Mothers: The Major Force in Preventing HIV/STD Risk Behaviors
5.3 Innovative HIV-Risk Reduction Interventions for Adolescents
To enhance adolescents’ HIV-risk reduction behaviors, several researchers have developed innovative HIV-risk reduction interventions for mothers and their adoles-cents. Family members, including mothers, are important in HIV-risk reduction because they can implement social control and provide adolescents HIV-risk reduc-tion knowledge and skills on a daily basis or during “teachable moments” (Pequegnat 2005 ) . The inclusion of parents in health interventions, including HIV/AIDS interven-tions, has especially been advocated for African American youths (Williams 2003 ) .
5.3.1 A Mother–Adolescent HIV Prevention Program
DiIorio et al. ( 2000 ) developed a mother–adolescent HIV prevention program based on Bandura’s social cognitive theory (SCT). In this HIV prevention program, adolescents and their mothers attended, over a 14-week period, 72-h sessions: four sessions together and three sessions separately (DiIorio et al. 2000, 2006 ) . During the four sessions where mothers and their adolescents attended together, facilitators covered topics related to HIV transmission and protection, communication, and values. The separate sessions for adolescents focused on peer pressure, sexual decision making, and consequences of early sexual initiation. The separate sessions for mothers focused on adolescent development, reproductive health, including condom and contraceptive use, peer pressure, and communication with adolescents.
The intervention consisted of role-plays, games, demonstrations, group discussions, videos, and homework assignments. This intervention was compared to a Life Skills Program (LSK) and a 1 hour intervention with a 20 minute video on HIV transmis-sion and prevention.
A randomized cluster trial was used to explore the effectiveness of these three HIV-risk reduction interventions. Adolescents ranged in age from 11 to 14 years with a mean age of 12.2 years. These adolescents were 98% African Americans and 60% males, with 90% residing with their biological mothers, and 46% residing with their biological, step, or adoptive fathers. Their mothers had a mean age of 38 years, and 97% were African Americans, 67% were single, and 56% had completed some college. Only 11% of their mothers had less than a high school diploma (DiIorio et al. 2006 ) .
DiIorio et al. ( 2006 ) results revealed that over the 24-month period, adolescents receiving the SCT, the LSK, and the control interventions did not differ in holding hands, touching their partners’ genitals, and initiating sexual intercourse. Condom use increased for sexually active adolescents at the 6- and 12-month period for the LSK, but not for the SCT and the control groups. Knowledge increased for mothers and adolescents in the SCT at the 4-month period. Compared to mothers in the control intervention, mothers in the SCT and LSK interventions were more likely to talk to their adolescents, intended to talk to their adolescents, and were more comfortable talking to their adolescents about sexual topics.
5.3.2 Mother/Daughter HIV-Risk Reduction
Dancy ( 2003 ) and Dancy et al. ( 2006b ) developed the Mother/Daughter HIV-Risk Reduction (MDRR) intervention. The MDRR intervention, based on the SCT and the theory of reasoned action, consisted of six weekly sessions taught by trained mothers. Each session lasted 2 hours. The content covered was sexual development, reproductive health, sexually transmitted illnesses, HIV transmission and preven-tion, assertiveness and decision-making, abstinence, and the correct use of the male and female condoms. Teaching strategies included didactic information, games,
role-plays, group discussions, modeling, return demonstration, and constructive feedback. Over a 12-week period in a group setting, facilitators provided to mothers intensive training on the MDRR intervention. The facilitators modeled the presenta-tion of the MDRR intervenpresenta-tion and had mothers select porpresenta-tions of the intervenpresenta-tion that they would present to their daughters in a group setting. Mothers were required to practice in-session and between-sessions to ensure that they were knowledgeable about the MDRR content and teaching strategies and were competent in their presentation. Facilitators and other mothers in the group provided mothers with constructive feedback. After the 12-week period, mothers implemented the MDRR intervention to their daughters with facilitators serving as consultants.
Using a longitudinal quasi-experimental comparison group design, Dancy et al.
( 2006a, b ) determined the effectiveness of the MDRR intervention by comparing it to two control interventions. The fi rst control intervention was the health expert HIV-risk reduction intervention (HERR) that consisted of the same HIV-risk reduc-tion content and teaching strategies as the MDRR, but was taught by facilitators and not by the girls’ mothers as in the MDRR intervention. The second control group was the mother/daughter health promotion (MDHP) intervention. Similar to the MDRR intervention, the MDHP intervention was taught by the girl’s mothers.
However, the content of the MDHP intervention focused on healthy eating and physical activity to promote health and prevent obesity-related diseases that are prevalent in the African American community, namely hypertension and diabetes.
The sample consisted of African American mother/daughter pairs. The adolescent girls ranged in age from 11 to 14 years with a mean age of 12.4 years. Their mothers ranged in age from 22 to 76 years with a mean age of 40.2 years. The majority of the mothers (45%) were single; 31% had less than a 12th grade education; 56% had completed 12th grade or received their graduation equivalency diploma (GED); and 62% had a monthly income of less than $1,100 (Dancy et al. 2006a, b ) .
At the 2-month posttest, compared to adolescents in MDHP interventions, the adolescents in the MDRR and HERR interventions had signifi cantly higher scores on HIV transmission knowledge, self-effi cacy to refuse sex, and intention to refuse sex. Also adolescents in the MDHP were more likely to be sexually active than the adolescents in the MDRR and HERR interventions (Dancy et al. 2006a, b ) .
5.3.3 Saving Sex for Later
O’Donnell et al. ( 2005 ) developed three CDs titled Saving Sex for Later based on the diffusion of innovation theory and the theory of planned behavior. The CDs were designed as a parent education program to increase parents’ self-effi cacy, attitudes, and skills to communicate with their adolescents about sexual topics and to promote their adolescents’ sexual abstinence. To provide parents an opportunity to view the CDs at a convenient time in the privacy of their homes, parents received the CDs via mail one every 10 weeks over a 6-month period. Topics covered in these CDs were adolescent development, sexual attraction to the opposite sex, peer pressure, and reasons why adolescents are not ready for sex.
In a randomized experiment, parent–adolescent pairs were randomly assigned to either the CD intervention or the no treatment control intervention. The adolescents ranged in age from 10 to over 13 years. Eighty-three percent were 10 or 11 years old;
48% were males; 64% were African Americans; and 90% qualifi ed for the public school free lunch program. Eighty-eight percent of the parents were mothers; 66% were African Americans; and 66% were 40-years-old or younger (O’Donnell et al. 2005 ) .
At the 3-month follow-up, compared to parents in the control intervention, parents in the CD intervention had signifi cantly higher scores on parental infl uence on their adolescent’s behavior, communication about sexual topics, and self-effi cacy to communicate about sexual topics. Adolescents in the CD intervention had signifi -cantly higher scores on perceptions of family rules and family support and reported fewer episodes of dating, kissing, and holding hands (O’Donnell et al. 2005 ) .
5.3.4 Informed Parents and Children Together
The Informed Parents and Children Together (ImPACT) intervention was designed to reduce adolescent truancy, substance abuse, and sexual risk behaviors through promoting adolescents’ parental monitoring and communication behaviors (Stanton et al. 2000, 2004 ) . Based on the SCT, the ImPACT intervention is a one-session 20-min video. It covers parental monitoring behavior of adolescent’s behavior, parental communication with adolescent about sex, factual information about HIV/AIDS and condom use, sexual risk reduction strategies, and risks related to substance use. An interventionist showed the video to the parent and the adolescent in their home. After the viewing of the video, the interventionist addressed any questions the parent and adolescent had and instructed the parent and adolescent to participate in a predetermined role-play. The interventionist reiterated the key points of the video and instructed the parent and adolescent to repeat the role-play and to incorporate the key points of the video in the role-play.
The parent and adolescent then practiced putting on and removing a condom and the interventionist gave the parent the copy of the video and notes stressing the key points (Stanton et al. 2000 ) .
Using a randomized, controlled longitudinal research design, the effectiveness of the ImPACT intervention was explored. Parent–adolescent pairs were randomly assigned to either the ImPACT intervention or the attention control intervention (Stanton et al. 2000, 2004 ) .
All participating parents and adolescents pairs were African American. Adolescents ranged in age from 12 to 16 years (Stanton et al. 2000, 2004 ) . Adolescents had a median age of 13.6 years (Stanton et al. 2000 ) and 14 years (Stanton et al. 2004 ) with 51% (Stanton et al. 2000 ) and 42% being male (Stanton et al. 2004 ) . Approximately 96% of the parents were mothers; no other parental demographic information was provided (Stanton et al. 2000, 2004 ) .
At 24 months, compared to the adolescents in the control interventions, the adolescents in the ImPACT intervention had signifi cantly higher self-effi cacy to practice low-risk behaviors. However, the adolescents in the control and ImPACT
interventions did not differ signifi cantly on school truancy, substance abuse, sexual risk behaviors (Stanton et al. 2000 ) , and participation in sexual intercourse (Stanton et al. 2004 ) . Additionally, the ImPACT intervention had no effect on increasing the use of condom and birth control (Stanton et al. 2004 ) .
5.3.5 Chicago HIV Prevention and Mental Health Project
Paikoff et al. designed the Chicago HIV Prevention and Adolescent Mental Health Project (CHAMP) Family Program (McKay et al. 2000, 2004 ) . CHAMP is a 12-session group intervention to promote parental communication, support, and monitoring and supervision as well as adolescents’ assertiveness and problem-solving skills. Each session lasted 90 min. Topics included communication tech-niques, monitoring skills, the development of rules for adolescents, talking to adolescents about and preparing them for puberty and adolescents, and factual information about HIV/AIDS. Each session began with parents and their adoles-cents meeting together in a group where the topic for the session was presented.
Then, a separate adolescent group and a separate parent group were conducted for detailed discussion of the topic. These groups were followed by the parent and adolescents meeting together again for the last 30 min to practice family activities.
The 12th session was a celebration of the completion of the program.
A quasi-experimental posttest-only research design was used to compare partici-pants in the CHAMP Family Program intervention with a comparison group of participants residing in the same community. The comparison group was assessed a year prior to the administration of the posttest to the CHAMP Family Program participants. This community was predominantly African American and 75% of the households were female-headed. Seventy-six percent of the parents in the CHAMP Family Program and 90% of the parents in the comparison group reported an annual income less than $14,000. In regards to education, 75% of the CHAMP Family Program adults and 46% of the comparison group adults had a 12th grade educa-tion. All adolescents were in the fourth and fi fth grades with approximately 60%
being female (McKay et al. 2004 ) .
Posttest data were collected during the 11th weeks. Compared to the comparison group, the parents in the CHAMP Family Program made more decisions, monitored their adolescents more, had increased communication with their adolescents, and were more comfortable talking to their adolescents about HIV/AIDS and sexuality (McKay et al. 2004 ) .
5.3.6 Parent–Adolescent Relationship Education Program
Lederman et al. developed the Parent–Adolescent Relationship Education (PARE) program for parents and their 12–14-year-old adolescents ( Lederman and Mian 2003 ; Lederman et al. 2004 ) . The PARE program is designed to reduce the rate of
adolescent pregnancy and acquisition of STDs by increasing communication about sexuality between parents and their adolescents and by enhancing adolescents’ risk reduction behaviors. Based on the social learning theory and the cognitive behav-ioral theory, the PARE program has four sessions that are taught over the course of 4 weeks. Each session is two and a half hours with parents and adolescents in separate classes during the fi rst half followed by parents and adolescents together in the same class for the last half. The content focuses on adolescent development, communication between parents and adolescents with emphasis on effective and ineffective communication and communication barriers, risk reduction behavioral skills, consequences of risky behaviors, stress reduction, and the development of future goals. Teaching strategies include didactic information, behavioral rehearsal, and role-playing.
Parent–adolescent dyads were randomly assigned to either the PARE program or to the attention control group. In addition, another control group of students were included who did not receive any intervention. The adolescents ranged in age from 11 to 15 years with 46% being between 11 and 12 years and 54% between 13 and 15 years. Fifty-fi ve percent were girls; 38% were Latino; 26% were African American; and 26% were Caucasian. No demographic characteristics were given for the parents (Lederman et al. 2004 ) .
Lederman et al. ( 2004 ) revealed that at 3–6 months after the initiation of the intervention, compared to adolescents in the control groups, adolescents in the par-ent-involved social learning curriculum had higher intention to delay sex. However, there were no differences among the adolescents in the three groups on level of par-ent–adolescent communication. The researchers also found no relationship between parent–child communication and these three determinants of risky sexual behavior:
the adolescents’ intention to engage in sex, attitude about risky sexual behavior, and perception of parental disapproval of risky sexual behavior.
5.3.7 Mothers and Sexual Communication
Lefkowitz et al. ( 2000 ) designed an intervention to enhance mothers’ communication skills with their adolescents (Lefkowitz et al. 2000 ) . The intervention consisted of two communication training sessions conducted in a group setting 1 week apart. The fi rst session focused on communication related to confl ict whereas the second session focused on communication related to sexuality and dating. In both sessions, the group facilitator stressed good communication techniques, such as, using open-ended and probing questions, listening more and talking less, providing the adolescent with ample opportunity to present his/her opinion, being supportive, and making every attempt not to lecture. During the fi rst session, the mothers listened to two two-minute audiotapes of a mother–adolescent conversation. The mothers critiqued these audiotapes for similarities and differences in communication and then role-played communication exercises. Mothers were given a communication techniques handout to use to complete the homework assignment, which was to practice the communication techniques before
the second session. The second session focused on the communication techniques for discussing sexuality and dating. This session ended with a homework assignment to discuss sexuality and dating with their adolescents.
Mother–adolescent pairs were randomly assigned to the intervention or the delayed control group. The age range for the adolescents was 10.7–14.5 years with a mean age of 12.5 years for the intervention group and 12.8 years for the delayed control group.
The mean age for mothers in the intervention group was 41.8 years and 44.0 years for the delayed control group mothers. Mothers in the intervention group had a mean of 15 years of education whereas those in the delayed control groups had a mean of 16.7 years of education. For both groups, the household income ranged from $10,000 to more than $100,000 with a median of $40,000 to $60,000. Half (50%) of the mothers were European–American with 18% being Latin American, 15% being African American, and 10% being Asian American (Lefkowitz et al. 2000 ) .
The results revealed that 7 weeks after session one, compared to mothers in the delayed control group, mothers in the intervention group talked less, used more open-ended questions, were less judgmental, and communicated about sexuality and dating more. The adolescents of mothers in the intervention group, compared to those adolescents of mothers in the delayed control group, reported being more comfortable talking to their mothers and engaged in more communication with their mothers about birth control (Lefkowitz et al. 2000 ) .
In summary, the interventions including mothers as agents to promote adoles-cents’ sexual risk reduction behaviors have used different innovative strategies and were successful in enhancing adolescents’ condom use, HIV knowledge, self- effi cacy to refuse sex, intention to refuse sex, perception of family rules and support, self-effi cacy to practice low-risk behaviors, comfort in talking with their mothers, and communication about birth control with their mothers. The interventions were also successful in increasing mothers’ effective communication, intention to communicate, and self-effi cacy to communicate with their adolescents about sexuality. Additionally, the interventions also increased maternal monitoring and infl uence on their adolescents’ behavior. However the interventions had no long-term impact on engaging in sexual intercourse.
Innovative strategies used in some of these interventions included the enhancement of intentions, behavioral skills, and environmental constraints, three components that Fishbein et al. ( 1992 ) advocated as both necessary and suffi cient to promote behavioral change (Pequegnat 2005 ) . Intentions are plans to behave in a manner that will promote HIV-risk reduction, behavioral skills are the actions needed to implement or perform risk reduction behaviors, and environmental constraints are the external factors that promote the performance of risk reduction behaviors. For adolescents, environmental constraints can include parental monitoring and supervision, familial rules and values, parent–
adolescent communication about adolescent issues and concerns, including sexuality, and peers and adults in the neighborhoods who sanction risk reduc-tion behaviors. These components interact reciprocally to promote behavioral change. Research is needed to systematically explore the pathway by which these components interact to promote behavior for specifi ed populations.