Lynette Deveaux

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

OBJECTIVES. The purpose of this work was to report the intervention effects of Focus on Youth in the Caribbean (youth HIV intervention), an HIV prevention intervention based on protection motivation theory, through 24 months of follow-up on sexual risk and protection knowledge, perceptions, intentions, and behavior among Bahamian sixth-grade youth. METHODS. We randomly assigned 1360 sixth-grade youth (and their parents) attending 15 government elementary schools in the Bahamas to 1 of 3 conditions: (1) youth HIV intervention plus a parental monitoring/communication/HIV education intervention; (2) youth HIV intervention plus a parental goal-setting intervention; or (3) an environmental protection intervention plus the parental goal-setting intervention. Baseline and 4 follow-up surveys at 6-month intervals were conducted. Intervention effects were assessed using the mixed model for continuous outcome variables and the generalized linear mixed model for dichotomous outcome variables. RESULTS. Through 24 months of follow-up, youth HIV intervention, in combination with the parent interventions, significantly increased youths’ HIV/AIDS knowledge, perceptions of their ability to use condoms, perception of the effectiveness of condoms and abstinence, and condom use intention and significantly lowered perceived costs to remaining abstinent. There was a trend for higher condom use among youth in the Focus on Youth in the Caribbean groups at each follow-up interval. CONCLUSIONS. Focus on Youth in the Caribbean, in combination with 1 of 2 parent interventions administered to preadolescents and their parents in the Bahamas, resulted in and sustained protective changes on HIV/AIDS knowledge, sexual perceptions, and condom use intention. Although rates of sexual experience remained low, the consistent trend at all of the follow-up periods for higher condom use among youth who received youth intervention reached marginal significance at 24 months. Additional follow-up is necessary to determine whether the apparent protective effect is statistically significant as more youth initiate sex and whether it endures over time.

Effects on condom use of an HIV prevention programme 36 months postintervention: a cluster randomized controlled trial among Bahamian youth

Data are lacking on long-term effects of HIV behavioural intervention programmes. In this study, we report intervention effects 36 months postintervention on condom use and relevant outcome variables from the theory-based programme ‘Focus on Youth in the Caribbean’ (FOYC). Participants (1360 sixth-grade youth) were randomized by school into: (1) FOYC, plus one of two brief parent interventions or (2) the control condition ‘Wondrous Wetlands’, plus a brief parent intervention. Mixed effect analysis demonstrated significant programme effects, including enhanced HIV/AIDS knowledge (effect size D = 0.44, 95% confidence interval [CI]: 0.43, 0.46), increased self-efficacy of (D = 0.42, 95% CI: 0.30, 0.54), skills for (D = 0.62, 95% CI: 0.56, 0.64) and intention to use a condom (D = 0.20, 95% CI: 0.03, 0.37). Youth who received FOYC plus the parental monitoring intervention had higher condom use rates (odds ratio = 1.49, 95% CI: 0.97, 2.28). Feedback effects from key variables were also detected, supporting the sustained effect.

Effect of a Grade 6 HIV Risk Reduction Intervention Four Years Later Among Students Who Were and Were Not Enrolled in the Study Trial

PURPOSE To assess the long-term impact of HIV-prevention interventions delivered to youth before sexual initiation and the effects of interventions delivered in nonstudy settings. METHODS A five-group comparison of HIV knowledge, and condom-use skills, self-efficacy, intentions, and practice among 1,997 grade 10 students attending one of the eight government high schools in Nassau, The Bahamas. Group 1 received an HIV-prevention intervention, Focus on Youth in the Caribbean (FOYC), in grade 6 as part of a randomized trial; group 2 received FOYC as part of the regular school curriculum but outside of the trial; group 3 received the control condition as part of the trial; group 4 received the control condition as part of the school curriculum but outside of the trial; and individuals in group 5 (naive controls) were not enrolled in a school receiving FOYC or the control conditon and did not participate in the trial. RESULTS FOYC youth compared with the control youth and naive controls had higher HIV knowledge, condom-use skills, and self-efficacy 4 years later. By subgroups, group 1 demonstrated higher HIV/AIDS knowledge than all groups except group 2, higher condom skills than all groups, and higher condom self-efficacy than Naive Controls. Youth in group 2 demonstrated higher HIV knowledge than youth in groups 3-5. Behavioral effects were not found. CONCLUSIONS FOYC delivered to grade 6 students continued to have protective effects 4 years later. Positive effects are present among youth who received FOYC as part of the school curriculum but were not enrolled in the trial.

tHe iMPAct Of PArent inVOlVeMent in An effectiVe ADOleScent riSK reDUctiOn interVentiOn On SeXUAl riSK cOMMUnicAtiOn AnD ADOleScent OUtcOMeS

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

Developmental Implications of HIV Prevention During Adolescence Examination of the Long-Term Impact of HIV Prevention Interventions Delivered in Randomized Controlled Trials in Grade Six and in Grade 10

Dramatic changes occur in abstract reasoning, physical maturation, familial relationships and risk exposure during adolescence. It is probable that delivery of behavioral interventions addressing decision-making during the preadolescent period and later in adolescence would result in different impacts. We evaluated the intervention effects of an HIV prevention program (Bahamian Focus on Older Youth, BFOOY) administered to grade 10 Bahamian youth and parents to target HIV protective and risk behaviors. We also examined the effects of prior exposure to a similar intervention (Focus on Youth in the Caribbean, FOYC) four years earlier. At six months post-intervention, receipt of BFOOY by youth unexposed to FOYC increased HIV knowledge and condom-use skills. Differences based on BFOOY exposure were not present among FOYC-exposed youth, whose knowledge and condom-use skills were already higher than those of unexposed youth. Youth receiving both interventions displayed a carryover effect from FOYC, demonstrating the highest scores six months post-intervention.

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

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

At greatest risk: pre- and early adolescent Bahamian youth experiencing anal intercourse

Although anal intercourse carries great risk for HIV transmission, little research has focused on it among the general population, particularly pre- and early adolescents. This study describes the prevalence of anal and vaginal intercourse among Bahamian pre- and early adolescents and associations with other risk behaviours, family interactions and intrapersonal correlates. Data were from 1274 sixth-grade students aged 9–14 years who completed self-administered questionnaires at baseline of a larger school-based behavioural intervention study. Youth who reported having had anal intercourse engaged in significantly higher rates of several risk behaviours and were significantly more likely to engage in risk behaviours over the next six months, compared with youth with a history of vaginal intercourse only, who in turn were more likely than virgin adolescents. Youth indulging in anal intercourse also perceived significantly lower levels of parental monitoring. Multivariate analyses revealed that anal intercourse, vaginal intercourse, reduced parental monitoring, depression and perceived friend high-risk involvement were associated with both past involvement and future intention to engage in other risk behaviours. Anal intercourse poses a direct threat to the health of these children and is a flag for a constellation of other risks.

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

BackgroundTeachers’ implementation of evidence-based prevention programs in schools is inconsistent. Using data gathered from the national implementation among grade six students in The Bahamas of an evidence-based HIV intervention [Focus on Youth in the Caribbean (FOYC)], this study examines differences in the degree of implementation (“dose”) and adherence to the core activities (“fidelity of implementation”) by teachers according to theoretically and historically relevant teachers’ characteristics, attitudes, and experiences pre-intervention and post-intervention. The relationship of implementation dose and implementation fidelity is assessed according to student outcomes.MethodsBeginning in 2008, the Bahamian Ministry of Education (MOE) included FOYC in the grade six curriculum nationwide. Consistent with standard practice, teachers were offered MOE training workshops in FOYC prior to delivery. The MOE conducted an anonymous curricular assessment among the grade six students at the beginning and end of the school year. Teachers agreeing to participate in the research component were asked to complete a pre-implementation and post-implementation assessment of attitudes and prior experiences.ResultsTeachers taught 15.6 out of 30 core activities, 24 out of the 46 total activities, and 4.6 out of 8 sessions on average. Three teachers’ implementation groups were identified: 1) High Implementation Group (31.7% of the teachers), characterized by high levels of implementation dose and fidelity of implementation; 2) Moderate Implementation Group (52.8%), showing moderate levels of implementation dose but high levels of fidelity of implementation; and 3) Low Implementation Group (15.6%), with low levels of implementation dose and fidelity of implementation. Low Implementation Group teachers compared to teachers in the two higher performing groups had less training in interactive teaching, limited prior exposure to the FOYC curriculum, incomplete attendance at FOYC training workshops, and low levels of comfort in teaching FOYC lessons. Students taught by teachers in the Low Implementation Group demonstrated poorer outcomes relevant to the four student outcomes (HIV/AIDS knowledge, preventive reproductive health skills, self-efficacy, and intention to use protection if they were to have sex).ConclusionsBoth implementation dose and implementation fidelity are related to student outcomes. Teachers at risk for limited implementation can be identified pre-intervention, thus opening the possibility for focused pre-intervention training.

Focus on Youth in the Caribbean Beyond the Numbers

In the 1990s, an interdisciplinary group including pediatricians, anthropologists, health educators, psychologists, and statisticians developed and evaluated an HIV prevention intervention targeting early adolescents living in public housing developments in the USA. The intervention, “Focus on Kids,” (FOK) was effective in reducing risk behaviors, intentions, and perceptions and ultimately was included in the Center for Disease Controls portfolio of effective adolescent programs, “Programs that Work.” Learning about FOK and concerned about the need for a structured program to address high rates of teen pregnancy and risk for HIV, professionals from the Ministries of Health of The Bahamas approached the researchers about collaborating to develop a program for Bahamian youth. A partnership developed which has spanned over a decade and led to the development of an intervention program targeting Bahamian children in grade six, a 10-session adolescent HIV prevention program entitled “Focus on Youth in the Caribbean” (FOYC). Two programs including a video and parent discussion were developed for their parents. Caribbean Informed Parents and Children Together (CImPACT) emphasizes the importance of parent-child communication about sexuality and “Goal for It” (GFI) emphasizes the importance of planning ahead. The US-Bahamian team evaluated these interventions through a randomized, controlled 3-celled longitudinal trial (36 months follow-up) involving 15 elementary schools in The Bahamas. The programs have been shown to be effective. This article describes the context in which the epidemic occurred, events leading up to the collaboration and the issues, decisions, processes, and relationships that we have developed that have allowed it to succeed.

Development of Condom-Use Self-Efficacy Over 36 Months Among Early Adolescents A Mediation Analysis

This research evaluates condom-use self-efficacy and its increase throughout adolescence. Documentation of the development of condom-use self-efficacy would be important for prevention efforts given the influence of self-efficacy on actual condom usage. This study assesses a hypothesized mediation mechanism of the development of self-efficacy using a mediation analysis approach. The participants, 497 Grade-6 Bahamian students, were randomly assigned to the control condition in a 3-year longitudinal HIV prevention program trial. Condom–use self-efficacy consistently increased and condom-use self-efficacy assessed at earlier periods was positively associated with its values at subsequent periods. Additionally, self-efficacy assessed between two time points 1 year apart or longer (e.g., 6 months between baseline and 12 months) significantly mediated the impact of its levels at the previous assessment on the level at the subsequent assessment. To sustain program effect, HIV prevention programs should strive to enhance self-efficacy and provide reinforcing “boosters” no later than 12 months postintervention.