), but there was no significant difference in the structure of perceived cost (p > 0.05). Also, the prevalence of hookah smoking among the target group for those who had ever consumed decreased from 8.9 to 4% and for those who used it occasionally decreased from 35 to 19.4%. The HEHC was effective in reducing hookah smoking, raising knowledge and improving the constructs of the protection motivation theory among the youth of Sirjan.

Preventive Behaviors Towards Covid-19 Pandemic Among Healthcare Providers in Saudi Arabia Using the Protection Motivation Theory

Purpose

The main objectives of the study are firstly to measure the COVID–19 preventive health behaviors related among health care providers (HCPs), then to identify the determinants of such behavior using the protection motivation theory (PMT).

Patients and Methods

An online cross-sectional survey, containing closed-ended questions, was distributed among healthcare professionals including physicians, pharmacists, technicians, and nurses. It consisted of questions assessing socio-demographic and occupational characteristics, in addition to questions from the modified PMT that has been tailored for the COVID-19 pandemic through five sub-constructs: perceived severity and perceived vulnerability, response efficacy, self-efficacy, response costs, and behavioral intention.

Results

A total of 385 HCPs have participated in the study with a mean age of 40.08±8.2 years; the majority was Saudi, married, and having children. There was a significant association between intention to comply with COVID-19 preventive behavior and being females, nurses, having training in Infection prevention and control (IPC) measures, and availability of personal protective equipment (PPE) during work time (p≤0.01). Other demographic variables, working experience, the status of being in the workforce during the pandemic COVID-19 in Saudi Arabia did not have a significant effect on the intention of HCPs to comply with COVID-19 preventive behavior. The vast majority 85.7% of HCPs answered “always” regarding the behavioral intention of HCPs to comply with COVID-19 preventive behavior. There was a significant positive correlation between COVID-19 behavioral intention and other constructs of PMT model, including perceived severity (r=0.272) perceived vulnerability (r= 0.248), self-efficacy (r=0.218), response-efficacy (r=0.167), and response-cost (r=0.13). Gender, availability of PPE, and self-efficacy had a significant prediction of COVID-19 behavioral intentions (P <0.05) with a predicted increase of 0.56, 0.37, and 0.12, respectively, in the mean of the intention score. Self-efficacy was the highest significant predictor of the behavior (p=0.008).

Conclusion

Females’ gender, nurses, having training in IPC measures, and availability of PPE during work time have a significant association with intention to comply with COVID-19 preventive behavior. The present study coping appraisal particularly self-efficacy predicted the COVID-19 pandemic protection motivation and preventive behavior more than threat appraisal. Therefore, future training programs must consider the level of self-efficacy of HCPS, and increase their knowledge regarding the effectiveness of recommendation strategies to perform protective measures against the COVID-19.

Structural equation modeling test of the pre-intentional phase of the health action process approach (HAPA) model on condom use intention among senior high school students in Tianjin, China

Based on the Theory of Health Action Process Approach (HAPA) Model, this study aimed to investigate factors associated with condom use intention in Chinese adolescents.In 2017, we conducted a cross-sectional study using stratified cluster, convenience sampling method to assess condom use intention among senior high school students in Tianjin, China. One thousand eighty two senior high school students were anonymously surveyed through self-administered questionnaires. Structural equation modelling was used to assess the pre-intentional phase of HAPA model.Among the participants, 41.5% (449/1082) were male, 54.1% (585/1082) were female, 4.4% (48/1082) were gender-deficient. The average age was 16.7 years. The final pre-intentional phase of HAPA model was acceptable (CFI = 0.95; GFI = 0.94; RMSEA = 0.06). Action self-efficacy (r = 0.60) had a strong direct effect on condom use intention.The pre-intentional phase of HAPA model is valid to assess condom use intention among Chinese senior high school students. The pre-intention phase of the HAPA model could be applied to guide AIDS health educations of students, and further research is needed to evaluate the effect.

Examining the roles of students' beliefs and security concerns for using smartwatches in higher education

Purpose

Despite the increased use of wearables in education, little attention has been paid to why some students are more likely to adopt smartwatches than others. The question of what impacts the adoption of smartwatches in educational activities is still neglected. In addition, the question of how security determinants can affect the adoption of smartwatches by students has not been addressed yet. Hence, this study aims to develop a theoretical model by integrating the technology acceptance model (TAM) and protection motivation theory (PMT) to study students' adoption of smartwatches for educational purposes.

Design/methodology/approach

Questionnaires were distributed to university students in Malaysia. A total of 679 valid responses were collected. The collected data were analyzed using partial least squares-structural equation modeling (PLS-SEM).

Findings

The results of data analysis provide support for the proposed model. Furthermore, the findings indicated that perceived vulnerability, self-efficacy, response efficacy, response cost, ease of use and perceived usefulness have significant effects on students' behavioral intention to use smartwatches for educational purposes. In addition, perceived ease of use of smartwatches for educational purposes helps students to realize the benefits of this technology.

Originality/value

This is an original study that develops a new holistic theoretical model by combining the PMT and TAM to study the effects of ease of use, usefulness and security-related factors on the adoption of smartwatches for educational purposes. The study offers practical implications for universities and higher education institutions to improve students' learning experiences to ensure their sustainability using new and innovative ways by exploiting new technologies such as smartwatches.

Protective Behavior against COVID-19 among the Public in Kuwait: An Examination of the Protection Motivation Theory, Trust in Government, and Sociodemographic Factors

With the COVID-19 pandemic threatening millions of lives around the world with no clear promises for treatment or vaccine yet, motivating the public to change their behaviors to prevent the spread of the disease becomes crucial and moral imperative. The current study investigated the associations between self-reported intentions to perform protective behaviors against COVID-19, the seven constructs of the Protection Motivation Theory PMT, trust in government, and sociodemographic factors within the general population in Kuwait. A cross-sectional design was adapted to explore the associations between study factors in a nonprobability voluntary response sample of 679 participants who completed an online public survey. Results indicate that the scores of trust in government and the severity, vulnerability, response efficacy, and self-efficacy subconstructs of the PMT were positively related to protective behavior intention, whereas intrinsic and extrinsic reward and response cost subconstructs were negatively associated with protective behavior intention. The results were discussed considering previous literature and future applications.

Predictors of Responsiveness Among American Indian Adolescents to a Community-Based HIV-Risk Reduction Intervention Over 12 Months

This analysis explored predictors of responsiveness to the Respecting the Circle of Life (RCL) intervention, a sexual and reproductive health program for American Indian (AI) youth. Data were collected over 12-month follow-up with 267 AI youth aged 13-19. We used mixed effects regression models to examine: (1) whether trajectory patterns of HIV/AIDS knowledge, condom beliefs, condom use self-efficacy, condom use intention and partner negotiation skills differed by baseline levels categorized into low, medium, and high scorers, and (2) the characteristics of youth who made no improvement over the post-intervention period. Results indicate the RCL intervention had greater longitudinal impact among subgroups with low and medium initial scores. High initial scores in knowledge, beliefs, efficacy, intention and skills predicted unresponsiveness to the RCL intervention. Youth differences in age, gender and school truancy (skipping/suspension) did not predict responsiveness to RCL. Results have important prevention science implications: (1) AI youth at greater risk (i.e., those with low initial levels of knowledge, beliefs, self-efficacy, intention and skills) are likely to respond to RCL and should be the target of replication and dissemination efforts. (2) Responsiveness analyses can guide adaptation of RCL and other sexual and reproductive health programs for AI youth to improve efficacy among unresponsive subgroups (i.e., high initial scorers). (3) RCL is equally likely to impact AI youth across different ages, genders and school status, thus validating population-wide implementation strategies.

Analysis of the environmental behavior of farmers for non-point source pollution control and management: An integration of the theory of planned behavior and the protection motivation theory

Agricultural non-point source (NPS) pollution in water source protection areas poses serious challenges for governments in developing countries. It is important to consider the environmental behavior of farmers when exploring the causes of NPS pollution as well as when establishing scientific controls and management measures. However, the poor understanding of factors influencing the environmental behavior of farmers and the lack of a suitable environmental socio-psychological model limit the application of the environmental behavior of farmers in NPS pollution management. In this study, we therefore integrated the theory of planned behavior (TPB) and the protection motivation theory (PMT) to identify the main determinants of the NPS pollution-related environmental behavior and intention of farmers in the Water Source Area of the Middle Route of the South-to-North Water Diversion Project in China. Results indicated that the integrated model provided a better understanding of the environmental behavior and intention of farmers than that provided by each component when used individually, and revealed that farmers perceived that the susceptibility and severity of threats caused by water deterioration influenced environmental intention through the mediating effects of subjective norm and attitude toward adopting pro-environmental behavior. At the same time, the perceived vulnerability of farmers was relatively high and their perceived severity was relatively low. Furthermore, the subjective norm, attitude, self-efficacy (i.e., the perceived behavioral control), and response efficacy positively and significantly influenced intention. However, response cost had a significantly negative effect on intention. Among them, subjective norm had the largest effect on intention. Intention was the key determinant for the actual environmental behavior of farmers, while self-efficacy also had a significantly positive effect on behavior. Managing and controlling agricultural NPS pollution requires a multi-disciplinary and comprehensive approach. Therefore, an integrated theoretical framework was developed in this study by integrating TPB and PMT to gain insight into the environmental behaviors and intention of farmers. The results provided a theoretical basis for NPS pollution control.

Effect of education based on protection motivation theory on adolescents' reproductive health self-care: a randomized controlled trial

BACKGROUND

Adolescents should be empowered to improve their reproductive and sexual health needs. The present study aimed to investigate effects of protection motivation theory-based education on student girls' reproductive and sexual health self-care.

METHODS

This randomized controlled trial was conducted in parallel on 90 female students living in dormitories of the Alborz University of Medical Sciences in Iran. The data collection lasted from January 2017 to May 2018. Convenience sampling was performed, and samples were put into intervention and control groups by block randomization. The intervention group received six educational sessions based on the protection motivation theory(PMT). The data collection tool of this research consisted of the protection motivation theory and reproductive health self-care questionnaires.

RESULTS

There was no significant difference between control and intervention groups in demographic characteristics. The results of the repeated measures test indicated that the reproductive health self-care variable had a significant change (p = 0.000), and there was a significant difference between groups (p = 0.000). The total score of the Protection Motivation Theory Questionnaire was not changed over time (p = 0.54) and there was no significant difference between groups (p = 0.51) according to results of the repeated measures test.

CONCLUSION

According to effects of an educational intervention based on the protection motivation theory, it is suggested to utilize this model as an educational framework for adolescents' reproductive and sexual health by healthcare providers, schools and universities as well as holding periodic courses educating adolescents within short-term intervals in order to achieve the higher sustainability of the educational results.

Sexual health interventions among early adolescents: an integrative review

Purpose

Adolescent pregnancy and sexually transmitted infections including HIV are important public health issues in many countries around the world. The trend is escalating among adolescents of younger ages. Many programmes aim to prevent adolescent sexual risk behaviours associated with these health outcomes. The purpose of this paper is to describe and analyse methodological and substantive features of research on interventions to delay the initiation of sexual intercourse and prevent other sexual risk behaviours among early adolescents.

Design/methodology/approach

The review includes studies published between 2006 and 2017 that appear in Thai and international databases.

Findings

A total of 33 studies met specified review criteria. Of the studies reviewed, 14 used randomized control designs, 16 used quasi-experimental designs and three used a pre-test, post-test design. Sample sizes ranged from 64 to 4,776 subjects; nearly two-thirds of the studies (n = 22) included multiple follow-up surveys. The programmes evaluated in these studies can be grouped into three categories: abstinence-based sexuality education programmes (n = 12), comprehensive sexuality education programmes (n = 13) and youth development programmes designed for early adolescents (n = 10). In total, 22 programmes reviewed were effective in changing targeted adolescent psychosocial and/or behavioural outcomes.

Research limitations/implications

One of the limitations encountered in this study involved the search in library databases published only in Thai and English. Due to the limitation of searching library databases included in the review that reported the effects and differences among the included studies. Moreover, the search included publications consisted of heterogeneous designs and purpose with reports of different types of outcomes made it impossible to compare effect sizes.

Practical implications

The knowledge gained can be used to design and implement effective sexual health promotion programmes for early adolescents. Moreover, the findings can be applied as a guideline for health provider working in a schools, communities and adolescent health services. Recommendations for future studies are needed to consider methodological and substantive characteristics as well as the people who are involved in youth sexual health outcomes.

Social implications

It is necessary for government to develop a policy for encouraging parents to be aware and participate in solving the problems.

Originality/value

The review indicated that the positive effects of parental involvement and technology media as a programme material on the psychosocial and behavioural outcomes.

Cusp Catastrophe Regression and Its Application in Public Health and Behavioral Research

The cusp catastrophe model is an innovative approach for investigating a phenomenon that consists of both continuous and discrete changes in one modeling framework. However, its application to empirical health and behavior data has been hindered by the complexity in data-model fit. In this study, we reported our work in the development of a new modeling method—cusp catastrophe regression (RegCusp in short) by casting the cusp catastrophe into a statistical regression. With the RegCusp approach, unbiased model parameters can be estimated with the maximum likelihood estimation method. To validate the RegCusp method, a series of simulations were conducted to demonstrate the unbiasedness of parameter estimation. Since the estimated residual variance with the Fisher information matrix method was over-dispersed, a bootstrap re-sampling procedure was developed and used as a remedy. We also demonstrate the practical applicability of the RegCusp with empirical data from an NIH-funded project to evaluate an HIV prevention intervention program to educate adolescents in the Bahamas for condom use. Study findings indicated that the model parameters estimated with RegCusp were practically more meaningful than those estimated with comparable methods, especially the estimated cusp point.

Rigorous evaluation of a pregnancy prevention program for American Indian youth and adolescents: study protocol for a randomized controlled trial

BACKGROUND

American Indian adolescents have one of the highest rates of teen pregnancy and repeat teen births in the US. Substance use is a significant risk factor for unprotected sex, and American Indian adolescents have the highest substance use-related morbidity and mortality of any US racial group. Despite these disparities, there are no existing, evidence-based programs for pregnancy prevention that have been rigorously evaluated among American Indian teens.

METHODS

The proposed study is a randomized controlled trial to test the efficacy of a comprehensive sexual and reproductive health program developed in partnership with an American Indian community. Participants will be American Indians ages 11-19 and their parent or trusted adult, randomized to receive the control condition or intervention called Respecting the Circle of Life: Mind, Body and Spirit. The intervention includes eight lessons delivered to self-selected peer groups during a summer basketball camp and one lesson delivered to the youth and parent/trusted adult together within 3 months after camp. All lessons are administered by trained community health workers from the participating American Indian community. Youth and parent/trusted adult participants will complete assessments at baseline, 3, 9, 12, 24 and 36 months post-intervention completion. The primary outcome variables are sexual/reproductive health knowledge, sexual initiation, condom use self-efficacy and intent to use a condom at next sex as changed from baseline to post-intervention between intervention and control participants. Selected primary outcomes are applicable to all study participants.

DISCUSSION

Currently there are no sexual and reproductive health programs designed specifically for American Indian youth that have been rigorously evaluated and found to have an evidence base. Respecting the Circle of Life is highly innovative by incorporating lesson delivery into a summer basketball camp and involving parents or other trusted adults in curriculum administration. If found successful, it will be the first evidence-based program for teen pregnancy prevention for American Indian youth and adolescents.

TRIAL REGISTRATION

Clinicaltrials.gov, NCT02904629 . Retrospectively registered on 23 September 2016.

Multi-year school-based implementation and student outcomes of an evidence-based risk reduction intervention

Background

Intervention effects observed in efficacy trials are rarely replicated when the interventions are broadly disseminated, underscoring the need for more information about factors influencing real-life implementation and program impact. Using data from the ongoing national implementation of an evidence-based HIV prevention program [Focus on Youth in The Caribbean (FOYC)] in The Bahamas, this study examines factors influencing teachers’ patterns of implementation, the impact of teachers’ initial implementation of FOYC, and subsequent delivery of the booster sessions on students’ outcomes.

Methods

Data were collected from the 80 government elementary and 34 middle schools between 2011 and 2014, involving 208 grade 6, 75 grade 7, and 58 grade 8 teachers and 4411 students initially in grade 6 and followed for 3 years. Student outcomes include HIV/AIDS knowledge, reproductive health skills, self-efficacy, and intention to use protection. Data from teachers includes implementation and modification of the curriculum, attitudes towards the prevention program, comfort level with the curriculum, and attendance at training workshops. Structural equation modeling and mixed-effect modeling analyses were applied to examine the impact of teachers’ implementation.

Results

Teachers’ attitudes towards and comfort with the intervention curriculum, and attendance at the curriculum training workshop had a direct effect on teachers’ patterns of implementation, which had a direct effect on student outcomes. Teachers’ attitudes had a direct positive effect on student outcomes. Teachers’ training in interactive teaching methods and longer duration as teachers were positively associated with teachers’ comfort with the curriculum. High-quality implementation in grade 6 was significantly related to student outcomes in grades 6 and 7 post-implementation. Level of implementation of the booster sessions in grades 7 and 8 were likewise significantly related to subsequent student outcomes in both grades.

Conclusions

High-quality initial implementation of a prevention program is significantly related to better program outcomes. Poor subsequent delivery of booster sessions can undermine the positive effects from the initial implementation while strong subsequent delivery of booster sessions can partially overcome poor initial implementation.

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-016-0539-7) contains supplementary material, which is available to authorized users.

An instrument based on protection motivation theory to predict Chinese adolescents' intention to engage in protective behaviors against schistosomiasis

Background

Further advancement in schistosomiasis prevention requires new tools to assess protective motivation, and promote innovative intervention program. This study aimed to develop and evaluate an instrument developed based on the Protection Motivation Theory (PMT) to predict protective behavior intention against schistosomiasis among adolescents in China.

Methods

We developed the Schistosomiasis PMT Scale based on two appraisal pathways of protective motivation- threat appraisal pathway and coping appraisal pathway. Data from a large sample of middle school students (n = 2238, 51 % male, mean age 13.13 ± 1.10) recruited in Hubei, China was used to evaluated the validity and reliability of the scale.

Results

The final scale contains 18 items with seven sub-constructs. Cronbach's Alpha coefficients for the entire instrument was 0.76, and for the seven sub-constructs of severity, vulnerability, intrinsic reward, extrinsic reward, response efficacy, self-efficacy and response cost was 0.56, 0.82, 0.75, 0.80, 0.90, 0.72 and 0.70, respectively. The construct validity analysis revealed that the one level 7 sub-constructs model fitted data well (GFI = 0.98, CFI = 0.98, RMSEA = 0.03, Chi-sq/df = 3.90, p < 0.001). Predictive validity showed that both the PMT instrument score and the 7 sub-construct scores were significantly correlated with the intention engaged in protective behavior against schistosomiasis (p < 0.05).

Conclusions

This study provides a reliable and valid tool to measure protective motivation in schistosomiasis prevention control. Further studies are needed to develop more effective intervention programs for schistosomiasis prevention.

The Impact of Teachers' Modifications of an Evidenced-Based HIV Prevention Intervention on Program Outcomes

The degree to which evidence-based program outcomes are affected by modifications is a significant concern in the implementation of interventions. The ongoing national implementation of an evidence-based HIV prevention program targeting grade 6 students in The Bahamas [Focus on Youth in The Caribbean (FOYC)] offers an opportunity to explore factors associated with teachers' modification of FOYC lessons and to examine the impact of types and degrees of modifications on student outcomes. Data were collected in 2012 from 155 teachers and 3646 students in 77 government elementary schools. Results indicate that teachers taught 16 of 30 core activities, 24.5 of 46 total activities and 4.7 of 8 sessions. Over one-half of the teachers made modifications to FOYC core activities; one-fourth of the teachers modified 25 % or more core activities that they taught (heavily modified FOYC). Omitting core activities was the most common content modification, followed by lengthening FOYC lessons with reading, writing assignments or role-play games, and shortening core activities or adding educational videos. Mixed-effects modeling revealed that omitting core activities had negative impacts on all four student outcomes. Shortening core activities and adding videos into lessons had negative impacts on HIV/AIDS knowledge and/or intention to use condom protection. Heavy modifications (>1/4 core activities) were associated with diminished program effectiveness. Heavy modifications and omitting or shortening core activities were negatively related to teachers' level of implementation. We conclude that poorer student outcomes were associated with heavy modifications.

Two-Year Follow-Up of a Sexual Health Promotion Program for Spanish Adolescents

The aim is to evaluate the effects of the Competencias para adolescentes con una sexualidad saludable (COMPAS) program and compare them with an evidence-based program ( ¡Cuídate!) and a control group (CG). Eighteen public high schools were randomly assigned to one of the three experimental conditions. Initially, 1,563 Spanish adolescents between 14 and 16 years of age participated, and 24 months after their implementation, 635 of them completed a survey. Self-report measures collected data on sexual behavior, knowledge, attitudes, intention, sexual risk perception, and perceived norm. Compared to the CG, COMPAS increased the level of knowledge about sexually transmitted infections and improved the attitudes toward people living with human immunodeficiency virus at the 2-year follow-up. Neither intervention had a long-term impact on behavioral variables. Results suggest that COMPAS has a comparable impact to the other intervention on the variables predicting consistent condom use. Reinforcing the messages and skills that have the greatest impact on condom use and adding booster sessions following program completion as strategies to maintain long-term effects are necessary.

Adolescent HIV Risk Reduction in the Bahamas: Results from Two Randomized Controlled Intervention Trials Spanning Elementary School Through High School

To address global questions regarding the timing of HIV-prevention efforts targeting youth and the possible additional benefits of parental participation, researchers from the USA and The Bahamas conducted two sequential longitudinal, randomized trials of an evidence-based intervention spanning the adolescent years. The first trial involved 1360 grade-6 students and their parents with three years of follow-up and the second 2564 grade-10 students and their parents with two years of follow-up. Through grade-12, involvement in the combined child and parent-child HIV-risk reduction interventions resulted in increased consistent condom-use, abstinence/protected sex, condom-use skills and parent-child communication about sex. Receipt of the grade-6 HIV-prevention intervention conferred lasting benefits regarding condom-use skills and self-efficacy. Youth who had not received the grade-six intervention experienced significantly greater improvement over baseline as a result of the grade-10 intervention. The HIV-risk reduction intervention delivered in either or both grade-6 and grade-10 conferred sustained benefits; receipt of both interventions appears to confer additional benefits.

Cross-sectional data on alcohol and marijuana use and sexual behavior among male and female secondary school students in New Providence, The Bahamas

BACKGROUND

While The Bahamas have significantly reduced poor reproductive health outcomes among adolescents and emerging adults, data indicate that youth are engaged in sexual risk behaviors. Substance use has been linked to increased risk for HIV and sexually transmitted infections in other contexts. There are limited data on Bahamian youth in relation to consumption of alcohol and marijuana use and engagement in sexual behaviors.

OBJECTIVE

This study aimed to assess potential relationships between alcohol and marijuana use and engagement in sexual behavior among government secondary school students in New Providence, The Bahamas.

MATERIALS AND METHODS

Total sample size was 2572, and about 56% of respondents were female. Mean age was 14.2 (SD 2.7 years). Cross-sectional data came from a baseline survey conducted as part of a longitudinal randomized controlled evaluation of a school-based HIV prevention and reproductive health program in New Providence.

RESULTS

Overall, 46.5% (519) males and 44.8% (652) females reported alcohol consumption; 7.3% (82) males and 1.7% (25) females reported use of marijuana in the last 6 months. About 43% (477) male respondents and 16% (231) female respondents reported ever having vaginal sex. Logistic regression analysis indicates that increased likelihood of engaging in sex during the past 6 months is associated with being older, male, and consuming alcohol and marijuana.

CONCLUSION

These data provide a 'global correlation' between substance use and engagement in sexual behaviors among Bahamian adolescents. Longitudinal research is needed to assess event specific risks and identify mediating and moderating factors. These findings indicate the importance of integrating reproductive health and substance use education.

The influence of sensation-seeking and parental and peer influences in early adolescence on risk involvement through middle adolescence: A structural equation modeling analysis

This study examined the relationships between youth and parental sensation-seeking, peer influence, parental monitoring and youth risk involvement in adolescence using structural equation modeling. Beginning in grade-six, longitudinal data were collected from 543 students over three years. Youth sensation-seeking in grade six contributed to risk involvement in early adolescence (grades six and seven) indirectly through increased peer risk influence and decreased parental monitoring but did not have a direct contribution. It contributed directly and indirectly to risk involvement in middle adolescence (grades eight and nine). Parent sensation-seeking at baseline was positively associated with peer risk influence and negatively associated with parental monitoring; it had no direct effect on adolescent risk involvement. Parental monitoring buffers negative peer influence on adolescent risk involvement. Results highlight the need for intervention efforts to provide normative feedback about adolescent risky behaviors and to vary among families in which parents and/or youth have high sensation-seeking propensities.

Fidelity of implementation of an evidence-based HIV prevention program among Bahamian sixth grade students

The Bahamian Ministry of Education has elected to implement at a national level in all Bahamian government grade six classes an evidence-based HIV prevention intervention [Focus on Youth in the Caribbean (FOYC)]. This study explores fidelity of implementation of the intervention, factors that may influence implementation fidelity, and the impact of variations in the implementation fidelity on student outcomes. Data were collected in the first wave of national implementation in 2011, involving 35 government primary schools and 110 teachers and 2,811 students. Structural equation modeling was performed to examine the relationships among factors which facilitated or impeded teachers’ implementation of FOYC. Results indicate that teachers taught 16.3 out of 30 core activities, 24.9 out of 46 total activities, and 4.4 out of 8 sessions on average. The strongest predictor of implementation fidelity was teacher comfort level with the FOYC curriculum. Teachers who did not perceive the FOYC intervention to be important for their students or who had attended only part of a FOYC training workshop were more likely to change the curriculum. Increased duration of experience as a teacher (>10 years) was negatively associated with fidelity of implementation. Teacher’s perception of the importance of the FOYC intervention and implementation fidelity had direct positive effects on students’ HIV/AIDS knowledge, reproductive health skills, protective intentions, and self-efficacy. Youth did not appear to benefit from FOYC if two or fewer sessions were delivered. We concluded that an evidence-based HIV prevention intervention can be implemented at a national level. Prior training of teachers in the intervention curriculum, teacher perception of the importance of the intervention, and fewer years as a teacher are associated with implementation fidelity. Implementation fidelity is associated with improved student outcomes.

Teachers' patterns of implementation of an evidence-based intervention and their impact on student outcomes: results from a nationwide dissemination over 24-months follow-up

More information is needed about factors influencing real-life implementation and program impact of interventions effective in controlled study conditions. Ongoing national implementation of an evidence-based HIV prevention program targeting grade 6 students in The Bahamas offers the opportunity to examine patterns of implementation and relate them to student outcomes. Data were collected from 208 grade 6 teachers, 75 grade 7 teachers and 4411 grade 6 students followed over 2 years. Mixed-effects modeling analysis examined the association of teachers' patterns of implementation with student outcomes. High quality program implementation in grade 6 (high implementation dosage and fidelity) was significantly related to student outcomes six and 18 months post-intervention. Quality of implementation of the booster session in grade 7 was also significantly related to student outcomes in grade 7. Quality of delivery of the brief booster session a year after initial implementation is important in maintaining or resetting the student outcome trajectory.

Effects of a Community-Based HIV Risk Reduction Intervention Among HIV-Positive Individuals: Results of a Quasi-Experimental Study in Nepal

We evaluated the efficacy of a sexual risk reduction intervention utilizing protection motivation and social cognitive theories to address knowledge, threat and coping appraisals, and condom use intentions among HIV-positive individuals in Nepal. Using a quasi-experimental research design, we assigned 277 participants to intervention (n=146) and control (n=131) groups. The intervention group received six sessions on sexual risk reduction strategies and the control group six sessions on medication adherence, smoking, and mental health. Data were collected at baseline and immediately after the intervention. Results indicate that the sexual risk reduction intervention produced a significant increase in HIV transmission knowledge, perceived threat and coping appraisals, and intentions to use condoms with regular, HIV-positive, and HIV-negative partners. The positive effects of the intervention remained significant after adjusting for baseline scores and other potential confounders. In conclusion, our theory-based sexual risk reduction intervention was effective in improving HIV transmission knowledge, perceived threat and coping appraisals, and condom use intentions. Further studies are needed to evaluate the long-term efficacy of the intervention in increasing protection motivation and maintaining preventive behaviors.

Factors influencing implementation dose and fidelity thereof and related student outcomes of an evidence-based national HIV prevention program

Background

Teachers’ implementation of evidence-based prevention programs in schools is inconsistent. Using data gathered from the national implementation among grade six students in The Bahamas of an evidence-based HIV intervention [Focus on Youth in the Caribbean (FOYC)], this study examines differences in the degree of implementation (“dose”) and adherence to the core activities (“fidelity of implementation”) by teachers according to theoretically and historically relevant teachers’ characteristics, attitudes, and experiences pre-intervention and post-intervention. The relationship of implementation dose and implementation fidelity is assessed according to student outcomes.

Methods

Beginning in 2008, the Bahamian Ministry of Education (MOE) included FOYC in the grade six curriculum nationwide. Consistent with standard practice, teachers were offered MOE training workshops in FOYC prior to delivery. The MOE conducted an anonymous curricular assessment among the grade six students at the beginning and end of the school year. Teachers agreeing to participate in the research component were asked to complete a pre-implementation and post-implementation assessment of attitudes and prior experiences.

Results

Teachers taught 15.6 out of 30 core activities, 24 out of the 46 total activities, and 4.6 out of 8 sessions on average. Three teachers’ implementation groups were identified: 1) High Implementation Group (31.7% of the teachers), characterized by high levels of implementation dose and fidelity of implementation; 2) Moderate Implementation Group (52.8%), showing moderate levels of implementation dose but high levels of fidelity of implementation; and 3) Low Implementation Group (15.6%), with low levels of implementation dose and fidelity of implementation. Low Implementation Group teachers compared to teachers in the two higher performing groups had less training in interactive teaching, limited prior exposure to the FOYC curriculum, incomplete attendance at FOYC training workshops, and low levels of comfort in teaching FOYC lessons. Students taught by teachers in the Low Implementation Group demonstrated poorer outcomes relevant to the four student outcomes (HIV/AIDS knowledge, preventive reproductive health skills, self-efficacy, and intention to use protection if they were to have sex).

Conclusions

Both implementation dose and implementation fidelity are related to student outcomes. Teachers at risk for limited implementation can be identified pre-intervention, thus opening the possibility for focused pre-intervention training.

Respecting the circle of life: one year outcomes from a randomized controlled comparison of an HIV risk reduction intervention for American Indian adolescents

Potential for widespread transmission of HIV/AIDS among American Indian (AI) adolescents exists, yet no evidence-based interventions (EBIs) have been adapted and evaluated with this population. Intensive psychoeducation may improve knowledge and decision-making which could potentially translate to reductions in HIV risk behaviors. A peer group randomized controlled comparison of an adapted EBI vs. control was delivered over an eight-day summer basketball camp in one reservation-based tribal community to adolescents ages 13-19. Outcome data were gathered immediately post-camp and at 6 and 12 months follow-up. Self-selected peer groups were randomized to intervention (n = 138) or control (n = 129) conditions for a total sample of 267 participants (56.2% female), mean age 15.1 years (SD = 1.7). Intervention participants had better condom use self-efficacy post-camp (Adjusted Mean Difference [AMD] = -0.75, p < 0.005) and at 6 (AMD = -0.44, p < 0.005) and 12 months (AMD = -0.23, p < 0.05) follow-up. Intervention participants also had higher HIV prevention and transmission knowledge (post-camp: AMD = 0.07, p < 0.01; 6 months: AMD = 0.06, p < 0.01) were more likely to believe condoms prevent sexually transmitted infections (post-camp: RR = 1.41, p < 0.005; 6 months: RR = 1.34, p < 0.05), to talk with an adult about HIV/AIDS (post-camp: RR=1.78, p < 0.005; 6 months: RR = 1.14, p < 0.005), had higher partner negotiation efficacy related to substance use during sex (post-camp: AMD = 0.37, p < 0.01), and were more likely to intend to use a condom (post-camp: RR = 1.39, p < 0.01). The adapted intervention had short- and medium-term impacts on AI adolescent risk for HIV/AIDS, but attenuated at 12 months. Intervention delivery through a community-based camp is feasible and acceptable with strong retention. Additional study is needed to evaluate the adapted intervention's impact on sexual risk behaviors and if booster sessions and parent involvement translate to long-term impacts.

The Respecting the Circle of Life trial for American Indian adolescents: rationale, design, methods, and baseline characteristics

This paper describes the rationale, design, methods, and baseline results of a randomized controlled trial to evaluate the impact of an adapted evidence-based intervention (EBI), "Respecting the Circle of Life" (RCL) to reduce behavioral risks for HIV/AIDS among American Indian (AI) adolescents. A participatory approach shaped intervention adaptation and study design. A total of 267 participants (aged 13-19) were randomized by peer groups of the same sex to receive the RCL intervention or a control condition. Self-report assessments were administered at four intervals. The sample was predominately female (57%), had low HIV knowledge prevention scores, early sexual initiation (mean 14.6 years), and 56% reported intention to use a condom at next sex. Baseline characteristics were evenly distributed between groups with the exception of age and extrinsic reward scores. This is the first rigorous evaluation of an adapted EBI for HIV/AIDS prevention among AI adolescents, an at-risk and understudied population.

Assessing the effects of a complementary parent intervention and prior exposure to a preadolescent program of HIV risk reduction for mid-adolescents

OBJECTIVES

We (1) evaluated the impact of an evidence-based HIV prevention program with and without a parent component among mid-adolescents living in the Caribbean and (2) determined the effect of prior receipt of a related intervention during preadolescence on intervention response.

METHODS

A randomized, controlled 4-cell trial of a 10-session, theory-based HIV prevention intervention involving 2564 Bahamian grade-10 youths (some of whom had received a comparable intervention in grade 6) was conducted (2008-2011). Randomization occurred at the level of the classroom with follow-up at 6, 12, and 18 months after intervention. The 3 experimental conditions all included the youths' curriculum and either a youth-parent intervention emphasizing adolescent-parent communication, a parent-only goal-setting intervention, or no parent intervention.

RESULTS

An intervention delivered to mid-adolescents in combination with a parent-adolescent sexual-risk communication intervention increased HIV/AIDS knowledge, condom-use skills, and self-efficacy and had a marginal effect on consistent condom use. Regardless of prior exposure to a similar intervention as preadolescents, youths benefited from receipt of the intervention.

CONCLUSIONS

Preadolescents and mid-adolescents in HIV-affected countries should receive HIV prevention interventions that include parental participation.

Effective nonvaccine interventions to be considered alongside human papilloma virus vaccine delivery

World Health Organization recommends that girls, ages 9-13 years, get the human papilloma virus (HPV) vaccine. Global Alliance for Vaccines Initiative, which provides low-cost vaccine to eligible countries, requires that an additional intervention to be offered alongside the vaccine. We systematically searched and assessed the published literature in lower- and middle-income countries to identify effective interventions. We conducted systematic searches of four databases: PubMed, EMBASE, Global Index Medicus Regional Databases, and Cochrane Reviews for effective adolescent health interventions that could be delivered with the HPV vaccine in the following areas: (1) iron and folic acid supplementation (iron alone or with folic acid); (2) voucher delivery and cash transfer programs; (3) hand washing and soap provision; (4) vision screening; (5) promotion of physical activity/exercise; (6) menstrual hygiene education; (7) sexual and reproductive health education; (8) human immunodeficiency virus prevention activities; and (9) condom promotion, condom use skill building, and demonstration. We found limited evidence of consistent positive impact. Iron supplementation reduced iron-deficiency anemia and raised serum ferritin levels. Promotion of physical activity lowered blood pressure and reduced weight gain. Sexual and reproductive health and human immunodeficiency virus interventions improved adolescent communication with adults but did not influence behavioral outcomes. Countries should consider locally relevant and proven interventions to be offered alongside the HPV vaccine.

The impact of parent involvement in an effective adolescent risk reduction intervention on sexual risk communication and adolescent outcomes

Parent involvement in prevention efforts targeting adolescents increases the impact of such programs. However, the majority of risk-reduction intervention programs that are implemented through schools do not include parents, in part because most existing parental interventions require significant time commitment by parents. We designed a brief parent-adolescent sexual risk communication intervention to be delivered with an effective HIV prevention intervention as part of a randomized, controlled trial among 2,564 grade 10 students and their parents in the Bahamas. Mixed effects modeling analysis was conducted to evaluate the effect of the brief parent-adolescent communication intervention using four waves of longitudinal data. Results indicate that a brief parent-adolescent communication intervention is effective in improving parent-adolescent communication on sex-related issues and perceived parental monitoring as well as the youth's condom use skills and self-efficacy. There is a marginal effect on consistent condom use. In addition, there is an apparent dose effect of the brief parent intervention on perceived parent-adolescent sexual risk communication and adolescent outcomes. These findings suggest that adolescent risk reduction interventions should include a brief parent-adolescent communication intervention that should be reinforced by periodic boosters in order to enhance the impact of adolescent HIV prevention programs.

Cusp Catastrophe Polynomial Model: Power and Sample Size Estimation

Guastello's polynomial regression method for solving cusp catastrophe model has been widely applied to analyze nonlinear behavior outcomes. However, no statistical power analysis for this modeling approach has been reported probably due to the complex nature of the cusp catastrophe model. Since statistical power analysis is essential for research design, we propose a novel method in this paper to fill in the gap. The method is simulation-based and can be used to calculate statistical power and sample size when Guastello's polynomial regression method is used to cusp catastrophe modeling analysis. With this novel approach, a power curve is produced first to depict the relationship between statistical power and samples size under different model specifications. This power curve is then used to determine sample size required for specified statistical power. We verify the method first through four scenarios generated through Monte Carlo simulations, and followed by an application of the method with real published data in modeling early sexual initiation among young adolescents. Findings of our study suggest that this simulation-based power analysis method can be used to estimate sample size and statistical power for Guastello's polynomial regression method in cusp catastrophe modeling.

Protection motivation theory in predicting intention to engage in protective behaviors against schistosomiasis among middle school students in rural China

Background

Among millions of people who suffer from schistosomiasis in China, adolescents are at increased risk to be infected. However, there is a lack of theory-guided behavioral prevention intervention programs to protect these adolescents. This study attempted to apply the Protection Motivation Theory (PMT) in predicting intentions to engage in protective behaviors against schistosomiasis infection.

Methods

The participants were selected using the stratified cluster sampling method. Survey data were collected using anonymous self-reported questionnaire. The advanced structural equation modeling (SEM) method was utilized to assess the complex relationship among schistosomiasis knowledge, previous risk exposure and protective measures in predicting intentions to engage in protective behavior through the PMT constructs.

Principal Findings

Approximately 70% of participants reported they were always aware of schistosomiasis before exposure to water with endemic schistosomiasis, 6% of the participants reported frequency of weekly or monthly prior exposure to snail-conditioned water. 74% of participants reported having always engaged in protective behaviors in the past three months. Approximately 7% were unlikely or very unlikely to avoid contact with snail-conditioned water, and to use protective behaviors before exposure. Results from SEM analysis indicated that both schistosomiasis knowledge and prior exposure to schistosomiasis were indirectly related to behavior intentions through intrinsic rewards and self-efficacy; prior protective behaviors were indirectly related to behavior intentions through severity, intrinsic rewards and self-efficacy, while awareness had an indirect relationship with behavior intentions through self-efficacy. Among the seven PMT constructs, severity, intrinsic rewards and self-efficacy were significantly associated with behavior intentions.

Conclusions

The PMT can be used to predict the intention to engage in protective behaviors against schistosomiasis. Schistosomiasis intervention programs should focus on the severity, intrinsic rewards and self-efficacy of protection motivation, and also increase the awareness of infection, and enrich the contents of schistosomiasis education.

In China, millions of population suffer from schistosomiasis infection and adolescents tend to have higher infection rates than adults. The Knowledge-Attitude-Practice (KAP) Theory has traditionally been used as guidance to schistosomiasis prevention in China. However, despite increases in knowledge among residents in the epidemic areas due to KAP theory-based schistosomiasis health education, no significant reduction in water-contact behavior was evident. Therefore, it is of crucial importance to seek alternative health behavior change theories/models that are more effective than the KAP theory to promote purposeful behavioral change. The Protection Motivation Theory (PMT) as a social cognitive model may be an alternative to the KAP theory. In this study, we found that the PMT can be used to predict intention to engage in protective behaviors against schistosomiasis infection among middle school students in rural China. Based on the PMT, in addition to enhancing awareness of schistosomiasis infection, intervention programs should focus on the severity, intrinsic rewards and self-efficacy of protection motivation.

Adolescent age at time of receipt of one or more sexual risk reduction interventions

PURPOSE

Age of the target audience at time of intervention is thought to be a critical variable influencing the effectiveness of adolescent sexual risk reduction interventions. Despite this postulated importance, to date, studies have not been designed to enable a direct comparison of outcomes according to age at the time of intervention delivery.

METHODS

We examined outcomes of 598 youth who were sequentially involved in two randomized controlled trials of sexual risk prevention interventions, the first one delivered in grade 6 (Focus on Youth in the Caribbean [FOYC]) and the second one in grade 10 (Bahamian Focus on Older Youth [BFOOY]). Four groups were examined, including those who received (1) both treatment conditions, FOYC and BFOOY; (2) FOYC in grade 6 and the control condition in grade 10; (3) the control condition in grade 6 and BFOOY in grade 10; and (4) both control conditions. Intentions, perceptions, condom-use skills, and HIV-related knowledge were assessed over 60 months.

RESULTS

Data showed that those who received both interventions had the greatest increase in condom-use skills. Youth who received FOYC in grade 6 had greater scores in knowledge and intention.

CONCLUSION

These results suggest that youth receive the most protection with early and repeated exposure to interventions. These findings suggest that educators should consider implementing HIV prevention and risk reduction programs as a fixed component of education curriculum beginning in the preadolescent years and if possible also during the adolescent years.

The impact of youth, family, peer and neighborhood risk factors on developmental trajectories of risk involvement from early through middle adolescence

Few studies have analyzed the development course beginning in pre-/early adolescence of overall engagement in health-risk behaviors and associated social risk factors that place individuals in different health-risk trajectories through mid-adolescence. The current longitudinal study identified 1276 adolescents in grade six and followed them for three years to investigate their developmental trajectories of risk behaviors and to examine the association of personal and social risk factors with each trajectory. Group-based trajectory modeling was applied to identify distinctive trajectory patterns of risk behaviors. Multivariate multinomial logistic regression analyses were performed to examine the effects of the personal and social risk factors on adolescents' trajectories. Three gender-specific behavioral trajectories were identified for males (55.3% low-risk, 37.6% moderate-risk, increasing, and 7.1% high-risk, increasing) and females (41.4% no-risk, 53.4% low-risk, increasing and 5.2% moderate to high-risk, increasing). Sensation-seeking, family, peer, and neighborhood factors at baseline predicted following the moderate-risk, increasing trajectory and the high-risk, increasing trajectory in males; these risk factors predicted following the moderate to high-risk, increasing trajectory in females. The presence of all three social risk factors (high-risk neighborhood, high-risk peers and low parental monitoring) had a dramatic impact on increased probability of being in a high-risk trajectory group. These findings highlight the developmental significance of early personal and social risk factors on subsequent risk behaviors in early to middle adolescence. Future adolescent health behavior promotion interventions might consider offering additional prevention resources to pre- and early adolescent youth who are exposed to multiple contextual risk factors (even in the absence of risk behaviors) or youth who are early-starters of delinquency and substance use behaviors in early adolescence.

Application of the protection motivation theory in predicting cigarette smoking among adolescents in China

Reducing tobacco use among adolescents in China represents a significant challenge for global tobacco control. Existing behavioral theories developed in the West - such as the Protection Motivation Theory (PMT) - may be useful tools to help tackle this challenge. We examined the relationships between PMT factors and self-reported cigarette smoking behavior and intention among a random sample of vocational high school students (N=553) in Wuhan, China. Tobacco-related perceptions were assessed using the PMT Scale for Adolescent Smoking. Among the total sample, 45% had initiated cigarette smoking, and 25% smoked in the past month. Among those who never smoked, 15% indicated being likely or very likely to smoke in a year. Multiple regression modeling analysis indicated the significance of the seven PMT constructs, the four PMT perceptions and the two PMT pathways in predicting intention to smoke and actual smoking behavior. Overall, perceived rewards of smoking, especially intrinsic rewards, were consistently positively related to smoking intentions and behavior, and self-efficacy to avoid smoking was negatively related to smoking. The current study suggests the utility of PMT for further research examining adolescent smoking. PMT-based smoking prevention and clinical smoking cessation intervention programs should focus more on adolescents' perceived rewards from smoking and perceived efficacy of not smoking to reduce their intention to and actual use of tobacco.

The influence of parental monitoring and parent-adolescent communication on Bahamian adolescent risk involvement: a three-year longitudinal examination

The literature suggests that parental monitoring can best be conceptualized and measured through the domains of parental knowledge, youth disclosure, parental solicitation, and parental control. Using longitudinal data on 913 grade-six Bahamian students followed over a period of three years, we examined the unique and independent roles of these domains of parental monitoring and parent-adolescent communication in relation to adolescent involvement in delinquency, substance use, and sexual risk behaviors. The results obtained with mixed-effects models indicate that parental knowledge, youth disclosure, and parental control are negatively associated with both delinquency and substance use. Open parent-adolescent communication was associated with decreased sexual risk behavior, whereas problematic parent-adolescent communication was associated with increased sexual risk behavior. The results obtained with path models indicate that youth disclosure is a significant longitudinal predictor of reduced adolescent delinquency and that parental control during early adolescence predicted reduced substance use in middle adolescence. The findings suggest that parental knowledge, youth disclosure and parental control differ in their impacts on substance use, delinquency and sexual risk behaviors. Problematic parent-adolescent communication is consistently associated with increases in all three types of adolescent risk behaviors. Future parental monitoring interventions should focus on enhancing parents' interpersonal communication skills and emphasize the differences in and importance of the unique components of parental monitoring.

Intention to use condom, cusp modeling, and evaluation of an HIV prevention intervention trial

Adolescents are at particularly high risk to acquire HIV infection; increasing the likelihood of condom use is an effective measure to reduce the risk of such infections. Challenges in assessing actual condom use behavior among early adolescents render the precursor measure, intention to use condoms, an appealing alternative. While analyzing data from a randomized controlled trial to evaluate a theory-based intervention program to promote condom use among early adolescents, we observed a modest effect with regard to condom use intention when the linear analytical approach was used. If intention, as a measure of the readiness to perform a behavior, also contains a nonlinear discrete component, it would be more appropriately modeled using a nonlinear approach. In this study, data from a randomized controlled trial (N=1360) were analyzed using the cusp catastrophe method with HIV knowledge and condom skills as the asymmetry variables and condom use self-efficacy as the bifurcation variables. Findings from concurrent and longitudinal modeling analyses indicated a much better fit of the cusp model (R2 = 0.85); AIC and BIC were one-fourth that of than the linear (R2 lt; 0.10) or the logistic model (R2 lt; 0.15). Receipt of the intervention as an asymmetry variable was significantly predicted condom use intention but did not as a bifurcation variable. In conclusion, adolescent intentions to use a condom contain both a continuous process and a discrete process and can better be modeled with cusp catastrophe methods. A much greater program effect is likely from the same prevention intervention if additional measures are taken to foster sudden changes in condom intention.

Sustained institutional effects of an evidence-based HIV prevention intervention

Limited data are available as to what happens in institutions involved in behavioral intervention trials after the trial has ended. Specifically, do the trainers continue to administer the behavioral intervention that had been the focus of the trial? To address this question, we examined data in grade six schools before a year-long behavioral intervention had been delivered in some schools (and a year-long control condition in others) and data obtained again 6 and 7 years later in the same two sets of schools. Data were derived from the baseline surveys of two interventions: (1) national implementation of the evidence-based Focus on Youth in the Caribbean (FOYC) intervention in 2011; and (2) the randomized, controlled trial of the FOYC intervention in 2004/2005. Cross-sectional, longitudinal comparisons and random coefficient regression analysis were conducted to evaluate long-term intervention effects. Results indicate that grade six students in 2011 from schools in which the FOYC intervention had been implemented in 2004/2005 had a higher level of HIV/AIDS knowledge, increased reproductive health skills, increased self-efficacy regarding their ability to prevent HIV infection, and greater intention to use protection if they were to have sex compared to their counterparts from schools where no such training took place. We concluded that new cohorts of students benefited from the extensive training and/or experience in teaching the FOYC curriculum received by teachers, guidance counselors and administrators in schools which had delivered the FOYC intervention as part of a randomized trial several years earlier. The findings suggest that teachers who previously were trained to deliver the FOYC intervention may continue to teach at least some portions of the curriculum to subsequent classes of students attending these schools.

The Continuing Challenge of Reducing HIV Risk among Haitian Youth

There is a dire need for interventions that will address the multiple factors—poverty, substance use, early sexual debut, and violence—that influence Haitian youth’s engagement in risky behaviors. The deteriorating socioeconomic and political state of the country has had a deleterious effect on the sociocultural milieu and on the boundaries that have heretofore kept risky behaviors in check. Historically, the lakou system, a community-based approach that supports the family unit, has disintegrated, leading to the disruption of traditional parenting patterns. The unstable economic system has also led to the increasing use of children from poor families, who through the restavek system, are sent to work as servants in other households. The breakdown of traditional systems, coupled with the increasing economic and political instability, has had a significant effect on Haitian adolescents. Among boys, increased levels of substance use have been associated with multiple sex partnerships and very early sexual debut. Among girls, extremely high rates of sexual abuse and forced sex have led to relatively high levels of HIV. While the majority of them have been exposed to behavior change messages, behavior change itself has lagged because many adolescents do not accurately perceive their risk exposure. This review explores the risks of HIV transmission among Haitian youth, with a focus on vulnerability factors, including substance use, culture, and the socioeconomic context, and provides recommendations for intervention. An ecosystemic approach, designed specifically for Haitian youth and that takes environmental context and culture into account, is needed.

Predictors of responsiveness among early adolescents to a school-based risk reduction intervention over 3 years

This study assesses potential predictive factors for unresponsiveness to the "Focus on Youth in the Caribbean (FOYC)" intervention using longitudinal data from 1,360 Bahamian sixth-grade youth. Results from hierarchical logistic regression analyses indicate that the intervention had a greater impact on knowledge, skills, self-efficacy, and condom use intention among low and medium initial scorers. High initial scores in knowledge, skills, self-efficacy, and intention were predictive of relative unresponsiveness to the intervention. Advanced age and male sex were predictive of unresponsiveness to the intervention for HIV/AIDS knowledge. Female gender was predictive of unresponsiveness to the intervention for self-efficacy. High academic self-evaluation was predictive of unresponsiveness to the intervention for condom use intention. The greatest intervention impact was observed at the 6-month post-intervention follow-up; these intervention-related gains were sustained over the subsequent follow-up periods. Youth with higher risk attributes (lower knowledge, skills and self-efficacy) were more likely to respond to a risk reduction intervention.

A Protection Motivation Theory-Based Scale for Tobacco Research among Chinese Youth

Rates of tobacco use among adolescents in China and other lower and middle-income countries remain high despite notable prevention and intervention programs. One reason for this may be the lack of theory-based research in tobacco use prevention in these countries. In the current study, a culturally appropriate 21-item measurement scale for cigarette smoking was developed based on the core constructs of Protection Motivation Theory (PMT). The scale was assessed among a sample of 553 Chinese vocational high school students. Results from correlational and measurement modeling analysis indicated adequate measurement reliability for the proposed PMT scale structure. The two PMT Pathways and the seven PMT constructs were significantly correlated with adolescent intention to smoke and actual smoking behavior. This study is the first to evaluate a PMT scale for cigarette smoking among Chinese adolescents. The scale provides a potential tool for assessing social cognitive processes underlying tobacco use. This is essential for understanding smoking behavior among Chinese youth and to support more effective tobacco use prevention efforts. Additional studies are needed to assess its utility for use with Chinese youth in other settings.

Development of Condom-Use Self-Efficacy over 36 months among Early Adolescents: A Mediation Analysis

This research evaluates condom-use self-efficacy and its increase throughout adolescence. Documentation of the development of condom-use self-efficacy would be important for prevention efforts given the influence of self-efficacy on actual condom-usage. This study assesses a hypothesized mediation mechanism of the development of self-efficacy using a mediation analysis approach. The participants, 497 grade-6 Bahamian students, were randomly assigned to the control condition in a 3-year longitudinal HIV prevention program trial. Condom-use self-efficacy consistently increased and condom-use self-efficacy assessed at earlier periods was positively associated with its values at subsequent periods. Additionally, self-efficacy assessed between two time points one year apart or longer (e.g., 6 months between baseline and 12 months) significantly mediated the impact of its levels at the previous assessment on the level at the subsequent assessment. To sustain program effect, HIV prevention programs should strive to enhance self-efficacy and provide reinforcing "boosters" no later than 12 months post-intervention.