# Presentation: 413432

## FROM RESEARCH TO PRACTICE TO POLICY: REDUCING HIV RISK AMONG AFRICAN AMERICAN ADOLESCENTS IN URBAN COMMUNITIES

**Loretta Sweet Jemmott, Ph.D., RN., FAAN**
**van Ameringen Professor in Psychiatric Mental Health Nursing**
***University of Pennsylvania -  School of Nursing***

**CO-INVESTIGATORS**

- John B. Jemmott III, Ph.D. Annenberg School of Communication
- Freida Outlaw, DNScSchool of Nursing
- M. Katherine Hutchinson, Ph.D, RNSchool of Nursing
- Larry Icard, Ph.D.School of Social Work
- Vivian Gadsden, Ph.D.Graduate School of Education

- David Metzger, Ph.D.Department of Psychiatry - Center for Studies      Addiction
- Ann O’ Leary, Ph.D.Centers for Disease Control and Prevention
- Erica Gollub, Ph.D.Department of Psychiatry - Center for Studies Addiction
- Geoff  Fong, Ph.D.Waterloo University, Canada

## National Institute of Nursing ResearchNational Institute of Mental HealthNational Institute of Child Health and    Human Development

- FUNDING SOURCES

##  Elucidate the social psychological factors that underlie HIV risk associated sexual behavior.  
Identify the particular conceptual variables that are most important to achieving intervention-induced sexual behavior change. 
Identify theory-based, culture-sensitive, developmentally appropriate strategies to reduce HIV risk-associated sexual behaviors. 

- Identify the particular conceptual variables that are most important to achieving intervention-induced sexual behavior change.
- Identify theory-based, culture-sensitive, developmentally appropriate strategies to reduce HIV risk-associated sexual behaviors.

**A PROGRAM OF RESEARCH THAT SEEKS TO:**

## A PROGRAM OF RESEARCH THAT SEEKS TO: (continued)

- Answer practical questions about the most effective way to implement HIV risk-reduction interventions with ethnic minority youth.
- Test the effectiveness of such interventions using scientifically rigorous methodologies and experimental designs.
- Disseminate effective research-based behavioral interventions to CBOs, schools, clinics, etc.

## ADOLESCENTS ARE AT RISK FOR SEXUALLY TRANSMITTED HIV INFECTION

- 17% of AIDS cases involve young adults 20 to 29 years of age.
- 17% of HIV infections reported during 2000 were among people 13 to 24 years of age.
- Adolescent pregnancy is a national concern.
- High rates of sexually transmitted diseases.
- Failure to use condoms

## CHALLENGES IN HIV RISK-REDUCTION RESEARCH WITH ADOLESCENTS

- Feelings of invulnerability
- Resistance to abstinence messages
- Negative beliefs about safer-sex practices
- Inadequate confidence to negotiate safer sex
- Legal or policy barriers
- Sporadic sexual behavior

## KEY RESEARCH QUESTIONS FOR ADOLESCENTS

- Can the behavior of high-risk youth be changed?
- Can culture-sensitive programs be effective when implemented by facilitators who do not share the ethnicity of participants?
- Can abstinence-based interventions be effective?
- How effective are peer educators?
- Can evidenced-based practices be disseminated and evaluated when implemented by end users?

## HOW DO WE CONDUCT OUR RESEARCH?

## PHASES OF RESEARCH

-       1. Elicitation (Focus Groups)
- 	2.  Questionnaire Development
- 	3.  Design Intervention
- 	4.  Pilot Intervention
- 	5.  Evaluation
- 	6.  Dissemination

## THEORETICAL MODELS

*Social Cognitive Theory **	*					Self-efficacy, Outcome Expectancy, (Hedonistic, Partner	 	Reaction, Prevention Beliefs) and Skills.
*Theory of Reasoned Action* 						Attitudes, Beliefs, Subjective Norms and Intentions.
*Theory  of Planned Behavior* 					Perceived Behavioral Control and Control Beliefs

## THEMES: (FAMILY, COMMUNITY, CULTURE & PRIDE)

*“**Respect Yourself, Protect Yourself...Because You  Are Worth It”** *
*“**Let’s Work Together to Save Our People & Community.”** *
*“**Be Proud, Be Responsible...Respect Yourself, Protect Yourself!”** *

## THE "BE PROUD! BE RESPONSIBLE!" THEME, ENCOURAGES ADOLESCENTS TO:

- Be proud of themselves, their family and their community,
- Behave responsibly for the sake of themselves their family and their community, and
- To consider their goals for the future and how unhealthful behaviors might thwart the attainment of their goals and dreams.

## WHAT DO OUR INTERVENTIONS INVOLVE?

- Small Group Discussion
- Culturally Appropriate Themes & Strategies
- Developmentally Appropriate Strategies
- Interactive Activities
- Audiovisuals

- Knowledge
- Self-efficacy
- Attitudes/Beliefs
- Goals & Dreams
- Technical Skill Building
- Role Playing
- Practice and Feedback

## JEMMOTT, JEMMOTT, & FONG (1992, AJPH)--DESIGN

- Randomized controlled trial
- 157 African American male adolescents at a weekend program
- Mean age was 14.6 years
- 83% reported ever having sexual intercourse

- Five hour cognitive-behavioral small group intervention
- Facilitator gender
- 96% 3-month follow-up return rate

## JEMMOTT, JEMMOTT, & FONG (1992, AJPH)--RESULTS

- Reduced HIV risk-associated sexual behavior
- Reduced frequency of sexual intercourse
- Reduced unprotected sexual intercourse
- Fewer sexual partners
- No consistent effect of gender of facilitator
- Self-reported sexual behavior change unrelated to social desirability bias

## JEMMOTT, JEMMOTT, FONG & MCCAFFREE (1999 AJCP) --DESIGN

- Randomized controlled trial
- 496 African American adolescents at a weekend program
- Mean age was 13.1 years
- 54% were female
- 55% reported ever having sexual intercourse

- 5-hour cognitive-behavioral small group intervention
- Facilitator race, facilitator gender, and group gender composition
- 96% 3-month follow-up return rate; 93% 6-month follow-up return rate

## JEMMOTT, JEMMOTT, FONG & MCCAFFREE (1999 AJCP) --RESULTS

- Reduced HIV risk-associated sexual behavior
- Reduced unprotected sexual intercourse
- Self-reported sexual behavior change unrelated to social desirability bias
- Intervention effects were the same irrespective of race of facilitator, gender of facilitator, and the gender composition of the group

## JEMMOTT, JEMMOTT, & FONG (1998, JAMA)--DESIGN

- Randomized controlled trial
- 659 African American adolescents at a weekend program
- Mean age was 11.8 years
- 53% were female
- 25% reported ever having sexual intercourse

- 8-hour abstinence-based, safer-sex, or general health promotion intervention
- Adult facilitator or peer co-facilitators
- 96% 3-month follow-up return rate

## JEMMOTT, JEMMOTT, & FONG (1998, JAMA)-- RESULTS

- Abstinence intervention reduced the frequency of coitus and, in virgins, delayed initiation of coitus
- Safer-sex intervention increased condom use
- Safer-sex intervention reduced unprotected coitus
- Adult and peer facilitators equally effective
- Self-reported sexual behavior change unrelated to social desirability bias

## HOW DO EFFECTIVE INTERVENTIONS GET DISSEMINATED TO END USERS, SUCH AS SCHOOLS, COMMUNITY BASED ORGANIZATIONS, OR HEALTH CLINICS?

## 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
*"Be Proud! Be Responsible! Strategies to Empower Youth to Prevent AIDS”* *(Jemmott, et al, 1994)*

## CDC'S DISSEMINATION PROJECT "RESEARCH TO CLASSROOMS: PROGRAMS THAT WORK"

*"Making A Difference! An Abstinence Based Approach to Prevent HIV, STD, and Teenage Pregnancy"  **(Jemmott,et al., 2001).**     **                                                                         *
*"Making Proud Choices! A Safer Sex Approach to Prevent HIV, STD, and Teenage Pregnancy" **(Jemmott, et al., 2001) *

## WHY DOES OUR INTERVENTION WORK?

- Teaches skills
- Emphasizes hedonistic beliefs
- Holds their attention
- Very interactive & fun
- Non judgmental, caring & supportive
- Culturally sensitive

- Videos are appropriate
- Excellent teacher-student interaction
- Age specific
- Good discussions
- Credible
- Promotes confidence
- Build pride/ responsibility

## WHAT ROLE HAS POLICY PLAYED IN DISSEMINATING THESE EVIDENCED BASED PROGRAMS TO END USERS?

## RESEARCH TO POLICY TO PRACTICE

- CDC's National Training of Trainers Project for "Research to Classrooms - Programs That Work" Curricula.
- CDC's Community Planning Group Initiative - A community level approach for providing evidenced-based strategies for reducing HIV risk associated behavior.

## SISTER TO SISTER:  THE BLACK WOMEN’S HEALTH PROJECT

- Funded by The National Institute for Nursing Research

## HIV PREVENTION FOR AFRICAN AMERICAN WOMEN IN PRIMARY CARE SETTINGS JEMMOTT, JEMMOTT & O'LEARY, et al., 

-  _*Purpose of Study*_:  To evaluate the effectiveness of HIV risk reduction intervention on self reported HIV sexual risk behaviors and incidence of sexually transmitted  diseases (STDs) among inner-city African American women attending a primary care clinic in Northern New Jersey.

## CHALLENGES IN HIV PREVENTION FOR AFRICAN AMERICAN WOMEN

- Feelings of invulnerability
- Resistance to condom use messages
- Negative beliefs about safer-sex practices
- Inadequate confidence to negotiate safer sex
- Inadequate confidence in condom use skills
- Concerns about partner reaction, poverty, violence, children, drug use, etc.

## KEY RESEARCH QUESTIONS FOR WOMEN

- Can the behavior of women be changed?
- What type of HIV risk reduction intervention is best for African American women in a primary care setting? Group vs. Individual? Information alone vs. Skill based?
- Can a single session, 20 minute 1-on-1 skill-based intervention reduce HIV risk-associated sexual behavior and the incidence of STDs?

## JEMMOTT, JEMMOTT, & O’LEARY DESIGN

- Nurse-led randomized controlled trial
- 564 African American women attending a primary care clinic
- Mean age, 27 years
- Facilitators: 27 African American nurses

- 1 of 5 conditions
- 3, 6, 12 month follow-up
- Self reported sexual behavior
- STD clinical exam
- 86.9% retained at 12-month follow-up

## THE 5 INTERVENTIONS

- Contrasted two methods of delivery - group vs. individual
- Two kinds of interventions content - information vs. skill-building
- Health promotion control group

## RANDOMLY ASSIGNED TO 1 OF 5 CONDITIONS

- 20 minute skill-based 1-on-1 intervention.
- 20 minute information-alone 1-on-1 intervention.
- 3.5 hour  skill based group intervention.
- 3.5 hour information alone group intervention.
- 3.5 hour health promotion control group.

## MOTHERS AND SONS HEALTH PROMOTION PROJECT

**MOTHERS AND SONS HEALTH PROMOTION PROJECT**

## MOTHERS AND SONS HEALTH PROMOTION PROJECT

- Randomized controlled trial
- 42 housing developments in Philadelphia
- 16-hour  cognitive-behavioral small group intervention over 4 Saturdays
- Homework assignments

- 630 single African American mothers and their sons ages 11-15
- Facilitators - 84 women residing in the housing developments
- Mother's sexual behavior
- Son's sexual behavior
- 24-month follow-up

## PURPOSE

-  The purpose of the study is to identify effective, theory - based, culturally sensitive behavioral interventions to help single African American mothers reduce their own and their son’s risk of sexually transmitted HIV infection.

## MOTHERS AND SONS HEALTH PROMOTION PROJECT

**MOTHERS AND SONS HEALTH PROMOTION PROJECT**

## MOTHERS AND SONS HEALTH PROMOTION PROJECT

**MOTHERS AND SONS HEALTH PROMOTION PROJECT**

## MOTHERS AND SONS HEALTH PROMOTION PROJECT

**MOTHERS AND SONS HEALTH PROMOTION PROJECT**

## MOTHERS AND SONS HEALTH PROMOTION PROJECT

**MOTHERS AND SONS HEALTH PROMOTION PROJECT**

## WHAT ARE MY NEW RESEARCH PROJECTS?  

## CHURCH & FAMILY HEALTH PROMOTION PROGRAM

**TOGETHER WE CAN DO ALL THINGS**

## CHURCH-BASED PARENT-CHILD HIV RISK REDUCTION PROJECT

- Randomized controlled trial
- 10 Black Baptist Churches in Philadelphia
- 12-hour small group intervention over 3 Saturdays
- 720 single African American parents and their children ages 11-14

- 1 of 3 conditions
- Facilitators - 18 adults from each church
- Parent-child communication
- Homework assignments & booster sessions
- Child's sexual behavior
- 24-month follow-up

## REDUCING SEXUAL RISK BEHAVIOR AMONG BLACK SUBSTANCE ABUSING WOMEN

## REDUCING SEXUAL RISK BEHAVIOR AMONG BLACK SUBSTANCE ABUSING WOMEN

- Randomized controlled trial
- Presbyterian Medical Center Detox facility
- One of three conditions
- 869 African American women

- Facilitators: nurses and certified addiction counselors
- Sexual behavior
- Clinically documented STDs
- 3- & 6-month booster sessions
- 12- & 18-month follow-up

## CONCLUSIONS  THE RESULTS SUGGEST THAT:

-  Relatively brief but intensive culturally sensitive and developmentally appropriate HIV risk-reduction interventions can have significant impact on HIV risk behavior and theory-based mediators of such behavior among African American youth and women.
- HIV Risk Reduction needs to consider partner approval, hedonistic expectancies, and skills when designing interventions for African American youth and women.

## CONCLUSIONS  THE RESULTS SUGGEST THAT: 

- By developing, testing and disseminating such interventions we can reduce the risk of sexually transmitted HIV infection among this population.
-  I am optimistic that continued work along these lines will curtail the spread of HIV.