HIV and STD Behavior Interventional

HIV and STD Behavior Interventional Strategies for Adolescents and Youths

Teenage sex has been viewed as a social problem for some time, but the spread of HIV / AIDS in society has increased fears of what can happen if young people have unprotected sex. The prevalence of HIV among young people has been increasing, with some populations seen as more vulnerable than others, such as homeless youth and black and Hispanic youth. Programs have been developed to educate these young people, and studies of how effective such programs can be have been undertaken to see if they do work and to improve them if they do not.

Many researchers focus on family influences on adolescent sexual behavior, and communication between parents and their children about sexual issues has been one important research area. Some studies show that parental discussions on sexual matters either delay the first sexual experience or encourage contraceptive use among adolescents, but others show no effect. In fact, some studies suggest that communication with parents may encourage sexual behavior. Studies show that these relationships depend on factors such as who reports the communication, whether the parents hold traditional or liberal attitudes, the sex of the adolescent, which parent conducts the discussion, and whether the outcome is sexual debut or contraceptive use. The researchers concluded,

We hypothesize that students who report having had discussions about HIV with their parents or other adults in their family will be less likely than those who had not to engage in HIV-related risk behaviors, discussed HIV with their peers will be more likely to report HIV? related risk behavior. We also expect that school-based instruction will increase communication with both parents and peers (Rubinson, 1995, p. 235).

Studies also show that many young people do not have such discussions and do not change their behaviors, and more concerted efforts have been developed to educate these young people and to change their behavior before they are infected.

Objectives

Below is a review of literature to suggest some of the approaches being taken today and how effective they have been found to be. The survey is also intended to show some of the ways in which the efficacy of these program has been tested and to suggest where more study is needed to improve these programs and make them as effective as possible, with the ultimate goal being to change risky behavior and so to reduce the incidence of HIV infection.

Selection Criteria

The studies examined include two types. One type offers surveys of a variety of studies to ascertain what sort of work is being done, what has been decided about the effectiveness of such programs, and so on. The other and more prevalent type consists of randomized controlled trials to test the effectiveness of specific programs and to demonstrate whether or not behavior is changed by exposure to these programs.

Participants considered in all cases are young people, most of high school age, examining both their sexual behavior and their exposure to some type of program intervention designed to change their behavior.

The types of intervention examined consisted of different forms of educational modules in different settings. Such programs were usually informative about HIV and its method of transmission and offered recommendations for how to reduce the likelihood of infection.

Outcomes were measured in terms of changes in behavior on the basis of such actions as increased use of condoms, reduced number of partners, lower drug use, and similar actions.

Search Strategy

Studies were found by making a systematic search of various electronic databases followed by a hand-search of journals to identify evaluations of behavioral interventions to reduce sexual risk behaviors among adolescents. Abstracts were read to determine the most relevant studies in each search.

Methods of the Review

Studies were selected if they illuminated some aspect of the issue and if they made a judgment about how effective either a given program or such programs in general were found to be. The sample, methodology, and results were extracted and used for purposes of comparison and explanation.

Description of Studies and Results

Numerous studies were found, with many in the 1990s as the scope of the AIDS problem was evident and as fears about the behavior of young people increased. Studies into this century have continued to address the increasing incidence of infection among certain populations, including young people, with more and more emphasis on the need for education to reduce the rate, though the question of how effective a given program might be was also given more and more attention.

Robin et al. (2004) offer a review of adolescent sexual risk-reduction programs that were evaluated using quasi-experimental or experimental methods and published in the 1990s. The authors describe evaluated programs and identify program and evaluation issues for health educators and researchers. They found the studies by making a systematic search of seven electronic databases and also hand-searched journals to identify evaluations of behavioral interventions to reduce sexual risk behaviors among adolescents. They included only articles that were published in the 1990s, that provided a theoretical basis for the program, offered information about the interventions, had clear aims, and used quasi-experimental or experimental evaluation methods, so identifying 101 articles and finding 24 that met the criteria for inclusion. The researchers then reviewed these evaluations to assess their research and program characteristics and found that the majority of studies included randomized controlled designs and employed delayed follow-up measures. They found that the most commonly measured outcomes were delay of initiation of sexual intercourse, condom use, contraceptive use, and frequency of sexual intercourse. The programs used ranged from 1 to 80 sessions, most with adult facilitators, and most commonly included skills-building activities about sexual communication, decision-making, and problem solving. The authors find that these programs suggest four overall factors that may impact program effectiveness, including the extent to which programs focus on specific skills for reducing sexual risk behaviors; program duration and intensity; what constitutes the content of a total evaluated program including researchers' assumptions of participants' exposure to prior and concurrent programs; and what kind of training is available for facilitators.

Emans et al. (1991) consider some of the newest medical advances in research on adolescent sexuality, such as contraceptive compliance, promotion of behavior change, relationships of ethnicity and pregnancy, and male reproductive health. Based on their analysis, the researchers find that the issues for the 1990's will be sexually transmitted diseases' morbidity and mortality, and they further identify such topics as sexual activity and adolescent pregnancy, care of the pregnant teen, sexually transmitted diseases, HIV infection, the male adolescent, sexual abuse in adolescents, gay and lesbian youth, interventions, reproductive health care of adolescents with disabilities and chronic illnesses, and training of primary care physicians. More attention has been directed at the reproductive behavior of males because of the HIV / AIDS. Research shows that sexual activity varies by racial/ethnic group, and this suggests that interventions to delay sexual initiation may be different for different racial/ethnic groups. The researchers say such issues need to be examined even though condom use has increased among 17- to 19-year-olds from 21% to 58% in metropolitan areas. At the same time, evidence shows that condom use is lowest among the group of men at highest risk of STDs, meaning those who had ever used drugs, those who had ever had sex with a prostitute, and those that had 5 or more partners per year. A survey of literature shows that male beliefs about contraception have been infrequently examined and that there are still misconceptions about heterosexual transmission of HIV. The authors call for better screening for STD detection. They also find that fathers are more involved in prenatal care and postnatal intervention programs and that 7% of children have been subjected to nonvoluntary sexual intercourse between the ages of 18-21, in the proportions of 12.7% of white women, 9% of black women, 1.9% of white males, and 6.1% of black males. Risk factors cited for white women include living apart form parents at 16 years of age, poverty, physical and emotional limitations, parental alcohol and smoking and drug use. Sexual assault is a problem associated with hitchhiking and alcohol and drug use. The authors state that physicians need to be sensitive to this issue and seek needed information from their patients. Among 12th graders. 1% of males and 1% of females saw themselves as mostly or completely homosexual or lesbian, and another 10% were unsure. Among the interventions the authors say are needed are reproductive and STD information, multiple approaches in a variety of settings, adolescent clinics, and outreach.

Crosby et al. (2003) note the value of condom promotion strategies for adolescents and find that such strategies typically include provision of STD/HIV-associated knowledge, fostering favorable attitudes toward condom use, promoting positive peer norms regarding condom use, improving condom-related communication skills and self-efficacy, and overcoming barriers to condom use. The authors conduct a study to identify which of these constructs were prospectively associated with condom use among a high-risk sample of African-American adolescent females reporting sexual activity with a steady male partner. The subjects were adolescents 14-18 years old. They were recruited from schools and health clinics. The subjects completed an in-depth survey and interview at baseline and again 6 months later. The subsequent analyses were limited to adolescents with steady partners who reported sexual activity between the baseline and 6-month follow-up assessment periods (N = 179). At baseline, five-scale measures and a single-item measure were used to assess predictive constructs, and at follow-up, the subjects were asked about their frequency of condom use over various periods of recall. The researchers created multivariate models to control for the confounding influence of pregnancy status. They then found that the findings were remarkably distinct, with evidence that strongly supports the predictive role of perceived barriers toward condom use and peer norms. Based on the measure of sexual communication, the researchers found significance for two of the six assessed outcomes. Alternatively, measures of attitudes toward condom use, condom negotiation self-efficacy, and knowledge about STD/HIV-prevention were found to be consistently nonsignificant. The researchers conclude that to improve the effectiveness of individual-level STD/HIV prevention programs, designed for this population, any program must place an emphasis on reducing barriers to condom use, teaching partner communication skills, and fostering positive peer norms relevant to condom use.

One examination of a community-based program is offered by Harvey, Stuart, and Swan (2000), considering a community intervention trial undertaken in KwaZulu Natal, South Africa to evaluate the effectiveness of a high school drama-in-education program. In this study, seven pairs of secondary schools were randomized to receive either written information about HIV / AIDS or the drama program. Questionnaire surveys of knowledge, attitude, and behavior were compared from before and 6 months after the interventions. The sample consisted of 1,080 students in the first survey and 699 in the second. Improvements in knowledge (P=0.0002) and attitudes (P < 0.00001) about HIV / AIDS were demonstrated in students at schools receiving the drama program when compared to pupils receiving written information alone, and these changes were found to be independent of age, gender, school, or previous sexual experience. In schools receiving the drama program, sexually active students increased thier condom use (P < 0.01). The authors state that it is important to provide resources to sustain such programs as well as to get stronger evidence of the effect on behavior by measuring changes in HIV incidence. The authors also note that adolescents' risk of becoming infected with HIV in South Africa is increased by a lifestyle involving a greater degree of exploration, experimentation, and rebellion. The high prevalence of sexually transmitted diseases and the high rate of adolescent pregnancy show a pattern of early onset of sexual intercourse, multiple partners, and a low incidence of condom use. Prevention programs such as the Drama Approach to AIDS (DramAide) were initiated in Africa to reduce HIV transmission. The approach to testing used a randomized community intervention trial, with the results noted above.

Another African study is reported by Munodawafa, Marty, and Gwede (1995), in this case in Zimbabwe analyzing the use of health instruction by students nurse in rural secondary schools and determining how effective such instruction may be.

The project used twelve nurses on community deployment to provide health instruction among rural school-age populations in Zimbabwe. The program was analyzed using a quasi-experimental (pre- and post-test), non-equivalent control group design consisting of 141 school pupils in the intervention group and 144 pupils in the comparison group (N = 285). The curriculum used focused on prevention of STDs, HIV / AIDS, and drugs (alcohol, tobacco and marijuana), and a gain in health knowledge scores among the intervention group was reported at post-test. More than 70% of the pupils who received health instruction from student nurses offered a high approval rating of the student nurses' performance, and student nurses, teachers, and tutors all supported school health instruction by student nurses, although tutors and teachers did differ on teaching about condoms. In the program, the 12 student nurses were sent by nursing schools to five rural secondary schools in Masvingo Province to provide health education over a seven-week period to 141 students (9.33 hours/student). Curriculum topics included AIDS, other sexually transmitted diseases (STDs), and drugs (alcohol, tobacco, and marijuana), and the AIDS/STD educational materials concentrated on modes of transmission, prevention methods, control of transmission, psychosocial issues, responsible sexual behavior, and problem-solving and decision-making strategies. This study really addresses how the student nurses and their instruction were received and did not show the effectiveness of that instruction in changing behavior, which is the analysis that is really needed.

Morrison-Beedy, Nelson, and Volpe (2006) undertake a study to examine the rates of HIV-related risk behaviors and HIV testing rates between Black and White adolescent girls consenting to participate in an HIV prevention intervention. The sample consisted of 116 unmarried sexually active girls ages 15 to 19 enrolled in a pilot randomized controlled trial of a gender-specific HIV prevention intervention who classified themselves as Black (N = 43) or White (N = 73). These girls were unmarried and sexually active with a male partner in the past three months, and the mean age for the Black girls was 16.7 years (SD=1.4) and for the White girls was 17.5 years (SD=1.3). The average level of education completed was 10th grade for Blacks and 11th grade for Whites, and sixty percent of the Black girls were classified as economically disadvantaged, versus 15% of the White participants. The girls were recruited by trained research assistants from an urban health clinic in central New York State that provides gynecologic and reproductive health services to teenagers.

Participants were asked to report on their sexual and substance use history and were then assessed on the basis of criteria set beforehand. Count data were used to report the following behaviors: (a) total number of sex partners in the past year, (b) number of men had sex with over the past 3 months, - number of partners who use IV drugs over the past 3 months, (d) number of times had sex for money or drugs over the past 3 months, (e) number of times had vaginal sex with and without a condom over the past 3 months, (f) number of times had anal sex with and without a condom over the past 3 months, (g) number of episodes received and gave oral sex over the past 3 months, and (h) number of times used alcohol or drugs before sex over the past 3 months.

The Statistical Package for the Social Sciences (SPSS) was used to conduct chi-squared analysis, and independent t-tests were also used to compare the mean variable scores between Black and White adolescent girls on HIV risk related and health promotion behavior items. It was found that Black and White adolescent girls differed on frequency and incidence of several HIV-related risk behaviors (p

One situation that appears to lead to greater awareness and more behavior change is noted by Staub et al. (2007), and that is when there is a case-finding for human immunodeficiency virus (HIV), and especially among high-risk youth. The researchers conduct a study that shows that there is a significant increase in participation in voluntary HIV counseling and testing services immediately after implementation of a brief sexually transmitted infection (STI)/HIV educational program in alternative education and juvenile detention facilities. The effectiveness of such programs, however, may be short-lived, an issue that needs to be given more attention.

Rotheram-Borus and Miller (1998) offer a similar finding, noting first that the number of youths infected with HIV has been rising and that secondary prevention programs are therefore needed to help youths living with HIV meet three goals: (1) increase self-care behaviors, medical adherence, and health-related interactions; (2) reduce transmission acts; and (3) enhance their quality of life. The authors describe such an intervention program for youths living with HIV, one delivered over 30 sessions in three modules. The program is based on modifications of the social action model, and sees to it that perceptions, attitudes, and skills to enhance affective awareness and positive behavioral routines are identified as prerequisites for meeting each of the targeted outcomes. In each module, youths engage in small-group activities over 8-12 sessions with other infected peers to modify their behavioral patterns. Module 1 focuses on choosing one's social identity with respect to a seropositive status, including implementing new daily routines to stay healthy, coping with receiving high quality medical care, and keeping safe from reinfection. Module 2 seeks to reduce substance use and unprotected sexual acts. Module 3 addresses using sensory awareness as a strategy for enhancing the quality of life. A variety of delivery strategies are discussed for secondary interventions. The program is found to be effective for most young people, though the authors suggest developing more such programs to improve the outcome. Some research has been conducted on the threat to specific populations within the larger population, suggesting different approaches for some ethnic or racial groups based on cultural differences. Villarruel, Jemmott, & Jemmott (2006), for instance, seek to test the efficacy of a prevention intervention to reduce sexual risk behavior among Latino adolescents. A randomized controlled trial was conducted from April 2000 through March 2003, with data collection before and after intervention and at 3, 6, and 12 months. Participants were Latinos aged 13 through 18 years (249 males and 304 females); with 81.6% retained at 12-month follow-up. These were students in northeast Philadelphia schools.

The HIV and health-promotion control interventions consisted of six 50-minute modules delivered by adult facilitators to small, mixed-gender groups in English or Spanish. Analyses using generalized estimation equations over the follow-up period showed that adolescents in the HIV intervention were less likely to report sexual intercourse (odds ratio, 0.66; 95% confidence interval [CI], 0.46-0.96), multiple partners (odds ratio, 0.53; 95% CI, 0.31-0.90), and days of unprotected intercourse (relative risk, 0.47; 95% CI, 0.26-0.84) and were more likely to report using condoms consistently (odds ratio, 1.91; 95% CI, 1.24-2.93). Baseline sexual experience and language use moderated intervention efficacy. Adolescents assigned to the HIV intervention who were sexually inexperienced at baseline reported fewer days of unprotected sex (relative risk, 0.22; 95% CI, 0.08-0.63), and Spanish speakers were found to be more likely to have used a condom at last intercourse (odds ratio, 4.73; 95% CI, 1.72-12.97) and had a greater proportion of protected sex (mean difference, 0.35; P