# Presentation: 521076

## HIV in Ethnic Minority Populations

- John B. Jemmott III
- Professor
- University of Pennsylvania
- Annenberg School for Communication
- jjemmott@asc.upenn.edu

## Goals of this presentation

- Provide an overview of HIV/AIDS among ethnic minority individuals.
- Describe our intervention research with ethnic minority adolescents.
- Highlight some directions for future research.

## Collaborators

- Loretta S. Jemmott, PhD, RN, FAAN--University of Pennsylvania
- Geoffrey T. Fong, PhD--University of Waterloo
- Paula K. Braverman, MD--University of Cincinnati
- Paulette M. Hines, PhD--University of Medicine & Dentistry of New Jersey

## Funding Sources

- National Institute of Mental Health
- National Institute of Child Health and Human Development
- National Institute of Nursing Research
- American Foundation for AIDS Research

## Objectives of our research program

- Identify social psychological factors that underlie HIV/STD risk behavior.
- Identify theory-based, culture-appropriate, developmentally appropriate strategies.
- Evaluate strategies with scientifically sound methodology.
- Address practical questions.
- Disseminate effective intervention strategies.

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## Slide 7

## Selected facts about adolescents and HIV/STD risk

- Sexual intercourse as risk behavior.
- Self-reported condom use declines with age.
- Adolescents and young adults are at higher risk for sexually transmitted diseases (STDs).
- For biological reasons, adolescent girls are more vulnerable than are  adult women.
- A worldwide problem

## A general strategy

- Use a theoretical framework.
- Recognize cultural and contextual factors.
- Identify which factors are relevant and which are not relevant to the behavior and intervention.
- Consider how the factors affect the acceptability, efficacy, and sustainability of interventions.
- Integrate relevant factors into the intervention.

## Theoretical Framework

- Social Cognitive Theory
- The Theory of Reasoned Action
- The Theory of Planned Behavior

## Phases of Our Research

- Conduct qualitative research to identify cultural and contextual factors.
- Conduct quantitative research to identify predictors of the relevant behavior.
- Develop or adapt the intervention for the population.
- Pilot test the intervention.
- Modify the intervention.
- Test the intervention in a randomized controlled trial.

## Key research questions

- Can interventions be effective when implemented by facilitators who do not share the participants’ ethnicity?
- Does matching the gender of facilitators and participants enhance efficacy?
- Can abstinence-based interventions be effective?
- How effective are peer educators?
- Can interventions reduce the STD rate in adolescents?
- Are evidence-based curricula effective when implemented by likely end-users?

- Can culturally appropriate programs be effective when implemented by facilitators who do not share the ethnicity of participants?
- Does matching the gender of participants and facilitators enhance intervention efficacy?

## Jemmott, Jemmott, Fong & McCaffree (1999, AJCP): Design

- Randomized controlled trial
- 496 African American adolescents at a weekend program
- Mean age, 13.1 years
- 54% were girls
- 55% were sexually experienced

- 5-hour HIV/STD Intervention
- Health promotion control group
- Facilitator race and gender, and group gender composition
- 93% retained at 6-months

## Be Proud! Be Responsible!:  Empowering youth to reduce their risk of HIV

- Behavioral beliefs
- Self-efficacy and skills
- HIV knowledge
- Culturally appropriate
- Developmentally appropriate

- Small group
- Interactive exercises
- Brainstorming
- Games
- Videos and video clips
- Role playing

## The “Be Proud! Be Responsible!” theme

*Which encourages adolescents: *
- To be proud of themselves, their family, and their community,
- To behave responsibly for the sake of themselves, their family, and their community, and
- To consider their goals for the future and how unhealthful behavior might hamper the attainment of their goals.

## Jemmott, Jemmott, Fong & McCaffree (1999, AJCP): Results

- Reduced HIV risk-associated sexual behavior.
- Reduced unprotected sexual intercourse.
- Race of facilitator, gender of facilitator, and the gender composition of the group did not matter.

## Which risk reduction messages are most effective with adolescents?

Which types of individuals are likely to be the most effective in delivering those messages? 

- Which types of individuals are likely to be the most effective in delivering those messages?

## Jemmott, Jemmott, & Fong (1998, JAMA)—Design

- Randomized controlled trial
- 659 African American adolescents at a weekend program
- Mean age, 11.8 years
- 53% were female
- 25% were sexually experienced

- Abstinence-based, safer-sex, or health promotion control intervention
- Adult facilitator or peer co-facilitators
- 93% retained at 12-month follow-up

## Slide 20

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## Slide 22

- Can behavioral interventions reduce the rate of STD among adolescents?

## Jemmott, Jemmott, Braverman, & Fong (In Press, Arch Ped & Adol Med): Design

- Randomized controlled trial
- Teen Clinic at an Adolescent Medicine Department
- Skill-building HIV/STD, information-based HIV/STD, or health promotion control intervention
- Mother’s interventions

## Jemmott, Jemmott, Braverman, & Fong: Participants

- 682 sexually experienced adolescent girls
- Informed consent
- 68% African American and 32% Latina
- 93% of Latinas were Puerto Rican
- Mean age, 15.5 years
- 87% had coitus in previous 3 months
- 22% had a STD at baseline
- 89% retained at 12-month follow-up

## Adjusted mean frequency of unprotected sexual intercourse in the previous 3 months8,9

## Adjusted Mean Number of Sexual Partners in Previous 3 Months8

## Adjusted mean frequency of sexual intercourse while high in the past 3 months2,3,5

## Adjusted rate of STD8

## CDC’s Dissemination Project “Research to Classrooms:  Programs that Work”

- Scientifically valid evidence of effectiveness
- User-friendly
- Dissemination to educators and other advocates for youth
- Good news/bad news

## “Programs that Work”

- “Reducing the Risk” (Kirby et al.)
- “Be Proud! Be Responsible!” (Jemmott et al.)
- “Get Real About AIDS” (Main et al.)
- “Becoming a Responsible Teen” (St. Lawrence et al.)
- “Focus on Kids” (Stanton et al.)
- “Making a Difference:  An Abstinence-Based Approach” (Jemmott et al.)
- “Making Proud Choices:  A Safer Sex Curriculum” (Jemmott et al.)

## Are evidence-based HIV/STD interventions effective when implemented by likely end-users?

## Phase IV Trial of the “Be Proud! Be Responsible!” HIV Intervention

- Randomized controlled trial
- 86 community-based organizations in Philadelphia and New Jersey
- Be Proud! or health promotion control intervention

- Intensity of facilitator training
- 3,448 adolescents 13 to 18 years of age
- Follow-up sample, N = 1,707
- Adolescents’ sexual behavior
- Fidelity of implementation

## CBO Facilitators

- Facilitators 20 to 70 years of age (_M_ = 37.6)
- 82% Black, 9% Latino, 7% White
- 73% Women
- 5% high school degree, 28% some college, 47% bachelor’s degree, 21% some graduate education

## Adolescent Participants

- 57% girls
- Mean age, 14.8 years
- 83% Black, 13% Latino, 1% White
- 57% ever had sexual intercourse
- 40% had sexual intercourse in past 3 months
- 53% did not use condoms consistently in the past 3 months

## Main findings

- Proportion protected sexual intercourse
- Percentage consistent condom use
- No significant effects on sexual intercourse
- Condom-use knowledge
- Self-efficacy to use condoms
- Condom-use hedonistic beliefs
- Intensity of training did not matter

## Implications

- CBOs can achieve sexual-risk-behavior change using an evidence-based curriculum.
- Training of facilitators need not be extraordinarily extensive or expensive to achieve desired results.

## Questions of current interest

- Adaptability/generalizability to adolescents in developing countries
- Implementation by teachers in classrooms
- Long-term effects and maintenance of behavior change
- Effects on rates of sexually transmitted diseases, including HIV

## A Final Word

- Adolescents are at high risk of HIV/STD in the US and worldwide.
- Interventions can be efficacious.
- Behavior-change theory and tailoring to the population.
- Efficient ways to provide effective interventions to the diverse populations in need.
- Important questions are unanswered.
- Still, considerable progress has been made.
- We are optimistic about yield of future studies.

*Thank you!*