# Presentation: 770217

## HIV Prevention among Adolescents:  Diffusion of Innovation in a Community Trial

- Kathleen J. Sikkema, Ph.D.
- Yale University School of Medicine
- Eileen S. Anderson, Ed.D.2; Jeffrey A. Kelly, Ph.D.1; Richard A. Winett, Ph.D.2; Cheryl Gore-Felton, Ph.D.1;; Roger Roffman, DSW 3; Timothy G. Heckman, Ph.D.
- Raymond Hoffmann, Ph.D.1 Michael J. Brondino, Ph.D.1
- 1Medical College of Wisconsin, Milwaukee, WI; 2Virginia Tech, Blacksburg, VA; 3University of Washington, Seattle, WA;

- Research was supported by grant R01-MH42908 from the National Institute of Mental Health (NIMH) and by NIMH Center grant
- P30-MH522776

## About 14,000 New HIV Infections a Day In 2003

**More than 95% are in developing countries**
**Almost 2000 are in children under 15 years of age**
**About 12 000 are in persons aged 15 to 49 years, of whom:**
**    ****almost 50% are women**
**  ****about 50% are 15–24 year  ****	****	**** olds**

## Community-Level Trials

- Change social networks and communities to reinforce risk avoidance and risk reduction efforts
- Potential to reach large numbers of people
- Be cost-effective
- Feasible for implementation in areas with limited resources

## Community-Level Interventions

- Diffusion of Innovation Theory (Rogers)
- Social Cognitive Theory (Bandura)

## What is Diffusion?

- Innovation: idea, practice or object perceived as new
- Communication channels by which messages are exchanged
- Time, or process
- Social system: structure and function of relations among individuals

## Diffusion Concepts for Targeted Groups

- Process over Time
- Opinion Leaders
- Decentralized Diffusion Systems
- Change Agents
- Compatibility

## Community Intervention Projects: United States	

- Men from gay bars in small cities
- Women in low-income housing developments
- Adolescents in urban housing developments

## Gay Bars in Small Cities

- Kelly JA, Murphy DA, Sikkema KJ, et al.  Randomized, controlled,
- community-level HIV prevention intervention for sexual risk
- behavior among homosexual men in US cities.  *The Lancet.  *
*1997; *_*350*_*: 1500-1505.*

## Women in Low-Income Housing Developments

- Sikkema KJ, Kelly JA, Winett RA, et al.  Outcomes of a randomized
- community-level prevention intervention for women living in 18
- low-income housing developments.  *American Journal of Public*
*Health*. 2000; _90_: 57-63.

## Scope of Project

- Seattle/Tacoma, WA

- Rochester, NY

- Roanoke, VA

- Cleveland, OH

- Milwaukee, WI

- 18 Housing Developments
- Moderate size (80-175 units);
-   cluster-type developments
- Female heads of household

## Research Design

- Baseline

- Community
- Intervention

- Follow-Up

- Baseline

- Brochures
- And
- Condoms

- Follow-up

- 18 months

## Community Intervention Elements

- Women’s Health Council
- Skills Training Workshops
- Community Activities and Events

## Baseline Results

-  1,265 females
-  Mean age – 33.8 (range 15-86)
-  75% African American
- 20% White
- 3% Hispanic/Latina
- 2% Other
-  Mean number of children – 2.8
- 	 (range 0-15)

## Intercourse Occasions with Condoms

- Significance with development as unit of analysis, df=1, 16; p<.01

- Percent

## HIV Prevention Among Adolescents

- Skills training interventions are state-of-the-science
- Interventions focused on individuals
- Limited studies targeted to pre- or early adolescence
- Focused on abstinence outcomes with conflicting findings
- Most are school-based
- Long term effectiveness is limited
- Need for interventions that change social networks and communities

## Can HIV prevention efforts be improved and better maintained by...?

- Skills training to enact behavior change
-                          AND
- Community-level intervention that provides modeling, peer norm and social reinforcement for _reducing_ or _avoiding_ HIV risk behavior

## Scope of Research

- Seattle/Tacoma, WA

- Milwaukee, WI

- Roanoke, VA

- 15 Housing Developments
-  5 sets of three matched  developments
-  56-350 adolescents

## Research Design

- Baseline

- Skills

- Short-term
- Follow-up

- Community
- Component

- Long-term
- Follow-up

- Baseline

- Skills

- Short-term
- Follow-up

- Long-term
- Follow-up

- Baseline

- Education

- Short-term
- Follow-up

- Long-term
- Follow-up

- Community:

- Skills:

- Control:

- 18 months

## Baseline Results

- 1172 adolescents (587 males, 585 females)
- Average age = 14.5
- 7th grade education
- 99% attending school
- 73% not yet in high school
- _Study Cohorts_ vs. _Baseline Only_
- Younger; lived in development longer
- Less likely to : have had sex
- 				 use substances
- 				 have had an STD

## Racial/Ethnic Characteristics(n = 1172)

##  Sexual Activity Among Cohort Adolescents at Baseline

- 25% had sexual intercourse
- 76% condom use last intercourse
- Average age first intercourse:
- 	12.5 years
- Average of 6 sexual partners past year
- 11% had anal intercourse past 3 months
- 9% ever had STD

## Skills Training

- Skills Training Group Intervention        	(4ME)
- “State-of-the-Science” cognitive- behavioral skills training
- Condoms and brochures available
- Two sessions (6 hours total)
- Groups by age and gender
- Delay/refrain from sexual activity
- Consistent condom use if sexually active

## Pre-Community Component Activities

- Social Events/Movies
- Follow-up Session
- Systematic Selection of Peer Leaders
- Focus Group and Team Building

## Community Component

- Teen Health Council of Peer Leaders
- Program Activities:  4ME participants
- Small Media:  Prevention messages
- Community Wide Events
- Parent Workshops:  HIV/AIDS and Talking to Your Children