1.5 Role of Family in Preventing the Spread of HIV
1.5.2 Family-Based Primary Prevention Programs
growing body of evidence indicative of the ineffectiveness of scare tactics to infl u-ence health behaviors (Taylor 2003 ) . The girls in this study whose parents reported discussing the consequences of HIV/AIDS, both in the presence and absence of communication about protective behavioral skills, reported higher rates of sexual risk-taking. In terms of communication quality, sexual risk-taking was higher among teens who reported lower levels of parental comfort and openness during discus-sions about sex. This fi nding departs somewhat from Wilson and Donenberg ( 2004 ) who found high quality discussions contributed to greater reported risk-taking.
However, differences may be more methodological than substantive, as Wilson and colleagues analyzed videotaped discussions and defi ned quality as the mutuality of the discussions. We defi ned quality as teens’ perceived parental comfort and open-ness (e.g., “My mother/father tries to understand how I feel about topics like this.”).
Importantly, parents may send different messages about HIV/AIDS to sons versus daughters, and messages related to consequences may not effectively reduce risk among daughters. However, for boys and girls seeking psychiatric care, teaching parents how to discuss HIV/AIDS may promote safer sexual behavior.
risky situations and an ability to be assertive in handling sexual peer pressure (McBride et al. 2007a, b ; McKay et al. 2004 ; Paikoff 1997 ) . The overall objective was to promote comfort and communication about puberty, early sexual behavior, and HIV/AIDS (McBride et al. 2007a, b ) . CHAMP family programs were deliv-ered by community members who co-facilitated multiple family groups with a uni-versity co-leader. When compared to the control group, families in CHAMP I showed increased family decision making, improvements in parental monitoring, family comfort in discussing sensitive topics, more neighborhood supports, and fewer disruptive diffi culties with children (McKay et al. 2004, 2007a ; McBride et al. 2007a, b ) . Parental anxiety and depression also decreased signifi cantly from pre- to post-test (Paikoff 1997 ) . The youth in the intervention families reported experiencing signifi cantly less frequent and fewer sexual possibility situations than those in the comparison condition. Youth in the intervention group, however, reported signifi cantly higher levels of family confl ict than the comparison group, which could be due to the fact that they were having more discussions about impor-tant topics (McBride et al. 2007a, b ) .
Based on fi ndings from the original study, CHAMP II (Southside of Chicago) was developed, consisting of a 12-week fourth- and fi fth-grade family intervention, in partnership with urban parents (McKay et al. 2007a, b ) . Five hundred families with 324 children were randomly assigned to receive the CHAMP Family Program with 73% of the families completing the entire program. The high rate of participa-tion was attributed to the intensive outreach strategies designed and implemented by the community collaborators. Sixty percent of the youth in the intervention families reported using condoms “every time” and 72% reported using condoms at last inter-course (Tolou-Shams et al. 2007 ) . The youth also reported less aggressive and dis-ruptive behaviors (Bannon and McKay 2007 ) .
To further explore how to transfer this family-based prevention program, CHAMP III (Bronx, New York and Westside of Chicago) was designed to hand off the CHAMP program to community service agencies in Chicago and New York (Baptiste et al. 2007a ) . This work highlights the dissemination process of an evi-dence-based, effi cacious intervention in the real world (McKay and Paikoff 2007 ) .
CHAMP IV – also known as CHAMPSA or the AmaQhawe Family Project – is a culturally appropriate adaptation for families and communities in Durban, South Africa (Bhana et al. 2004 ) . It is based on the Theory of Triadic Infl uence (TTI) and seeks to intervene in three sources of behavioral infl uence: (1) an intrapersonal stream, (2) a social normative stream, and (3) a cultural/attitudinal stream (Petraitis et al. 1995 ; Bell et al. 2007 ; Baptiste et al. 2007c ) . This study recruited 450 South African pre-adolescents (9–12 years old) and their adult caregivers from 20 equiva-lent schools (10 experimental and 10 control). The control group received an exist-ing school-based HIV information curriculum.
Youth and families who participated in CHAMPSA were likely to be better informed about HIV/AIDS transmission, have less HIV stigmatizing attitudes, have greater parental monitoring of children’s activities and adherence to the family rules, and have increased parental comfort communicating about diffi cult topics.
There was also less neighborhood disorganization and greater neighborhood social
control and cohesion. CHAMPSA has signifi cant potential to enhance protective infl uences in communities (Bell et al. 2008 ) . CHAMPSA is a potential model for adapting HIV intervention programs to meet local needs internationally (Baptiste et al. 2007c ) .
CHAMP was also adapted for the Caribbean, which has the second highest rate of HIV per capita in the world (Baptiste et al. 2005, 2007b ) . CHAMP V (Trinidad and Tobago) was a pilot study conducted with 32 parents/caregivers and youth (average age 12.5 years), attending two public schools, situated in high HIV/AIDS sero-prevalent counties. Comparing the mean change from pretest to posttest, youth in the CHAMP group reported increased frequency of discussions about HIV/AIDS, decreased frequency of discussions about gangs, and increased parental expecta-tions that they be at a certain place at a particular time. As with other CHAMP programs, there was strong community participation in the design and administra-tion of the pilot study (Baptiste et al. 2007b ; Voisin et al. 2005 ) .
While most family-based prevention programs have been developed for mothers, Krauss and colleagues ( 2000 ) designed PATH which is a prevention pro-grams for both mothers and fathers, acknowledging fathers’ important role in the sexual health of their 10- to 13-year-old preadolescents. This trial recruited 238 parent and 238 child participants in dyads (father–son; father–daughter; mother–
daughter; mother–son). They were randomized to receive either a parent training program plus materials or materials only. Parents participated in four 3 hour group training sessions, given once a week, covering knowledge and safety skills regarding sex, drugs, and HIV; child development; parent–child communication.
The initial parent training was followed by a parent child session in which each parent and child met alone with a facilitator. Parents chose activities to perform with their child and children had an opportunity to ask questions. The parent group met again after three months to discuss real-life situations that had occurred.
This study demonstrated that an intervention delivered by either a mother or father can reduce HIV-risk-associated sexual behaviors of adolescents (Krauss et al.
2002 ; Freidin et al. 2005 ) . These interventions are aimed at fostering family involve-ment in the sexual health of adolescents, including delay of sexual intercourse, acquiring information about HIV/AIDS, interacting comfortably with community members and family who may have HIV, and ensuring HIV risk-reduction skills.
At the request of parents and youth, two 1.5 hour sessions on risk-reduction communication during the transition to adolescence were added to the “basic train-ing.” These sessions emphasize household safety, affi rming fi ndings that youth worry as much about their parents’ risks as parents worry about youth’s (Krauss et al. 2002 ) . Aside from increased comfort in interacting with persons with HIV, fi ndings indicate that children of trained parents have increased practical HIV knowledge, decreased unrealistic worry, and higher intention to use condoms at fi rst and subsequent intercourse (Krauss et al. 1997 ) . This intervention also dem-onstrated a protective effect in increased delay of fi rst intercourse for male and female youth who have their fi rst sexual experience at age 15 or younger (Krauss et al. 2007 ) . In this study they found at baseline that HIV information was not
shared within households. Six months post-intervention, children of parents offered training evidenced signifi cantly more HIV knowledge and less unrealistic worries about HIV worry than children of parents not offered training – moderated through parent knowledge only for children of trained parents (Krauss et al. 2002 ) . As the youth matured to age 15, approximately 25.3% of control and intervention youth became sexually active. The delay in sexual initiation, however, was longer for children of parents offered training (a protective effect of 25–30 months) and more uniform across genders (Krauss et al. 2007 ) .
DiIorio and colleagues ( 2000 ) developed a prevention program for mothers and adolescents and a later one for fathers and sons. The primary objective of the mother–adolescent program, called Keepin’ it R.E.A.L.! (Responsible, Empowered, Aware, Living) was to enhance the role of mothers in postponing sexual debut of their 11 through 14-year-old adolescents (DiIorio et al. 2000 . Embedded within Keepin’ it R.E.A.L.! are two programs – one based on social cognitive theory (SCT) and the other on problem behavior theory (PBT). The SCT program was built on the recognition that behavior is dependent on a dynamic interaction of personal, envi-ronmental, and behavioral factors (Bandura 1997 ) . The facilitation of desirable behaviors, such as delaying the initiation of sexual intercourse, requires supporting the development of behavior-specifi c cognitive, behavioral, and effi cacy skills.
Thus, the SCT program included sessions on sexual health, HIV transmission and protection, communication skills, and peer pressure. The second program was built on PBT principles, which propose that problem behaviors in adolescents arise from common underlying psychological attributes or a predisposition (Jessor et al. 1997 ) . The incorporation of PBT principles was refl ected in the program by addressing a wide variety of adolescent behaviors including smoking, violence, sexual inter-course, and school performance. Both the SCT and the PBT programs were designed to be interactive with games, videos, role plays and skits to demonstrate and practice skills learned in the sessions. There were take-home activities in which each partici-pant sets a personal goal to be accomplished by the following session. The effi cacy of the two programs in reducing sexual involvement of adolescents was assessed in a study that compared the programs to each other and to a control group (Dilorio et al. 2007 ) . The results of this study showed that although there were no differences in delay of sexual intercourse among the three groups, those who participated in the PBT program reported an increase in condom use, and those in the SCT and the control group demonstrated higher levels of knowledge about HIV. Mothers reported more comfort talking about sex with their adolescents and greater confi dence in doing so over time. Mothers in the SCT program reported talking about more sex topics, and mothers in the SCT and PBT programs indicated a greater intent to dis-cuss and more comfort disdis-cussing sexual topics than those in the control group.
Mothers in the SCT program also demonstrated higher levels of HIV knowledge than mothers in the PBT and control groups.
The program for fathers, called R.E.A.L. (Responsible, Empowered, Aware, Living) was designed to enhance the father’s role in postponing the sexual debut of their 11 through 14-year-old adolescent sons (DiIorio et al 2007). Fathers attended the
pro-gram once a week for 7 weeks, bringing their sons for the fi nal session. Similar to sessions for mothers in Keepin’ it R.E.A.L.!, the sessions for fathers were interactive and included goal setting and take-home activities. The effi cacy of the program was assessed in a study comparing the SCT program to a nutrition and exercise program for fathers. Adolescents whose fathers participated in the SCT program reported sig-nifi cantly higher rates of sexual abstinence, condom use, and intent to delay initiation of sexual intercourse. Fathers in the program reported signifi cantly more discussions about sexuality and greater intention to discuss sexuality in the future with their sons.
They also reported more confi dence discussing sexual issues with their sons and more positive outcomes associated with those discussions.
Jemmott and colleagues ( 2000 ) designed a family-based prevention program to enable mothers to teach their sons about sex and to decrease their risky behavior.
This program helps mothers examine their values related to sexuality and provide them with factual information to share with their sons. Activities are intended to increase mothers’ understanding about developmental challenges and social stres-sors that their sons are experiencing and to improve their parental communication skills. Unfortunately, no results are yet available from this study.
Another intervention in which the parents assume the role of AIDS educators is Familias Unidas . An ecodevelopmental, Hispanic-specifi c, ecologically focused, parent-centered preventive intervention, Familias Unidas promotes protection for adolescents against HIV and substance use. This program promotes four major family processes operating at different systemic levels: (1) increasing family func-tioning (e.g., positive parenting), (2) promoting parent–adolescent communication, (3) fostering proactive connections between the family and other important systems such as peers and school, and (4) gathering external support for parents (Pantin et al.
2004 ). The group format of the intervention was designed to provide social support for Hispanic immigrant parents by introducing them to other parents in similar situations.
The Familias Unidas intervention has been evaluated in two separate random-ized controlled trials. In the fi rst randomrandom-ized controlled trial, Pantin et al. ( 2003 ) found that this 9-month intervention was effi cacious (in a sample of 167 Hispanic youth), relative to a no-intervention control group, in increasing parental involve-ment, parent–adolescent communication, and parental support for the adolescent;
and in reducing adolescent behavior problems. Not surprisingly, active participation in the group was shown to predict engagement and retention in the intervention (Prado et al. 2006a ) , and in turn engagement and retention have been shown to facilitate improved outcomes for adolescents (decrease in behavior problems) and families participating in the intervention (Prado et al. 2006a, b ) . The intervention did not signifi cantly impact adolescent school bonding/academic achievement (see Chap. 11 ).
In the second randomized controlled trial, evaluated the effi cacy of Familias Unidas + PATH relative to (a) English for Speakers of Other Languages ( ESOL ) + PATH and (b) ESOL + HEART , a family-centered adolescent cardiovascular health inter-vention. In the ESOL + PATH and ESOL + HEART conditions, ESOL served as an
attention control (i.e., equivalent dosage and contact hours) for Familias Unidas. In the ESOL + HEART condition, HEART served as an attention control for PATH . The outcomes examined in that study included substance use and unsafe sexual behavior, as well as family functioning (parental involvement, parent–adolescent communica-tion, positive parenting, and family support).
The results showed that Familias Unidas + PATH were effi cacious in reducing current illicit drug use relative to ESOL + HEART . The results also showed that Familias Unidas + PATH were effi cacious, relative to both ESOL + PATH and ESOL + HEART in reducing current cigarette use. Moreover, Familias Unidas + PATH were effi cacious, relative to ESOL + PATH in reducing unprotected sexual behavior at last sexual encounter. What is remarkable about these fi ndings is that for both cigarette smoking and unsafe sex, the condition with only the module targeting the outcome in question was less effi cacious than the intervention including Familias Unidas , the family strengthening intervention.
These fi ndings suggest that targeting problem behaviors outside the context of a family intervention was not effi cacious with our target sample. Post-hoc analyses also showed that adolescents in the Familias Unidas condition reported signifi cantly lower rates of sexual transmitted diseases than adolescents in the two control condi-tions. Finally, the effects of Familias Unidas + PATH on smoking and illicit drug use were partially mediated by improvements in family functioning. Specifi cally, improvements in positive parenting (reward contingencies offered by parents) and in parent–adolescent communication explained some of the effects of intervention condition on cigarette and illicit drug use.
A third and fourth trial of the Familias Unidas intervention are ongoing. In the fi rst of these, Pantin and colleagues are evaluating the effi cacy of Familias Unidas (relative to community referrals) in reducing HIV-risk behaviors and substance use in a sample Hispanic youth with behavior problems. In the second of these two studies, Prado is evaluating the effi cacy of a 6-week version of the Familias Unidas intervention, relative to prevention as usual services. This streamlined version of the intervention targets those family processes that have been found to mediate the effects of the Familias Unidas intervention on the two prior randomized trials.
Based on over a decade of longitudinal research with rural African American families and youth, Murry and associates designed a family-based preventive inter-vention to deter HIV-related risk behavior among rural African American youth. The Strong African American Families (SAAF) program is the only universal random-ized prevention trial designed specifi cally for rural families and youth. Analyses of data gathered from 667 rural African American families with an 11-year-old youth supported SAAF’s effi cacy in deterring youths’ vulnerability to HIV-related risk behavior 2 years post-intervention (Brody et al. 2006 ). The 7-week intervention includes separate programming for youth and their parents, as well as activities in which parents and youth engage together. Key curriculum content for the seven ses-sions is presented on videotapes, which Murry and Brody produced, depicting fam-ily interactions that illustrate targeted intervention concepts. SAAF was implemented in community settings during youths’ transition to middle school, an important
developmental juncture for preventive intervention (Jemmott et al. 1999 ; Kirby 2001 ) . Results revealed that SAAF was effi cacious in reducing rural African American youths’ vulnerability to HIV-related risk behavior through the interven-tion’s effect on parenting practices and its effect on youth intrapersonal protective factors. Specifi cally, families who participated in SAAF experienced increases in regulated-communicative parenting (Brody et al. 2004 ; Murry et al. 2005 ) and in youth intrapersonal protective processes, namely heightened racial identity, elevated self-esteem, increased acceptance of body image and physical attractiveness (Murry et al. 2005, 2007 ) . SAAF-induced effects on parenting behavior deterred not only precursors to risk behavior such as risk-related attitudes, future orientation, self-regulatory capacity, and resistance effi cacy (Gerrard et al. 2006 ) , but also immediate HIV-related risk behavior (Brody et al. 2006 ), including early onset of substance use and sexual intercourse (Murry et al. 2007 ) and alcohol use trajectories (Brody et al.
2005 ) . These fi ndings support the SAAF curriculum’s potential public health impact (see Chap. 11 ).
Project STYLE is a multi-site (Providence, Chicago, Atlanta) randomized controlled trial evaluating the comparative effi cacy of three interventions: (1) family-based HIV prevention intervention, (2) adolescent-only HIV prevention intervention, and (3) general health promotion intervention; in increasing safer sexual behavior among 13- to 18-year-old adolescents with psychiatric disorders.
All three interventions were delivered during a 1-day workshop in groups of 6–8 and led by two facilitators. In the family-based intervention, parents and teens were assigned at-home exercises that targeted communication and risk reduction whereas in the adolescent-only and health promotion interventions only the adolescents were given take-home exercises targeting adolescent risk reduction and health promo-tion, respectively. Participants in all three arms attended individualized 2-week follow-up appointments during which monitoring plans (family), risk plans (family and adolescent-only), and health promotion plans (health promotion) were reviewed and problem solving was used to remedy specifi c areas of diffi culty. All partici-pants attended a 3-month booster session with their same group members and facilitators to review material previously covered during the 1-day workshop.
Assessments occurred at baseline, 3, 6, 12, 24, 30, and 36 months (see Chap. 13 ).
Initial fi ndings revealed important associations. Contrary to reports of youth in outpatient care (Donenberg et al. 2001 ), sexual risk behavior was associated with a wide range of psychiatric disorders including internalizing problems (Brown et al.
2010 ).
In summary, these studies demonstrate that parents can be taught to be effective AIDS educators: they can effectively impart information as well as teach their chil-dren skills to protect themselves in risky situations. The studies also provide cor-roborative evidence that the quality of parent–child relations and communication is an important predictor of sexual risk behaviors. Across the studies, adolescents who reported low levels of parental support or more emotional distance from their fami-lies were more likely to engage in sexual behaviors at a younger age. Conversely, adolescents’ belief that they have a close relationship with their parents was protec-tive against early sexual intercourse.