The Role of Settings in Family Based Prevention of HIV/STDs
3.3 Settings or Physical and Social Environments
3.3.2 School
School settings are important for understanding the social and structural factors that confer risk and/or protection for development of adolescents’ HIV/STD-related behaviors. Children and adolescents spend much of their day in school where they are exposed to positive role models, such as counselors, teachers, and coaches. On the other hand, schools may also expose adolescents to antisocial peers who engage in a number of related problem behaviors, including substance use and unsafe sexual behavior, all of which may increase HIV/STD risk (e.g., Capaldi et al. 2002 ; Clark and Loheac 2007 ; Harper et al. 2008 ; Jones et al. 2003 ) .
Several behaviors in school setting have been linked to either concurrent or future HIV/STD risk in adolescents. For example, lack of interest in school may indicate increased risk for substance abuse and unsafe sexual behavior (e.g., Simons-Morton
et al. 1999 ; Vazsonyi and Flannery 1997 ) . Additionally, academic failure and school conduct problems have both been linked to substance abuse, unsafe sex, and other behaviors that put the adolescent at risk for HIV/STDs (Gruber and Machamer 2000 ; Hops et al. 1999 ; Manlove 1998 ) . Moreover, once adolescents drop out of school, their risk for substance use and unsafe sexual behavior may increase dramatically (Ellickson et al. 1998 ; Guagliardo et al. 1998 ; Hallfors et al. 2007 ) .
One of the most important infl uences on behaviors related to HIV/STD risk in the school setting is the infl uence of peers. Adolescents are vulnerable to the pressures exuded by their peer groups, and those pressures may be amplifi ed in the school set-ting where adolescents spend much of their time, at a point in the life course that may be considered a particularly sensitive window for exposure to adopting risky behav-iors (e.g., Clark and Loheac 2007 ) . While having a network of friends in the school setting is a crucial component to healthy adolescent development, an adolescent’s peers have a major infl uence on many potentially risky behaviors such as substance use, sexual behavior, negative attitudes toward school, and delinquent behavior (Harper et al. 2008 ) . Pressure by friends and infl uence from antisocial peers engag-ing in problem behaviors has been linked to HIV/STD risk behaviors of drunkenness and unsafe sexual behavior (Clark and Loheac 2007 ; Harper and Robinson 1999 ) . However, parents continue to play a major role in the sexual development of their children during adolescence (Stanton et al. 2002 ; Dancy et al. 2006 ) .
Other studies have focused on school connectedness as a protective factor against HIV/STD risk behaviors. School connectedness is defi ned as the feeling of close-ness to school personnel and the school environment (Bonny et al. 2000 ) . School connectedness may provide an environment within which an adolescent feels cared for and connected to school personnel and peers, which in turn may reduce the like-lihood that the adolescent will use substances or initiate sexual activity at an early age (McNeely et al. 2002 ) . The Centers for Disease Control ( 2009 ) has acknowl-edged school connectedness as a protective factor against the development of these risks (including alcohol and drug use, violence and gang involvement, and early sexual initiation) (e.g., McNeely et al. 2002 ; Taylor-Seehafer and Rew 2000 ) and provides various science-based recommendations for increasing school connected-ness. These recommendations include creating decision-making processes that facilitate engagement, academic achievement, and staff empowerment; providing education and opportunities to enable families to be actively involved; and provid-ing students with the academic, emotional, and social skills necessary to be actively engaged in school ( Centers for Disease Control 2009 ) .
Schools have also been shown to provide an effective setting for implementing intervention programs aimed at promoting healthy behaviors and preventing risk for HIV/STDs. A recent systematic review analyzed the impact of curriculum-based sex and HIV education programs on sexual behaviors and mediating factors among youth under 25 years anywhere in the world (Kirby et al. 2007 ) . Two-thirds of the 83 programs reviewed signifi cantly improved one or more sexual behaviors, which suggest that programs were effective in delaying or decreasing sexual behav-iors and/or in increasing condom or contraceptive use. This review (Kirby et al.
2007 ) cited 17 characteristics that make for effective curricula, including using a logic model approach to develop the curriculum; addressing multiple risk and protective
factors; designing activities consistent with community values and resources; and actively involving youth through lessons. Programs that incorporated these charac-teristics were more likely to change behavior positively, and skill-based programs were more effective at changing behavior than knowledge-based programs. Such programs may provide an important positive context in which to implement family based HIV/STD preventive interventions, given the importance of establishing consistent prevention messages across multiple settings that impact the adolescent family member (Dittus et al. 2004 ) .
3.3.2.1 Examples of HIV Family Based Preventive Interventions Embedded in School Settings
Safer Choices (Coyle et al. 1999 ) is a 2-year, school-based HIV, other-STD, and pregnancy-prevention program for high school youth. The program seeks to modify several factors related to sexual risk-taking behavior, such as increasing knowledge of HIV/STDs; enhancing students’ belief in their abilities to refuse sexual intercourse or unprotected sexual intercourse, and to use a condom; and improving communica-tion with parents. This multicomponent intervencommunica-tion focuses on curriculum and staff development, peer resources and school environment, parent education, and school-community linkages. Safer Choices was found to be effective in increasing the extent to which students talked with parents regarding ways to prevent HIV/STDs, includ-ing abstinence and condom use. Intervention students reported signifi cantly greater increases in adolescent–parent communication than did comparison students.
Another HIV/STD preventive intervention in the school setting involves the Familias Unidas intervention (in English, “United Families”) (Prado et al. 2007 ) . This is a family based intervention which aims to prevent substance use and unsafe sexual behavior in Hispanic adolescents, by targeting positive parenting and parent–
adolescent communication about substance use, unsafe sex, and other HIV/STD risks (Pantin et al. 2004 ) . Adolescents’ participation in intervention activities is lim-ited to family visits and parent–adolescent discussion circles in the schools.
Facilitators meet separately with each parent and adolescent dyad and conduct exer-cises to help parents to reinforce skills learned by their adolescents in group ses-sions. Results suggest that there were signifi cantly greater improvements in illicit drug use, incidence of STDs, protected sex, and family functioning through 36-month follow-up in the Familias Unidas intervention condition, as compared to a control condition which presented HIV/STD prevention messages without addressing family functioning (Prado et al. 2007 ) .
3.3.2.2 Summary of the School Setting and HIV/STD Risk
Although certain negative school environments may increase risk for HIV/STDs in adolescents, schools with protective policies that promote high levels of school connectedness as well as HIV/STD prevention curricula may be protective against the development of risky behaviors such as unsafe sexual behavior (Centers for
Disease Control 2009 ; Kirby et al. 2007 ) . Moreover, embedding family based interventions in the schools may be an effective means of reducing HIV/STD risk, by bolstering parent–child communication processes and parent/teacher collabora-tion in monitoring of children, and by educating parents about HIV/STD risk factors and thus facilitating more consistent HIV/STD preventive messages across settings (Coyle et al. 1999 ) .