mental health AIDS

Spring 2008 Newsletter / Volume 9, Issue 3

HIV Prevention News

About Adolescents & Young Adults

Zimmerman et al. (2007) proposed and tested a comprehensive multiple domain model (MDM) of condom use in adolescents. In this model,

[t]he most proximal influences on condom use were hypothesized to be situational/contextual variables [i.e., relationship status and length, use of a hormonal contraceptive, substance use] and preparatory behaviors [e.g., buying and carrying condoms]. ... The next most proximal factors thought to influence condom use were previous condom use and intentions to use condoms. ... The next most proximal factors thought to influence condom use were the following, in order of most to least proximal: (1) social psychological variables of condom attitudes, norms, and self-efficacy; (2) personality [factors, i.e., sensation-seeking, impulsivity] and social environment factors [e.g., educational aspirations]; [and] (3) social structural variables [i.e., gender, race, age, socioeconomic status or SES]. (p. 383)

Data were drawn from 511 high school students at three points in time. "Adolescents who were sexually active at time 2 (6 months after baseline) and time 3 (1 year after time 2) and completed surveys at all three time points were included in the analyses" (p. 380). The model-testing process "resulted in a structural equation model that provided a good fit to the data" (p. 380). In brief,

[t]he strongest direct predictors of condom use were preparatory behaviors ... and intentions to use condoms ..., and the combination of variables directly related to condom use explained 28% of the variance in condom use ... . As hypothesized, attitudes, norms, and self-efficacy significantly were related to intentions to use condoms. In addition, high sensation seekers were found to have more negative condom norms ..., while impulsive decision makers had lower self-efficacy ..., more negative condom attitudes ..., and more negative norms ... . Those with higher SES had higher educational aspirations ..., which in turn positively related to condom attitudes ... . Gender and race also were related to variables in the model, with non-Whites being significantly less likely to be high sensation seekers compared with their White counterparts ..., and males being more likely to have intentions to use condoms than females ... . (pp. 387-388)

Additionally, "[m]odels comparing gender and race as moderators also were calculated and supported the generalizability of the ... [MDM]" (p. 380).

According to Zimmerman and colleagues, "the proposed MDM provides a possible explanation of pathways to condom use among sexually active adolescents" (p. 389), one "that goes beyond traditional social psychological models for a broader understanding of condom use in adolescents" (p. 380). As with other condom use models,

interventions based upon the MDM should strive to modify individuals' attitudes toward condoms, their perceptions of social norms surrounding condoms, and their self-efficacy to engage in condom use. The MDM goes a step further, however, in suggesting ... [that] individuals need to not only have favorable beliefs toward condom use, but also must possess the skills (preparatory behaviors) to procure condoms, have them available in a sexual situation, and talk to a partner about their use.

In addition, the model also suggests that particular subgroups of adolescents, such as higher sensation seekers and impulsive decisionmakers, may need targeted risk reduction messages. For instance, impulsive decisionmakers may have lower self-efficacy because they recognize their lack of a tendency to plan ahead for sexual situations. Messages directed toward this group might put a greater emphasis on planning ahead to specifically address impulsive decisionmakers' proclivity to make what are often poor decisions ... . Sensation seekers may be more likely to befriend individuals who also are sensation seekers, and may in turn underestimate how often their peers use condoms. Such individuals may need messages that reinforce the use of condoms among their peers at large and the normative support for condom use that exists among people important to an individual.

Finally, the MDM also suggests that it is not just the preexisting personality and attitudinal factors that are important in safer sex, but that situational and contextual influences on sexual behavior also can have an influence. Evidence for the role of hormonal birth control use as a barrier to condom use was found in the current study, suggesting that beliefs about hormonal versus barrier methods should be addressed within interventions. (p. 391)

Several other researchers have focused, in recent publications, on the role of parents in moderating risk behavior. Prado et al. (2007) "evaluated the efficacy of Familias Unidas 2 + Parent-Preadolescent Training for HIV Prevention (PATH), 3 a Hispanic-specific, parent-centered intervention, in preventing adolescent substance use and unsafe sexual behavior" (p. 914). The investigators randomly assigned 286 Hispanic 8th graders and their primary caregivers to one of three conditions: Familias Unidas + PATH, English for Speakers of Other Languages (ESOL) 4 + PATH, and ESOL + HeartPower! for Hispanics (HEART). 5 Assessments were conducted at baseline and at 6, 12, 24, and 36 months. Prado and colleagues found that "(a) Familias Unidas + PATH was efficacious in preventing and reducing cigarette use relative to both control conditions; (b) Familias Unidas + PATH was efficacious, relative to ESOL + HEART, in reducing illicit drug use; and (c) Familias Unidas + PATH was efficacious, relative to ESOL + PATH, in reducing unsafe sexual behavior. The effects of Familias Unidas + PATH on these distal outcomes were partially mediated by improvements in family functioning" (p. 914).

On this point, the investigators note their surprise

that the ESOL + HEART condition, in which the HEART module was specifically designed to prevent cardiovascular risk behaviors, such as cigarette smoking, was less efficacious in preventing smoking than Familias Unidas + PATH, in which smoking was not directly addressed. Of similar interest is the fact that ESOL + PATH, in which the PATH module was specifically designed to target HIV risks, was not efficacious in preventing unsafe sexual intercourse. However, Familias Unidas + PATH was efficacious in preventing both cigarette smoking and unsafe sexual behavior at last intercourse. These findings suggest that targeting specific health behaviors in the context of strengthening the family system may be most efficacious in preventing or reducing cigarette smoking and unsafe sex in Hispanic adolescents. (p. 923)

Despite a number of limitations, including sampling from a Hispanic population that was not representative of the larger U.S. Hispanic population, Prado and colleagues conclude

that working primarily with parents may be an especially effective strategy for preventing or reducing negative behaviors among Hispanic adolescents and perhaps among adolescents in general. Improving family functioning – especially parent-adolescent communication and positive parenting – is critical in preventing substance use and unsafe sex in Hispanic adolescents. Educating parents and adolescents about risks associated with substance use and with unsafe sex appears to be less effective, especially without attention to family functioning beforehand. (p. 924)

To evaluate the efficacy of a parent-based sexual-risk prevention program for African American children between the ages of 9 and 12 years, Forehand et al. (2007) conducted a community-based, randomized controlled trial that included a convenience sample of 1,115 African American parent-preadolescent dyads enrolled in three locations (Athens and Atlanta, Georgia; and Little Rock, Arkansas). Participants were randomly assigned to one of three study conditions: an enhanced communication intervention, consisting of five 2½-hour group sessions; a single-session communication intervention, consisting of one 2½-hour group session; and a general health intervention, a control condition consisting of one 2½-hour group session. 6 All group sessions had African American facilitators, all of whom co-led groups in all three study conditions. Sexual communication between the parent and the preadolescent, as well as parental responsiveness to sex-related questions, was measured at baseline, postintervention, and at 6- and 12-month follow-ups. Additionally, the preadolescents were asked if they had engaged in or were intending to engage in sexual intercourse at the 12-month follow-up. According to Forehand and colleagues,

[t]his study provides some preliminary evidence for the efficacy of a program for parents of preadolescents. Specifically, after intervention, parents participating in the enhanced intervention, relative to the control, demonstrated higher levels of parent-preadolescent sexual communication and comfort with and responsiveness to sex-related questions. In addition, at the 12-month follow-up, preadolescents whose parents attended all 5 sessions of the enhanced intervention ... [were less likely to have] had sexual intercourse or anticipat[e] ... engaging in such behavior during the next year, compared with controls and those receiving the single-session intervention. The beneficial effects for the single-session intervention were minimal. The enhanced intervention appears promising as an innovative method of conveying risk reduction messages. However, longer follow-up is needed to determine if group differences persist as preadolescents progress through adolescence.

The findings suggest that effective prevention efforts require repeated exposure and opportunities for practice to produce lasting behavioral effects. Participants attending all 5 sessions of the enhanced intervention were provided more exposure (12½ hours) to the key intervention targets than those in the single-session (2½ hours) and control (0 hours) interventions as well as opportunities to observe models, practice new skills, and obtain performance feedback and social support. These exposures and opportunities allow for greater skill acquisition and more lasting behavioral change.

This study had several limitations. First, the participants were a convenience sample. Second, there was a high rate of attrition; however, the intent-to-treat analyses suggest that, even when those who did not complete the intervention and/or assessments were considered, group differences still emerged. Third, sexual behavior other than intercourse and intentions to engage in such behavior were not examined. Among its strengths, this study represents the first empirically validated skills-based intervention designed for parents of preadolescent children with the goals of modifying sexual intentions and preventing early initiation of sexual behaviors. The findings suggest that, with intervention, parents can learn sexual communication skills and enhance their communication, which may prevent early adolescent high-risk sexual behavior. (pp. 1127-1128)

In this same vein, Glenn, Demi, and Kimble (2008) "examine[d] the relationship between fathers' influences and African American male adolescents' perceptions of self-efficacy to reduce high-risk sexual behavior" (p.73). Data came from a convenience sample of 70 fathers recruited from churches in a large metropolitan area in the southern United States. Glenn and colleagues found that "the greater the son's perception of his father's communication of sexual standards (more communication about sexual issues and positive attitudes about HIV prevention) and ... [the] greater [the] father's perception of ... [his] son's self-efficacy[, the] ... greater [the] son's self-efficacy for abstinence" (p. 84). The relationship between fathers' influences and sons' self-efficacy for safer sex was not statistically significant. Nevertheless, the investigators conclude that the "[d]ata support the need for fathers to express confidence in their sons' ability to be abstinent or practice safer sex and to communicate with their sons regarding sexual issues and standards" (p. 73).

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 2 "Familias Unidas is a Hispanic-specific, family-based preventive intervention designed to reduce risk for and increase protection against substance use and sexual risk behaviors in Hispanic adolescents. Hispanic-specific cultural issues are integrated in all aspects of the intervention, from the underlying theoretical model to the specific content of the intervention to the format of the intervention activities[.] ... Familias Unidas aims to prevent substance use and sexual risk behaviors by (a) increasing parental involvement in the adolescent's life, (b) increasing family support for the adolescent, (c) promoting positive parenting, and (d) improving parent-adolescent communication" (pp. 917-918).

 3 "PATH ... is a theoretically based HIV prevention curriculum designed to promote responsible sexual behavior by training parents to become effective HIV educators for their children. PATH is designed to increase parents' and adolescents' knowledge about HIV and to promote parent-adolescent communication about HIV risks" (p. 918).

4 "The ESOL classes aimed to help parents communicate more effectively in English. It was expected that parents would be interested in this module because the majority of them were monolingual and had no working knowledge of English" (p. 918).

5 "HEART is designed to reduce adolescents' risk for cardiovascular disease and to promote adolescent cardiovascular health by (a) increasing awareness of cardiovascular risk factors, such as cigarette use, and (b) improving attitudes toward exercise and nutrition. HEART encourages parents to be involved in their adolescents' cardiovascular health, but it is not specifically designed to reduce risk for adolescent illicit drug use or unsafe sexual behavior" (p. 918).

6 "The enhanced intervention's first 2 sessions ... focused on raising parents' awareness of adolescent sexual-risk behavior and teaching parents how they can help their preadolescents avoid such risks[. These sessions also focused on] ... skills known to reduce sexual-risk behavior among adolescents, including the use of positive reinforcement, monitoring, and effective parent-preadolescent communication. Sexual communication – focused on increasing parents' communication about sexual topics and their confidence, comfort, and responsiveness in communicating with their preadolescents about sexual behavior – was delivered in sessions 3 through 5. The enhanced intervention used multiple teaching strategies, including structured learning experiences, discussion, videotapes, overhead projections, modeling, role playing, group exercises, and homework assignments. Preadolescents attended part of the fifth session so that parents could practice and receive feedback on their communication skills.

The single-session intervention covered the same topics as the enhanced intervention but in a single session that was primarily a lecture format with visual aids and some videos but no opportunity to practice skills. The single-session control intervention focused on general health issues and emphasized how parents can help their preadolescents establish long-term health habits that would reduce the risk of such diseases as obesity, diabetes, cardiovascular disease, and hypertension. Preadolescents did not attend the single-session or control interventions" (pp. 1124-1125).

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