0
Article |

HIV/STD Risk Reduction Interventions for African American and Latino Adolescent Girls at an Adolescent Medicine Clinic:  A Randomized Controlled Trial FREE

John B. Jemmott III, PhD; Loretta Sweet Jemmott, PhD; Paula K. Braverman, MD; Geoffrey T. Fong, PhD
[+] Author Affiliations

Author Affiliations: Annenberg School for Communication (Dr J. B. Jemmott) and School of Nursing (Dr L. S. Jemmott) University of Pennsylvania, Philadelphia; the Department of Psychology, Princeton University, Princeton, NJ (Dr J. B. Jemmott); Drexel University College of Medicine and the Department of Pediatrics, St Christopher’s Hospital for Children, Philadelphia (Dr Braverman); and the Department of Psychology, University of Waterloo, Waterloo, Ontario (Dr Fong). Dr Braverman is now with Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, Ohio.


Arch Pediatr Adolesc Med. 2005;159(5):440-449. doi:10.1001/archpedi.159.5.440.
Text Size: A A A
Published online

Background  Adolescent girls in the United States and around the world are at a heightened risk for sexually transmitted diseases (STDs), including human immunodeficiency virus (HIV).

Objective  To determine the efficacy of a skill-based HIV/STD risk-reduction intervention in reducing self-reported unprotected sexual intercourse among African American and Latino adolescent girls.

Design  Randomized controlled trial with 3-, 6-, and 12-month follow-ups.

Setting and Participants  Sexually experienced African American and Latino adolescent girls recruited from the adolescent medicine clinic of a children's hospital serving a low-income inner-city community (N = 682, mean age, 15.5 years); 88.6% were retained at the 12-month follow-up.

Interventions  Three 250-minute interventions based on cognitive-behavioral theories and elicitation research: an information-based HIV/STD intervention provided information necessary to practice safer sex; a skill-based HIV/STD intervention provided information and taught skills necessary to practice safer sex; or a health-promotion control intervention concerned with health issues unrelated to sexual behavior.

Main Outcome Measures  Primary outcome measure was self-reported frequency of unprotected sexual intercourse; secondary outcomes included the frequency of sexual intercourse while intoxicated, the number of sexual partners, biologically confirmed STDs, and theoretical mediator variables, including the intention to use condoms, beliefs about using condoms, and condom-use knowledge.

Results  No differences between the information intervention and the health control intervention were statistically significant. Skills-intervention participants (mean [SE], 2.27 [0.81]) reported less unprotected sexual intercourse at the 12-month follow-up than did information-intervention participants (mean [SE], 4.04 [0.80]; P = .03), or health control–intervention participants (mean [SE], 5.05 [0.81]; P = .002). At the 12-month follow-up, skills-intervention participants (mean [SE], 0.91 [0.05]) reported fewer sexual partners (P = .04) compared with health control–intervention participants (mean [SE], 1.04 [0.05]) and were less likely to test positive for STD (mean [SE], 10.5% [2.9%]) than were health control–intervention participants (mean [SE], 18.2% [2.8%]; P = .05). No differences in the frequency of unprotected sexual intercourse, the number of partners, or the rate of STD were observed at the 3- or 6-month follow-up between skill-intervention participants and information-intervention or health control–intervention participants.

Conclusion  Skill-based HIV/STD interventions can reduce sexual risk behaviors and STD rate among African American and Latino adolescent girls in clinic settings.

Figures in this Article

One quarter of the 15 million cases of sexually transmitted diseases (STDs) in the United States occur among adolescents, and sexually active adolescents have the highest rate of STDs of any age group.1,2 The chances of a sexually active 15-year-old girl having pelvic inflammatory disease is 1:8 compared with 1:80 for a 24-year-old woman.3 Moreover, the number of cases of sexually transmitted human immunodeficiency virus (HIV) infection among adolescent girls continues to increase,4 especially among African Americans and Latinos.4 The high rate of STDs in adolescent girls is due to several biologic and psychosocial factors.57 If adolescents choose not to be abstinent, the prevention of STDs, including HIV, requires correct and consistent use of condoms. Yet only half of sexually active adolescent girls report having used condoms the last time they had sexual intercourse.5 The high rate of STDs even in adolescent medicine clinics where condoms are provided8 suggests that simply providing access to condoms is insufficient to prompt their correct and consistent use. There is a need for programs that are designed to eliminate the unsafe sexual practices that persist among adolescents who have access to condoms.

To be sure, randomized controlled trials have demonstrated that HIV/STD prevention interventions for adolescents are effective in reducing sexual risk behavior.9,10 However, few such trials have been conducted in adolescent medicine clinic settings,11 and fewer still have considered the relative efficacy of different intervention strategies. For instance, interventions can simply provide information about how to reduce risk or interventions can provide skills training to empower adolescents to protect themselves. Furthermore, although HIV/STD risk-reduction interventions have been successful in reducing self-reported sexual risk behavior, less well documented is whether such interventions also reduce the rate of STDs among adolescents.12,13

The present study tested the effects of HIV/STD risk-reduction interventions on unprotected sexual intercourse and the rate of STDs among African American and Latino female patients in a low-income, inner-city adolescent medicine clinic that provided confidential and free family planning services. We randomly assigned the participants to 1 of 3 interventions based on cognitive behavioral theories and formative research. An information-based HIV/STD intervention provided information needed to reduce sexual risk, but it provided no practice or direct experience with condoms or role-playing. A skill-based HIV/STD intervention provided information and taught skills necessary to practice and negotiate condom use. A health-promotion control intervention concerned health issues unrelated to sexual behavior.

We hypothesized that (1) the skill-based intervention would reduce unprotected sexual intercourse and STD rate compared with the health-promotion control intervention, (2) the information-based intervention would reduce unprotected sexual intercourse and STD rate compared with the health-promotion control intervention, and (3) the skill-based intervention would reduce unprotected sexual intercourse and STD rate compared with the information-based intervention.

PARTICIPANTS

The participants were 682 sexually experienced African American (n = 463) and Latino (n = 219) adolescent girls, 12 to 19 years of age (mean age, 15.5 years) who were family planning patients at the adolescent medicine clinic in a children's hospital serving a low-income, inner-city community in Philadelphia, Pa. Of the Latinos, 92.7% were Puerto Rican. The participants had volunteered for the “Women's Health Project” designed to reduce the chances that African American and Latino adolescent girls would develop devastating health problems, including cardiovascular diseases, cancer, and AIDS. They were reimbursed up to $120 for participating: $40 for completing the intervention and the preintervention and postintervention questionnaires, $25 for the 3-month follow-up, $25 for the 6-month follow-up, and $30 for the 12-month follow-up.

PROCEDURES

The institutional review boards of Princeton University, Princeton, NJ, and the University of Pennsylvania, St Christopher’s Hospital for Children, and the Family Planning Council, Philadelphia, approved the study. African American and Latino adolescent girls were eligible to participate if they (1) were patients at the adolescent medicine clinic, (2) were sexually experienced, (3) were not pregnant, (4) were 12 to 19 years of age, (5) could read and speak English, and (6) did not plan to move from the area of the clinic. During the adolescents' biannual STD screening visit, clinicians referred eligible adolescents to the site coordinator who informed them about the study and scheduled interested adolescents to participate.

RANDOMIZATION TO INTERVENTIONS

The study was a randomized controlled trial conducted at the hospital where the adolescents were recruited. Participants were stratified by age, and based on computer-generated random number sequences, they were assigned to 1 of the following 3 interventions: skill-based HIV/STD intervention, information-based intervention, or health-promotion control intervention. One researcher conducted the computer-generated random assignments; others executed the assignments. One week later, mothers of participants who consented to having their mother invited to participate were randomized to 1 of 3 interventions—skill-based HIV/STD intervention, information-based intervention, or health-promotion control intervention—to help them communicate with their daughter about health issues. The mothers' randomization was independent of the daughters' randomization. Findings from that aspect of the trial will be the subject of a separate article.

FORMATIVE RESEARCH

Before conducting this trial, we conducted focus groups and elicitation surveys, and we pilot tested both the questionnaire and the interventions with African American and Latino adolescent girls from the study population. The results suggested that it was feasible to develop, and acceptable to use, interventions that would be implemented with both Latino and African American participants.

INTERVENTION METHODS

The interventions were based on cognitive behavioral theories1418 and the formative research we conducted with adolescents from the study population. Designed to be culturally and developmentally appropriate for inner-city African American and Latino adolescent girls, each intervention involved 250 minutes of group discussions, videotapes, games, and experiential exercises implemented in a single session with 2 to 10 participants (mean, 5.3 participants). Many of the activities have been used successfully in previous studies with inner-city African American adolescents.1923

INFORMATION-BASED HIV/STD RISK-REDUCTION INTERVENTION

The information-based HIV/STD risk-reduction intervention addressed the elevated risk of HIV and STD among inner-city African American and Latino young women, personal vulnerability to HIV and STD, HIV transmission, the diverse messages about sex to which adolescents are exposed, responsibility for sexual risk reduction in romantic relationships, and the importance of using condoms. It also addressed the belief that condoms interfere with sexual enjoyment. Human immunodeficiency virus educational videotapes illustrated correct condom use with a demonstration model and depicted effective negotiation of condom use. However, participants were not given the opportunity to practice skills relevant to negotiating condom use or using condoms correctly.

SKILL-BASED HIV/STD RISK-REDUCTION INTERVENTION

The skill-based HIV/STD risk-reduction intervention addressed beliefs relevant to HIV/STD risk reduction, illustrated correct condom use, and depicted effective condom-use negotiation. It differed from the information intervention in that participants practiced the skills needed to use condoms. It addressed the elevated HIV and STD risk among inner-city African American and Latino young women and personal vulnerability to HIV. It addressed barriers to condom use, including alcohol and drug use and the belief that condoms interfere with enjoyment, and ways to surmount such barriers. Most important, participants handled condoms, practiced correct use of condoms with anatomical models, and engaged in role-playing to increase skill in negotiating the use of condoms.

HEALTH-PROMOTION CONTROL INTERVENTION

To control for Hawthorne effects to reduce the likelihood that effects of the HIV/STD interventions could be attributed to nonspecific features,24 including group interaction and special attention, some participants received a health-promotion control intervention designed to be as valuable and enjoyable as the HIV interventions. It covered beliefs and skills relevant to behaviors associated with the risk of heart disease, cancer, and stroke. Specifically, it concerned food selection and preparation, physical activity, breast self-examination, cigarette smoking, and alcohol use.

FACILITATORS AND FACILITATOR TRAINING

The facilitators were 14 African American women (mean age, 38.2 years) who had at least a baccalaureate degree and experience working with inner-city adolescents. Implementation fidelity was emphasized during the 8-hour facilitator training and before each intervention session when the facilitators met with the project coordinator.

DATA COLLECTION AND MEASURES

The adolescents completed confidential self-administered questionnaires preintervention, immediately after the intervention, and at the 3-, 6-, and 12-month follow-ups. Preintervention and follow-up questionnaires assessed sexual behavior, demographic variables, and conceptual mediator variables. The postintervention questionnaire included conceptual mediator variables and evaluations of the interventions. Biological specimens for STD testing were collected at baseline and at the 6- and 12-month follow-ups.

We attempted to increase the validity of self-reported sexual behavior. To reduce potential memory problems, we asked adolescents to report their behaviors over a brief period (ie, 3 months), wrote the dates comprising the period on a chalkboard, and distributed calendars clearly highlighting the period. To reduce the likelihood of demand from giving their responses to the intervention facilitators, proctors blind to the participants’ intervention assignment collected the questionnaire data. The proctors emphasized to participants the importance of responding honestly and assured them that their responses were confidential. Participants signed an agreement pledging to answer the questions honestly, a procedure that has been shown to yield more valid self-reports on sensitive issues.25

Primary Outcome Measure

The primary outcome measure was the number of days on which the adolescent reported having unprotected sexual intercourse in the previous 3 months.

Secondary Outcome Measures

The secondary outcome measures included other sexual risk behaviors in the previous 3 months, STD rate, and conceptual mediator variables. Participants reported the number of sexual partners, the number of days on which they had sexual intercourse while high on drugs or alcohol, and the number of days on which they had unprotected sexual intercourse while high on drugs or alcohol in the previous 3 months.

The routine screening procedures in the adolescent medicine clinic included screening all sexually experienced adolescents, including asymptomatic patients, for Neisseria gonorrhoeae, Chlamydia trachomatis, and Trichomonas vaginalis every 6 months by performing a pelvic examination. As patients in the clinic, all the participants would have undergone biannual STD screening by clinicians who were blind to their intervention assignment. Sexually transmitted disease data were obtained by clinical medical record review, and any participants who did not return for their routine biannual STD screen were followed up to arrange for an expedited clinic appointment. The presence of N gonorrhoeae, C trachomatis, or T vaginalis infection was used as the measure of STD presence. Participants who tested positive for STDs were notified and treated according to Centers for Disease Control and Prevention guidelines. Details about STD testing methods are available from us.

Several variables from the theory of reasoned action,16,17 the theory of planned behavior,18 and social cognitive theory14,15 that might mediate the efficacy of our interventions were measured with 5-point Likert scales. These theoretical mediator variables were targeted by the HIV/STD interventions. Three items measured the intention to use condoms (α = .86). Condom use hedonistic beliefs were measured with 7 items concerning the belief that condoms do not interfere with sexual enjoyment (α = .84). One item measured normative beliefs regarding sexual partner’s approval of using condoms. Three items measured condom use technical skills beliefs (participants’ confidence they could use condoms skillfully; α = .65). Two items measured condom use impulse control beliefs (participants’ confidence they could control themselves enough to use condoms; α = .61). Three items measured condom use negotiation beliefs (α = .82). In addition, HIV/STD risk-reduction knowledge was the number correct on 48 true-false items regarding the transmission and consequences of AIDS and STDs, and knowledge specific to condom use was the number correct on 6 true-false items.

Participants also evaluated the interventions. A 5-item scale measured how much participants liked their intervention (α = .87). A 3-item scale measured how much they thought they learned (α = .83). One item measured the extent to which they would recommend it to others.

SOCIAL DESIRABILITY RESPONSE MEASURE

The Marlowe-Crowne Social Desirability Scale26 assessed the tendency of participants to describe themselves in favorable, socially desirable terms. The scale has been used extensively in studies of adolescents, including inner-city adolescents.

SAMPLE SIZE AND STATISTICAL ANALYSES

With α = .05, 2-tailed, a total sample size of 506 participants completing the trial was projected to provide a power of 80% to detect a 0.25-SD difference in self-reported frequency of unprotected sexual intercourse between each of the 2 HIV/STD risk-reduction interventions and the health-promotion control intervention.

χ2 Tests, analyses of variance, and Poisson regression analyses were performed to identify significant differences among conditions on preintervention measures. The χ2 and t tests were performed to analyze attrition. Hypotheses regarding primary and secondary outcomes were tested in analyses that used planned contrasts27 of prespecified hypotheses, controlling for preintervention scores on the criterion, ethnicity (Latino vs black), and a 4-category variable on which 3 categories represented the 3 aforementioned mothers' conditions (ie, health promotion, information, and skill) and the fourth category represented mothers who did not participate. The first planned contrast compared the information-based intervention with the health-promotion control intervention. The second contrast compared the skill-based intervention with the health-promotion control intervention. The third compared the skill-based intervention and the information-based intervention. The standardized effect size estimate (d) is presented for each significant contrast. Analyses on counts of sexual behaviors were performed using Poisson regression. Analyses on conceptual mediator variables used analyses of covariance. Hypotheses regarding STDs and sexual behaviors measured with dichotomous variables were tested in logistic regression analyses. Interactions were tested hierarchically, that is, by controlling for the main effects of all variables involved in the interactions.

PARTICIPANTS

As shown in the Figure, 59.3% of the eligible adolescents (ie, 682 of 1150) participated. Those enrolled were younger than were the eligible nonparticipants (mean age, 15.5 vs 16.1 years, P<.001). A greater percentage of the eligible African Americans compared with Latinas enrolled in the study (68.7% vs 46.0%, P<.001). Participants and eligible nonparticipants did not differ in STD prevalence at baseline (P = .42).

Place holder to copy figure label and caption
Figure.

Progress of participants through the trial. Those not randomized failed to appear for unknown reasons.

Graphic Jump Location

At baseline, 87.1% of the respondents reported having sexual intercourse in the previous 3 months. About 52.0% of the respondents had unprotected sexual intercourse in the previous 3 months, 15.8% had sexual intercourse with multiple partners in the previous 3 months, 9.5% had a least 1 child, and 21.6% tested positive for N gonorrhoeae, C trachomatis, or T vaginalis. Few respondents (0.4%) reported having same-gender sexual relationships or using injection drugs (0.6%).

PREINTERVENTION COMPARABILITY OF INTERVENTION CONDITIONS

Table 1 gives the descriptive statistics for preintervention reports of demographic characteristics, sexual behavior, conceptual mediator variables, and STD test results by intervention assignment. Analyses revealed no statistically significant differences among the conditions.

Table Graphic Jump LocationTable 1. Demographic Characteristics, STD Test Results, Self-reported Sexual Behavior, and Theoretical Mediator Variables at Baseline by Intervention Condition*
ATTRITION

As shown in the Figure, there was little attrition. About 97.6% of the adolescents attended at least 1 follow-up: 94.3% attended the 3-month follow-up, 92.8% attended the 6-month, and 88.6% attended the 12-month follow-ups. The intervention conditions did not differ significantly in the percentage of adolescent participants who attended at least 1 follow-up, 2 follow-ups, or all 3 follow-ups.

Considering preintervention STD prevalence, sexual behavior, conceptual variables, evaluations of the interventions, and demographic variables, there were only 4 significant differences between returnees (ie, adolescents who attended a follow-up) and nonreturnees (ie, adolescents who failed to attend a follow-up). Nonreturnees reported more frequent intercourse while intoxicated (mean, 3.44 vs 0.40,P<.001) and more unprotected sexual intercourse while intoxicated than did returnees (mean, 0.94 vs 0.24, P<.001). Latinos compared with African Americans were less likely to return (95.9% vs 98.5%, P = .04). Adolescents who did not live with their mother were less likely to return than were those who lived with their mother (93.9% vs 98.7%, P = .001).

About 87.8% returned for the 6-month STD examination and 82.3% returned for the 12-month STD examination. The interventions did not differ significantly in the percentage of adolescents who returned for STD examinations.

UNPROTECTED SEXUAL INTERCOURSE

As given in Table 2, although the interventions did not differ significantly at the 3- or 6-month follow-up, the participants who received the skill-based intervention reported less frequent unprotected sexual intercourse at the 12-month follow-up than did those who received the health-promotion control intervention (d = 0.28; P = .002) or the information-based intervention (d = 0.19; P = .033).

Table Graphic Jump LocationTable 2. Self-reported Sexual Behavior in the Previous 3 Months and Clinically Documented STD Rate by Intervention Condition and at Baseline* and Follow-up Data-Collection Periods
OTHER SEXUAL RISK BEHAVIORS

The skill-based intervention also had significant effects on other sexual risk behaviors. At the 12-month follow-up, the adolescents who received the skill-based intervention reported fewer sexual partners than did the adolescents who received the health-promotion control intervention (d = 0.17; P = .04). Those who received the skill-based intervention were also less likely to report having multiple partners than were their counterparts who received the health-promotion control intervention (d = 0.25; P = .002). No differences in the reported number of sexual partners were observed at the 3- or 6-month follow-up. The skills-based intervention caused a significantly lower self-reported frequency of sexual intercourse while intoxicated compared with the health-promotion control (d = 0.18; P = .03) and information-based (d = 0.18; P = .03) interventions at the 3-month follow-up and compared with the health-promotion control intervention (d = 0.23; P = .005) at the 6-month follow-up. No differences were observed at the 12-month follow-up. In addition, although no difference was observed at the 3- or 6-month follow-up, the skill-based intervention caused less frequent reports of unprotected sexual intercourse while intoxicated at the 12-month follow-up than did the health-promotion control intervention (d = 0.20; P = .02).

STD RATE

The skills intervention did not reduce the STD rate at the 6-month follow-up. However, at the 12-month follow-up, adolescents who received the skill-based intervention were significantly (d = 0.18; P = .05) less likely to have an STD (10.5%) than were those in the health-promotion control intervention (18.2%). There were no significant differences between the information-based intervention and the other 2 interventions at either of the follow-ups where STD data were collected.

CONCEPTUAL MEDIATOR VARIABLES

The HIV/STD risk-reduction interventions also had significant effects on the conceptual mediator variables. As given in Table 3, adolescents who received the skill-based intervention scored higher in postintervention HIV/STD knowledge (d = 0.62; P<.001), condom use knowledge (d = 0.59; P<.001), intentions (d = 0.21; P = .008), hedonistic beliefs (d = 0.28; P <.001), sexual partner approval (d = 0.20; P = .009), technical skills beliefs (d = 0.20; P = .01), and impulse control beliefs (d = 0.19; P = .02) than did those who received the health-promotion control intervention. In addition, the skill-based intervention caused significantly greater increases in condom use knowledge than did the information-based intervention (d = 0.30; P<.001). No other differences on conceptual mediator variables between the skill- and information-based interventions were statistically significant.

Table Graphic Jump LocationTable 3. Adjusted* Postintervention Means (SEs) on Conceptual Variables by Intervention Condition

Information-based intervention participants scored higher in HIV/STD knowledge (d = 0.72; P<.001), condom use knowledge (d = 0.30; P<.001), intentions (d = 0.29; P<.001), hedonistic beliefs (d = 0.31; P<.001), technical skills beliefs (d = 0.15; P = .049), and impulse control (d = 0.19; P = .02) than did health-promotion control intervention participants.

EVALUATIONS OF THE INTERVENTIONS

Participants gave high ratings of how much they liked their intervention, how much they learned, and the extent to which they would recommend it to others (means for all 3 intervention groups were >4.5 on 5-point scales). Information-based intervention participants (mean [SE], 4.67 [0.04]) gave higher liking ratings than did the health-promotion control intervention participants (mean [SE], 4.46 [0.04]; P<.001) or the skill-based intervention participants (mean [SE], 4.55 [0.04]; P = .01). Information-based intervention participants (mean [SE], 4.75 [0.04]) also gave higher learning ratings than did the health-promotion control intervention participants (mean [SE], 4.61 [0.04]; P = .008). No other differences were significant.

DIFFERENTIAL EFFICACY AMONG AFRICAN AMERICANS AND LATINOS?

Analyses testing whether the efficacy of the interventions was different with African Americans and Latinos revealed no significant differences on the STD rates, sexual risk behavior, or evaluations of the interventions. However, the skill-based intervention was significantly more effective with Latinos than with African Americans in increasing condom negotiation beliefs (P = .02) and technical skill beliefs (P = .02) compared with the health-promotion control intervention, and with condom negotiation beliefs (P = .05) compared with the information-based intervention. In addition, the information-based intervention was more effective with Latinos than with African Americans in increasing hedonistic beliefs (P = .007) compared with the health-promotion control intervention, and in increasing HIV/STD knowledge (P = .02) compared with the skill-based intervention.

SOCIAL DESIRABILITY RESPONSE BIAS

Hierarchical multiple regression analyses revealed that social desirability scores did not interact with intervention condition to influence sexual behavior at any of the follow-ups. Analyses on the subsample of adolescents in the 2 HIV/STD interventions also revealed that social desirability scores were unrelated to self-reported sexual behavior at the follow-ups.

The results of this study suggest that behavioral interventions, particularly those that focus on skills training, may be helpful in reducing unprotected intercourse and STD rate among adolescent girls. This is particularly important for African American and Latino adolescents, whose rate of STDs is considerably higher than the rate among other adolescents. The skills intervention also reduced self-reports of multiple of sexual partners at the 12-month follow-up compared with the health-promotion control intervention. Both unprotected intercourse and multiple sexual partners are important risk factors for STD.

Several randomized controlled trials have demonstrated that behavioral interventions can reduce adolescents’ sexual risk behavior.2830 However, an important feature of the present trial was the use of biologically confirmed measures of STD rate. Although other trials have shown that interventions can reduce the STD rate among adults,31,32 this is one of the first randomized controlled trials of an intervention for adolescents to report reductions in biologically confirmed STD rates. Thus, this study shows that HIV/STD interventions for adolescents can, indeed, influence a health outcome, not only self-reported behavior.

Many writers have raised concern about the potentially adverse influence of alcohol and drug use in increasing sexual risk behavior.33,34 This concern is not allayed by data from the 6 Centers for Disease Control and Prevention’s Youth Risk Behavior surveys during 1991-2001 documenting increases over time in adolescents’ reports of alcohol and drug use in conjunction with sexual intercourse.35 Despite the concern, no previous trials have demonstrated intervention-induced reductions in alcohol and drug use during sex. In the present study, the skill-based intervention, compared with the health-promotion control intervention, significantly reduced the reported use of alcohol and drugs during sexual activity. This raises the hope that skill-based interventions can influence sexual behavior under high-risk circumstances characterized by cues that prompt failure to use condoms.

Although other sexual risk reduction studies36,37 have contrasted skills interventions with information interventions, this study differs from many of those in an important respect. Both the skill-based intervention and the information-based intervention covered not just facts about HIV but also attitudes and beliefs regarding using condoms. The critical between-intervention difference was that the skill-based intervention focused on skills, whereas the information-based intervention did not. Thus, the present study provides some of the strongest evidence that enhancing skills should be a critical goal for interventions designed to reduce risk sexual behavior. The present results may mean that although it is necessary for interventions to cover factual information and relevant beliefs and attitudes, such a limited focus is insufficient. Interventions must also develop skills. Methods for enhancing condom use skills include handling condoms, practicing putting condoms on anatomical models, and role-playing realistic situations that involve pressure to have unprotected intercourse. The implementation of such activities with adolescents may be controversial in certain settings, yet, the present results suggest that they hold the promise of reductions in sexual risk behavior.

In the present study, the effects of the intervention were significant primarily at 12-month follow-up, not at the shorter-term follow-ups. Such a delayed effect has been observed in other prevention trials.38,39 One possible explanation for why the magnitude of intervention effects might increase at later follow-ups is that people have difficulty introducing safer-sex practices into existing relationships.4042 As they become involved with new partners over time, they are able to implement those practices; hence, intervention effects on behavior are larger at longer-term follow-up.

An important issue for HIV/STD prevention research is the extent to which the same intervention can be effective with people who differ in key characteristics, including ethnicity. We know that interventions are apt to be more effective if they are tailored to the population. The trouble is sometimes it is impossible to separate people by ethnicity and provide them tailored interventions. Under such circumstances, can an intervention be effective? The present findings suggest that, at least with regard to inner-city African Americans and Latino (ie, Puerto Rican) adolescent girls, the answer may be yes. Despite the fact that some of the intervention activities had been originally designed for African Americans and African American facilitators implemented the activities, the interventions were not less effective in reducing sexual risk behavior or STD rates with Latinos than with African Americans, and Latinos and African Americans gave equally positive evaluations of the interventions. Accordingly, it cannot be assumed that an intervention developed for one ethnic group will be ineffective with another group.

The limitations of the present study should be considered. The self-report measures are a limitation. The participants were African American and Latino, chiefly Puerto Rican, adolescent girls; hence, we do not know whether similar findings would be obtained with adolescent boys or with adolescents from other Latino backgrounds. It is possible that the participants in the HIV/STD interventions, compared with the controls, were less likely to return for STD testing because they felt more ashamed for having unprotected intercourse despite receiving an intervention. However, we believe this is an unlikely explanation for our STD findings. The participants were patients attending family planning services in an adolescent medicine clinic that was their primary family-planning provider. The clinic offered a 24-hour on-call system with confidential and free services. The clinicians who performed the STD examinations were blind to the participants' intervention. Moreover, the return rates for STD testing were high and did not vary by intervention assignment.

The present study also includes particular strengths. It was a randomized controlled trial. It used a single-session intervention, which ensured that all participants attended the entire intervention. Attrition was low, and it did not differ by condition. Both self-report and biologically confirmed outcomes were collected. The significant effects of the interventions cannot be explained as a simple result of special attention the participants in the HIV/STD interventions received because the HIV/STD and control interventions were matched in length and involved similar kinds of activities. Moreover, participants' evaluations of their experiences were similar across the interventions.

The findings from this study are consistent with a growing body of evidence that interventions that are based on a solid theoretical framework and formative research with members of the study population and that provide practice in risk-reduction skills are effective in reducing HIV/STD risk behavior and STD rates. A notable feature of the present results was that they were produced by a single-session intervention of only 250 minutes. This suggests that it is possible to effect significant long-term changes in sexual behavior among adolescent girls—over 12 months in the present study—without great expenditure of time and effort. Future research must explore the generalizability of the present results. Methodologically rigorous studies20 hold considerable promise in the development of effective, evidence-based strategies for reducing sexual risk behavior—and the adverse consequences of such behavior.

Since this article has been accepted for publication, we have become aware of another randomized controlled trial of an HIV prevention intervention for adolescent girls.43 The results of both trials support the view that theory-based interventions can reduce self-reported sexual risk behavior, theoretical mediators of such behavior, and biologically confirmed STDs. Unlike the present trial, which focused on both African American and Latino adolescent girls, the other trial focused exclusively on African American adolescent girls.

Correspondence: John B. Jemmott III, PhD, University of Pennsylvania, Annenberg School for Communication, Center for Health Behavior and Communication Research, 3535 Market St, Suite 520, Philadelphia, PA 19104-3309 (jjemmott@asc.upenn.edu).

Accepted for Publication: July 20, 2004.

Funding/Support: This study was supported by grant R01 MH45668 from the National Institute of Mental Health, Bethesda, Md, and a grant from the Social Science and Humanities Research Council of Canada, Ottawa, Ontario.

Acknowledgment: We gratefully acknowledge the contributions to this research of Konstance McCaffree, PhD; Stephanie Bray; Daria Boccher-Lattimore, MPH; Carla Cooke-Harris, EdM; Barbara Siebert, CRNP; Laura Fuchs-Moore, CRNP; Hsiao-Wei Chan, SM; Kimberly Mack, MSW; Tatiana Perrino, PhD; Melissa Chido; Hannah Barksdale; Tami Williscroft; Candace I. Hacker; Tara Elton; Amanda Hogan; Vanessa Stankiewicz; and Anna Magolon. We also express our appreciation to Dana Fry, PhD, and Antonia M. Villarruel, PhD, RN, FAAN, for their comments on an earlier version of the manuscript.

Cates  W  Jr Estimates of the incidence and prevalence of sexually transmitted diseases in the United States: American Social Health Association Panel. Sex Transm Dis 1999;26 ((suppl 4)) S2- S7
PubMed
Centers for Disease Control and Prevention, Sexually Transmitted Diseases Survey, 2000.  Atlanta, Ga US Dept of Health and Human Services, Centers for Disease Control and Prevention September2001;
Westrom  LEschenbach  D Pelvic inflammatory disease. Holmes  KKSparling  PFMardh  P-Aeds.Sexually Transmitted Diseases 3rd ed. New York, NY McGraw-Hill Co1999;791
Centers for Disease Control and Prevention, HIV/AIDS Surveillance Report.  Atlanta, Ga Division of HIV/AIDS Prevention2001;131- 41
Centers for Disease Control and Prevention, Youth risk behavior surveillance—United States, 1999. MMWR Morb Mortal Wkly Rep 2000;49 ((No. SS-5)) 1- 96
Braverman  PK Sexually transmitted diseases in adolescents. Med Clin North Am 2000;84869- 889
PubMed
Berman  SMHein  K Adolescents and STDs. Holmes  KKSparling  PMardh  P-A  et al. eds.Sexually Transmitted Diseases. 3rd ed. New York, NY McGraw-Hill Co1999;129- 142
Braverman  PKSchwarz  DFDeforest  A  et al.  Use of ligase chain reaction for laboratory identification of Chlamydia trachomatis and Neisseria gonorrhoeae in adolescent women. J Pediatr Adolesc Gynecol 2002;1537- 41
PubMed
Jemmott  JB  IIIJemmott  LS HIV risk reduction behavioral interventions with heterosexual adolescents. AIDS 2000;14 ((suppl 2)) S40- S52
PubMed
Kim  NStanton  BLi  XDickersin  KGalbraith  J Effectiveness of the 40 adolescent AIDS risk-reduction interventions: a quantitative review. J Adolesc Health 1997;20204- 215
PubMed
DiClemente  RJWingood  GMSionean  C  et al.  Association of adolescents' history of sexually transmitted disease (STD) and their current high-risk behavior and STD status: a case for intensifying clinic-based prevention efforts. Sex Transm Dis 2002;29503- 509
PubMed
Orr  DPLangefeld  CDKatz  BPCaine  VA Behavioral intervention to increase condom use among high-risk female adolescents. J Pediatr 1996;128288- 295
PubMed
Shrier  LAAncheta  RGoodman  EChiou  VMLyden  MREmans  SJ Randomized controlled trial of a safer sex intervention for high-risk adolescent girls. Arch Pediatr Adolesc Med 2001;15573- 79
PubMed
Bandura  A Social Foundations of Thought and Action: A Social Cognitive Theory.  Englewood Cliffs, NJ Prentice-Hall International Inc1986;
Bandura  A Social cognitive theory and exercise of control over HIV infection. DiClemente  RPeterson  Jeds.Preventing Aids: Theories and Methods of Behavioral Interventions New York, NY Plenum Publishing Corp1994;25- 60
Ajzen  IFishbein  M Understanding Attitudes and Predicting Social Behavior.  Englewood Cliffs, NJ Prentice-Hall International Inc1980;
Fishbein  MAjzen  I Belief, Attitude, Intention and Behavior.  New York, NY Addison-Wesley Longman Inc1975;
Ajzen  I The theory of planned behavior. Organ Behav Hum Decis Process 1991;50179- 211
Jemmott  JB  IIIJemmott  LSFong  GT Reductions in HIV risk-associated sexual behaviors among black male adolescents: effects of an AIDS prevention intervention. Am J Public Health 1992;82372- 377
PubMed
Jemmott  JB  IIIJemmott  LSFong  GT Abstinence and safer sex HIV risk-reduction interventions for African American adolescents: a randomized controlled trial. JAMA 1998;2791529- 1536
PubMed
Jemmott  JB  IIIJemmott  LSFong  GTMcCaffree  K Reducing HIV risk-associated sexual behavior among African American adolescents: testing the generality of intervention effects. Am J Community Psychol 1999;27161- 187
PubMed
Jemmott  LSJemmott  JB  IIIMcCaffree  K Be Proud! Be Responsible! Strategies to Empower Youth to Reduce Their Risk for AIDS.  New York, NY Select Media Publications1995;
Jemmott  JB  IIIJemmott  LSSpears  HHewitt  NCruz-Collins  M Self-efficacy, hedonistic expectancies, and condom-use intentions among inner-city black adolescent women: a social cognitive approach to AIDS risk behavior. J Adolesc Health 1992;13512- 519
PubMed
Cook  TDCampbell  DT Quasi-Experimentation: Design and Analysis Issues for Field Settings.  Chicago, Ill Rand McNally & Co1979;
Sudman  SBradburn  NM Response Effects in Surveys.  Chicago, Ill Aldine Press1974;
Crowne  DMarlowe  D The Approval Motive.  New York, NY John Wiley & Sons Inc1964;
Rosenthal  RRosnow  RL Contrast Analysis: Focused Comparisons in the Analysis of Variance.  New York, NY Cambridge University Press1985;
Rotheram-Borus  MJGwadz  MFernandez  MISrinivasan  S Timing of HIV interventions on reductions in sexual risk among adolescents. Am J Community Psychol 1998;2673- 96
PubMed
St Lawrence  JSCrosby  RABrasfield  TLO'Bannon  RE  III Reducing STD and HIV risk behavior of substance-dependent adolescents: a randomized controlled trial. J Consult Clin Psychol 2002;701010- 1021
PubMed
Stanton  BLi  XRicardo  IGalbraith  JFeigelman  SKaljee  L A randomized, controlled effectiveness trial of an AIDS prevention program for low-income African American youths. Arch Pediatr Adolesc Med 1996;150363- 372
PubMed
Shain  RNPiper  JMNewton  ER  et al.  A randomized, controlled trial of a behavioral intervention to prevent sexually transmitted disease among minority women. N Engl J Med 1999;34093- 100
PubMed
Kamb  MLFishbein  MDouglas  JM  et al. Project RESPECT Study Group, Efficacy of risk-reduction counseling to prevent human immunodeficiency virus and sexually transmitted diseases: a randomized controlled trial. JAMA 1998;2801161- 1167
PubMed
MacDonald  TKMacDonald  GZanna  MPFong  GT Alcohol, sexual arousal, and intentions to use condoms in young men: applying alcohol myopia theory to risky sexual behavior. Health Psychol 2000;19290- 298
PubMed
Leigh  BC Alcohol and condom use: a meta-analysis of event-level studies. Sex Transm Dis 2002;29476- 482
PubMed
Centers for Disease Control and Prevention, Trends in sexual risk behaviors among high school students—United States, 1991-2001. MMWR Morb Mortal Wkly Rep 2002;51856- 859
PubMed
St Lawrence  JSBrasfield  TLJefferson  KWAlleyne  EO'Bannon  RE  IIIShirley  A Cognitive-behavioral intervention to reduce African American adolescents' risk for HIV infection. J Consult Clin Psychol 1995;63221- 237
PubMed
Kalichman  SCRompa  DColey  B Experimental component analysis of a behavioral HIV-AIDS prevention intervention for inner-city women. J Consult Clin Psychol 1996;64687- 693
PubMed
Kirby  DBarth  RPLeland  NFetro  JV Reducing the risk: impact of a new curriculum on sexual risk-taking. Fam Plann Perspect 1991;23253- 263
PubMed
Johnson  WDHedges  LVRamirez  G  et al.  HIV prevention research for men who have sex with men: a systematic review and meta-analysis. J Acquir Immune Defic Syndr 2002;30 ((suppl 1)) S118- S129
PubMed
Morrill  ACIckovics  JRGolubchikov  VVBeren  SERodin  J Safer sex: social and psychological predictors of behavioral maintenance and change among heterosexual women. J Consult Clin Psychol 1996;64819- 828
PubMed
Sanderson  CAJemmott  JB  III Moderation and mediation of HIV prevention interventions: relationship status, intentions, and condom use among college students. J Appl Soc Psychol 1996;262076- 2099
St Lawrence  JSWilson  TEEldridge  GDBrasfield  TLO'Bannon  RE  III Community-based interventions to reduce low income, African American women's risk of sexually transmitted diseases: a randomized controlled trial of three theoretical models. Am J Community Psychol 2001;29937- 964
PubMed
DiClemente  RJWingood  GMHarrington  KF  et al.  Efficacy of an HIV prevention intervention for African American adolescent girls: a randomized controlled trial. JAMA 2004;292171- 179
PubMed

Figures

Place holder to copy figure label and caption
Figure.

Progress of participants through the trial. Those not randomized failed to appear for unknown reasons.

Graphic Jump Location

Tables

Table Graphic Jump LocationTable 1. Demographic Characteristics, STD Test Results, Self-reported Sexual Behavior, and Theoretical Mediator Variables at Baseline by Intervention Condition*
Table Graphic Jump LocationTable 2. Self-reported Sexual Behavior in the Previous 3 Months and Clinically Documented STD Rate by Intervention Condition and at Baseline* and Follow-up Data-Collection Periods
Table Graphic Jump LocationTable 3. Adjusted* Postintervention Means (SEs) on Conceptual Variables by Intervention Condition

References

Cates  W  Jr Estimates of the incidence and prevalence of sexually transmitted diseases in the United States: American Social Health Association Panel. Sex Transm Dis 1999;26 ((suppl 4)) S2- S7
PubMed
Centers for Disease Control and Prevention, Sexually Transmitted Diseases Survey, 2000.  Atlanta, Ga US Dept of Health and Human Services, Centers for Disease Control and Prevention September2001;
Westrom  LEschenbach  D Pelvic inflammatory disease. Holmes  KKSparling  PFMardh  P-Aeds.Sexually Transmitted Diseases 3rd ed. New York, NY McGraw-Hill Co1999;791
Centers for Disease Control and Prevention, HIV/AIDS Surveillance Report.  Atlanta, Ga Division of HIV/AIDS Prevention2001;131- 41
Centers for Disease Control and Prevention, Youth risk behavior surveillance—United States, 1999. MMWR Morb Mortal Wkly Rep 2000;49 ((No. SS-5)) 1- 96
Braverman  PK Sexually transmitted diseases in adolescents. Med Clin North Am 2000;84869- 889
PubMed
Berman  SMHein  K Adolescents and STDs. Holmes  KKSparling  PMardh  P-A  et al. eds.Sexually Transmitted Diseases. 3rd ed. New York, NY McGraw-Hill Co1999;129- 142
Braverman  PKSchwarz  DFDeforest  A  et al.  Use of ligase chain reaction for laboratory identification of Chlamydia trachomatis and Neisseria gonorrhoeae in adolescent women. J Pediatr Adolesc Gynecol 2002;1537- 41
PubMed
Jemmott  JB  IIIJemmott  LS HIV risk reduction behavioral interventions with heterosexual adolescents. AIDS 2000;14 ((suppl 2)) S40- S52
PubMed
Kim  NStanton  BLi  XDickersin  KGalbraith  J Effectiveness of the 40 adolescent AIDS risk-reduction interventions: a quantitative review. J Adolesc Health 1997;20204- 215
PubMed
DiClemente  RJWingood  GMSionean  C  et al.  Association of adolescents' history of sexually transmitted disease (STD) and their current high-risk behavior and STD status: a case for intensifying clinic-based prevention efforts. Sex Transm Dis 2002;29503- 509
PubMed
Orr  DPLangefeld  CDKatz  BPCaine  VA Behavioral intervention to increase condom use among high-risk female adolescents. J Pediatr 1996;128288- 295
PubMed
Shrier  LAAncheta  RGoodman  EChiou  VMLyden  MREmans  SJ Randomized controlled trial of a safer sex intervention for high-risk adolescent girls. Arch Pediatr Adolesc Med 2001;15573- 79
PubMed
Bandura  A Social Foundations of Thought and Action: A Social Cognitive Theory.  Englewood Cliffs, NJ Prentice-Hall International Inc1986;
Bandura  A Social cognitive theory and exercise of control over HIV infection. DiClemente  RPeterson  Jeds.Preventing Aids: Theories and Methods of Behavioral Interventions New York, NY Plenum Publishing Corp1994;25- 60
Ajzen  IFishbein  M Understanding Attitudes and Predicting Social Behavior.  Englewood Cliffs, NJ Prentice-Hall International Inc1980;
Fishbein  MAjzen  I Belief, Attitude, Intention and Behavior.  New York, NY Addison-Wesley Longman Inc1975;
Ajzen  I The theory of planned behavior. Organ Behav Hum Decis Process 1991;50179- 211
Jemmott  JB  IIIJemmott  LSFong  GT Reductions in HIV risk-associated sexual behaviors among black male adolescents: effects of an AIDS prevention intervention. Am J Public Health 1992;82372- 377
PubMed
Jemmott  JB  IIIJemmott  LSFong  GT Abstinence and safer sex HIV risk-reduction interventions for African American adolescents: a randomized controlled trial. JAMA 1998;2791529- 1536
PubMed
Jemmott  JB  IIIJemmott  LSFong  GTMcCaffree  K Reducing HIV risk-associated sexual behavior among African American adolescents: testing the generality of intervention effects. Am J Community Psychol 1999;27161- 187
PubMed
Jemmott  LSJemmott  JB  IIIMcCaffree  K Be Proud! Be Responsible! Strategies to Empower Youth to Reduce Their Risk for AIDS.  New York, NY Select Media Publications1995;
Jemmott  JB  IIIJemmott  LSSpears  HHewitt  NCruz-Collins  M Self-efficacy, hedonistic expectancies, and condom-use intentions among inner-city black adolescent women: a social cognitive approach to AIDS risk behavior. J Adolesc Health 1992;13512- 519
PubMed
Cook  TDCampbell  DT Quasi-Experimentation: Design and Analysis Issues for Field Settings.  Chicago, Ill Rand McNally & Co1979;
Sudman  SBradburn  NM Response Effects in Surveys.  Chicago, Ill Aldine Press1974;
Crowne  DMarlowe  D The Approval Motive.  New York, NY John Wiley & Sons Inc1964;
Rosenthal  RRosnow  RL Contrast Analysis: Focused Comparisons in the Analysis of Variance.  New York, NY Cambridge University Press1985;
Rotheram-Borus  MJGwadz  MFernandez  MISrinivasan  S Timing of HIV interventions on reductions in sexual risk among adolescents. Am J Community Psychol 1998;2673- 96
PubMed
St Lawrence  JSCrosby  RABrasfield  TLO'Bannon  RE  III Reducing STD and HIV risk behavior of substance-dependent adolescents: a randomized controlled trial. J Consult Clin Psychol 2002;701010- 1021
PubMed
Stanton  BLi  XRicardo  IGalbraith  JFeigelman  SKaljee  L A randomized, controlled effectiveness trial of an AIDS prevention program for low-income African American youths. Arch Pediatr Adolesc Med 1996;150363- 372
PubMed
Shain  RNPiper  JMNewton  ER  et al.  A randomized, controlled trial of a behavioral intervention to prevent sexually transmitted disease among minority women. N Engl J Med 1999;34093- 100
PubMed
Kamb  MLFishbein  MDouglas  JM  et al. Project RESPECT Study Group, Efficacy of risk-reduction counseling to prevent human immunodeficiency virus and sexually transmitted diseases: a randomized controlled trial. JAMA 1998;2801161- 1167
PubMed
MacDonald  TKMacDonald  GZanna  MPFong  GT Alcohol, sexual arousal, and intentions to use condoms in young men: applying alcohol myopia theory to risky sexual behavior. Health Psychol 2000;19290- 298
PubMed
Leigh  BC Alcohol and condom use: a meta-analysis of event-level studies. Sex Transm Dis 2002;29476- 482
PubMed
Centers for Disease Control and Prevention, Trends in sexual risk behaviors among high school students—United States, 1991-2001. MMWR Morb Mortal Wkly Rep 2002;51856- 859
PubMed
St Lawrence  JSBrasfield  TLJefferson  KWAlleyne  EO'Bannon  RE  IIIShirley  A Cognitive-behavioral intervention to reduce African American adolescents' risk for HIV infection. J Consult Clin Psychol 1995;63221- 237
PubMed
Kalichman  SCRompa  DColey  B Experimental component analysis of a behavioral HIV-AIDS prevention intervention for inner-city women. J Consult Clin Psychol 1996;64687- 693
PubMed
Kirby  DBarth  RPLeland  NFetro  JV Reducing the risk: impact of a new curriculum on sexual risk-taking. Fam Plann Perspect 1991;23253- 263
PubMed
Johnson  WDHedges  LVRamirez  G  et al.  HIV prevention research for men who have sex with men: a systematic review and meta-analysis. J Acquir Immune Defic Syndr 2002;30 ((suppl 1)) S118- S129
PubMed
Morrill  ACIckovics  JRGolubchikov  VVBeren  SERodin  J Safer sex: social and psychological predictors of behavioral maintenance and change among heterosexual women. J Consult Clin Psychol 1996;64819- 828
PubMed
Sanderson  CAJemmott  JB  III Moderation and mediation of HIV prevention interventions: relationship status, intentions, and condom use among college students. J Appl Soc Psychol 1996;262076- 2099
St Lawrence  JSWilson  TEEldridge  GDBrasfield  TLO'Bannon  RE  III Community-based interventions to reduce low income, African American women's risk of sexually transmitted diseases: a randomized controlled trial of three theoretical models. Am J Community Psychol 2001;29937- 964
PubMed
DiClemente  RJWingood  GMHarrington  KF  et al.  Efficacy of an HIV prevention intervention for African American adolescent girls: a randomized controlled trial. JAMA 2004;292171- 179
PubMed

Correspondence

CME
Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).
Submit a Comment

Multimedia

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.