Susan R. Tortolero

It's Your Game: Keep It Real: Delaying Sexual Behavior with an Effective Middle School Program

PURPOSE This study tested the effects of a theory-based, middle-school human immunodeficiency virus, STI, and pregnancy prevention program, Its Your Game: Keep it Real (IYG), in delaying sexual behavior. We hypothesized that the IYG intervention would decrease the number of adolescents who initiated sexual activity by the ninth grade compared with those in the comparison schools. METHODS The target population consisted of English-speaking middle school students from a large, urban, predominantly African-American and Hispanic school district in Southeast Texas. Ten middle schools were randomly assigned either to receive the intervention or to the comparison condition. Seventh-grade students were recruited and followed through ninth grade. The IYG intervention comprises 12 seventh-grade and 12 eighth-grade lessons that integrate group-based classroom activities with computer-based instruction and personal journaling. Ninth-grade follow-up surveys were completed by 907 students (92% of the defined cohort). The primary hypothesis tested was that the intervention would decrease the number of adolescents who initiated sexual activity by the ninth grade compared with those in the comparison schools. RESULTS Almost one-third (29.9%, n=509) of the students in the comparison condition initiated sex by ninth grade compared with almost one-quarter (23.4%, n=308) of those in the intervention condition. After adjusting for covariates, students in the comparison condition were 1.29 times more likely to initiate sex by the ninth grade than those in the intervention condition. CONCLUSIONS A theory-driven, multi-component, curriculum-based intervention can delay sexual initiation up to 24 months; can have impact on specific types of sexual behavior such as initiation of oral and anal sex; and may be especially effective with females. Future research must explore the generalizabilty of these results.

Perceived Racial/Ethnic Discrimination Among Fifth-Grade Students and Its Association With Mental Health

OBJECTIVES We sought to describe the prevalence, characteristics, and mental health problems of children who experience perceived racial/ethnic discrimination. METHODS We analyzed cross-sectional data from a study of 5147 fifth-grade students and their parents from public schools in 3 US metropolitan areas. We used multivariate logistic regression (overall and stratified by race/ethnicity) to examine the associations of sociodemographic factors and mental health problems with perceived racial/ethnic discrimination. RESULTS Fifteen percent of children reported perceived racial/ethnic discrimination, with 80% reporting that discrimination occurred at school. A greater percentage of Black (20%), Hispanic (15%), and other (16%) children reported perceived racial/ethnic discrimination compared with White (7%) children. Children who reported perceived racial/ethnic discrimination were more likely to have symptoms of each of the 4 mental health conditions included in the analysis: depression, attention deficit hyperactivity disorder, oppositional defiant disorder, and conduct disorder. An association between perceived racial/ethnic discrimination and depressive symptoms was found for Black, Hispanic, and other children but not for White children. CONCLUSIONS Perceived racial/ethnic discrimination is not an uncommon experience among fifth-grade students and may be associated with a variety of mental health disorders.

Racial and Ethnic Health Disparities among Fifth-Graders in Three Cities

BACKGROUND For many health-related behaviors and outcomes, racial and ethnic disparities among adolescents are well documented, but less is known about health-related disparities during preadolescence. METHODS We studied 5119 randomly selected public-school fifth-graders and their parents in three metropolitan areas in the United States. We examined differences among black, Latino, and white children on 16 measures, including witnessing of violence, peer victimization, perpetration of aggression, seat-belt use, bike-helmet use, substance use, discrimination, terrorism worries, vigorous exercise, obesity, and self-rated health status and psychological and physical quality of life. We tested potential mediators of racial and ethnic disparities (i.e., sociodemographic characteristics and the childs school) using partially adjusted models. RESULTS There were significant differences between black children and white children for all 16 measures and between Latino children and white children for 12 of 16 measures, although adjusted analyses reduced many of these disparities. For example, in unadjusted analysis, the rate of witnessing a threat or injury with a gun was higher among blacks (20%) and Latinos (11%) than among whites (5%), and the number of days per week on which the student performed vigorous exercise was lower among blacks (3.56 days) and Latinos (3.77 days) than among whites (4.33 days) (P<0.001 for all comparisons). After statistical adjustment, these differences were reduced by about half between blacks and whites and were eliminated between Latinos and whites. Household income, household highest education level, and the childs school were the most substantial mediators of racial and ethnic disparities. CONCLUSIONS We found that harmful health behaviors, experiences, and outcomes were more common among black children and Latino children than among white children. Adjustment for socioeconomic status and the childs school substantially reduced most of these differences. Interventions that address potentially detrimental consequences of low socioeconomic status and adverse school environments may help reduce racial and ethnic differences in child health. (Funded by the Centers for Disease Control and Prevention.).

Neighborhood characteristics favorable to outdoor physical activity: Disparities by socioeconomic and racial/ethnic composition

This paper uses a socioecological framework to investigate socioeconomic and racial/ethnic disparities in neighborhood characteristics that are associated with outdoor physical activity. We surveyed 632 parents of 5th graders about perceptions of their neighborhood social processes and collected systematic observations of the physical environment on their block-face of residence. Higher poverty neighborhoods and non-White neighborhoods have better accessibility; however, they are less safe, less comfortable, and less pleasurable for outdoor physical activity, and have less favorable social processes. Interventions to reduce disparities in physical activity should address not only the physical environment, but also social processes favorable to physical activity.

Cultural, social, and intrapersonal factors associated with substance use among alternative high school students

The purpose of this study was to identify cultural, social, and intrapersonal factors associated with tobacco, alcohol, and illicit drug use among students attending dropout prevention/recovery high schools. Four mutually exclusive categories of substance use were used as outcome measures, and religiosity, educational achievement, educational aspiration, family caring, others caring, self-esteem, optimism, coping, depression, loneliness, and self-efficacy were used as predictor variables. In the final multivariate model more family caring and loneliness were inversely associated with marijuana use; young age, more family caring, less coping ability, church attendance, and low educational aspirations were significantly associated with cocaine use. This study demonstrates the importance of health education and health promotion programs for students attending alternative high schools which include prevention of initiation, as well as treatment.

Prevalence and risk factors of work related asthma by industry among United States workers: data from the third national health and nutrition examination survey (1988–94)

Objectives: To estimate the prevalence of work related asthma and work related wheezing in United States workers. To identify high risk industries that could be targeted for future intervention. To determine the population attributable risk of work related asthma and work related wheezing. Methods: The third national health and nutrition examination survey, 1988–1994 (NHANES III) was analyzed to determine the prevalence of work related asthma and wheezing and to identify initially defined industries at risk among United States workers aged 20 and older. Separate logistic models were developed with work related asthma and work related wheezing as outcomes. Work related asthma was defined as affirmative response to questions on self reported physician diagnosed asthma and work related symptoms of rhinitis, conjunctivitis, and asthma. Work related wheezing was defined as affirmative response to questions on self reported wheezing or whistling in the chest in the previous 12 months and work related symptoms of rhinitis, conjunctivitis, and asthma. All analyses were adjusted for age, sex, smoking, and atopy. Results: The prevalence of work related asthma was 3.70% (95% confidence interval (95% CI) 2.88 to 4.52) and the prevalence of work related wheezing was 11.46% (95% CI 9.87 to 13.05). The main industries identified at risk of work related asthma and wheeze included the entertainment industry; agriculture, forestry, and fishing; construction; electrical machinery; repair services; and lodging places. The population attributable risk for work related asthma was 36.5% and work related wheezing was 28.5%. Conclusions: The findings provide impetus for further research and actions by public health professionals which prioritise occupational asthma on the public health agenda. Future intervention strategies need to be developed for effective control and prevention of asthma in the workplace.

Using Intervention Mapping to Adapt an Effective HIV, Sexually Transmitted Disease, and Pregnancy Prevention Program for High-Risk Minority Youth

Although many programs have been developed to reduce adolescent pregnancy and sexually transmitted diseases (STDs) (including HIV), with some showing promise in reducing sexual risk-taking behavior, little guidance has been given as to how to adapt existing interventions to new communities. When adapting a program, effective elements deemed necessary to change behaviors need to be preserved, while cultural competence and relevance for the new population must be considered in creating new elements. To address these needs, the authors describe the application of a systematic process, intervention mapping (IM), to adapt a theory-based, multicomponent HIV, STD, and pregnancy prevention program titled Safer Choices to a new target population, at-risk youth attending alternative schools and at risk of dropping out. IM is a detailed process that provides planners with a systematic method for decision making in each phase of developing or adapting an intervention to influence changes in behavior and environmental conditions.

Sexual Risk Avoidance and Sexual Risk Reduction Interventions for Middle School Youth: A Randomized Controlled Trial

PURPOSE To evaluate the efficacy of two, theory-based, multimedia, middle school sexual education programs in delaying sexual initiation. METHODS Three-armed, randomized controlled trial comprising 15 urban middle schools; 1,258 predominantly African American and Hispanic seventh grade students followed into ninth grade. Both programs included group and individualized, computer-based activities addressing psychosocial variables. The risk avoidance (RA) program met federal abstinence education guidelines; the risk reduction (RR) program emphasized abstinence and included computer-based condom skills-training. The primary outcome assessed program impact on delayed sexual initiation; secondary outcomes assessed other sexual behaviors and psychosocial outcomes. RESULTS Participants were 59.8% females (mean age: 12.6 years). Relative to controls, the RR program delayed any type of sexual initiation (oral, vaginal, or anal sex) in the overall sample (adjusted odds ratio [AOR]: .65, 95% CI: .54-.77), among females (AOR: .43, 95% CI: .31-.60), and among African Americans (AOR: .38, 95% CI: .18-.79). RR students also reduced unprotected sex at last intercourse (AOR: .67, 95% CI: .47-.96), frequency of anal sex in the past 3 months (AOR: .53, 95% CI: .33-.84), and unprotected vaginal sex (AOR: .59, 95% CI: .36-.95). The RA program delayed any sexual initiation among Hispanics (AOR: .40, 95% CI: .19-.86), reduced unprotected sex at last intercourse (AOR: .70, 95% CI: .52-.93), but increased the number of recent vaginal sex partners (AOR: 1.69, 95% CI: 1.01-2.82). Both programs positively affected psychosocial outcomes. CONCLUSIONS The RR program positively affected sexually inexperienced and experienced youth, whereas the RA program delayed initiation among Hispanics and had mixed effects among sexually experienced youth.

Assessing physical activity among minority women: focus group results.

Focus group findings indicate a need to develop physical activity surveys that are more relevant for women, that include well-defined, inoffensive terminology, and that improve recall of unstructured and intermittent physical activities.

Peer Victimization in Fifth Grade and Health in Tenth Grade

BACKGROUND AND OBJECTIVES: Children who experience bullying, a type of peer victimization, show worse mental and physical health cross-sectionally. Few studies have assessed these relationships longitudinally. We examined longitudinal associations of bullying with mental and physical health from elementary to high school, comparing effects of different bullying histories. METHODS: We analyzed data from 4297 children surveyed at 3 time points (fifth, seventh, and tenth grades) in 3 cities. We used multivariable regressions to test longitudinal associations of bullying with mental and physical health by comparing youth who experienced bullying in both the past and present, experienced bullying in the present only, experienced bullying in the past only, or did not experience bullying. RESULTS: Bullying was associated with worse mental and physical health, greater depression symptoms, and lower self-worth over time. Health was significantly worse for children with both past and present bullying experiences, followed by children with present-only experiences, children with past-only experiences, and children with no experiences. For example, 44.6% of children bullied in both the past and present were at the lowest decile of psychosocial health, compared with 30.7% of those bullied in the present only (P = .005), 12.1% of those bullied in the past only (P < .001), and 6.5% of those who had not been bullied (P < .001). CONCLUSIONS: Both chronic and current bullying are associated with substantially worse health. Clinicians who recognize bullying when it first starts could intervene to reverse the downward health trajectory experienced by youth who are repeated targets.