Development and Testing of a Jamaican Mother-daughter HIV Risk-reduction Program
Condition: Parent-Child Relations; HIV Prevention; Adolescent Behavior
Study type: Interventional

Summary: 
      Caribbean nations, including Jamaica, exhibit HIV rates that are second only to sub-Saharan
      Africa. Jamaican young women and adolescent girls are at particularly high risk due to a
      number of cultural factors, gender norms, partnering with older male partners, and lack of
      knowledge and skills related to sexual refusal and HIV prevention. U.S. studies have shown
      that mothers may act as a key influence of their daughters' sexual risk beliefs and
      behaviors. However, no such studies have documented these effects outside of the U.S. and no
      studies have evaluated HIV risk-reduction interventions with Jamaican adolescent girls and
      their mothers. Hence, the purpose of this study is to partner with the University of the West
      Indies, Jamaican community based organizations (CBOs) and families in order to develop and
      test a culture-specific mother-daughter HIV risk-reduction intervention in a randomized field
      experiment. Specifically, the investigative team will evaluate whether a culture-specific,
      theory-based, skill-building intervention with Jamaican adolescent girls and their mothers
      can directly and/or indirectly reduce these girls' HIV risk-associated sexual behaviors.
      Jamaican girls, ages 13 - 17, and their mothers/female guardians will be recruited from CBOs
      and randomly assigned to either: (a) a mother-daughter HIV risk-reduction intervention
      condition or (b) a "no intervention" waitlist control condition. The HIV risk-reduction
      intervention includes 12 1-hour modules scheduled over 2 days and implemented by trained
      adult Jamaican women (nurses and CBO staff). The mother component is designed to increase
      those parenting behaviors (e.g., monitoring and parent-teen sexual risk communication
      [PTSRC]) associated with reduced adolescent sexual risk-taking; the teen component is
      designed to improve girls' beliefs and skills related to abstinence, sexual negotiation and
      condom use. A "waitlist" control condition is being employed as the proposed project is a
      pilot study of the HIV risk-reduction intervention. Primary outcomes include
      mothers'/daughters' reports of parenting behaviors (monitoring and PTSRC) and daughters'
      self-reports of sexual risk behaviors (sexual intercourse, unprotected sex, condom use,
      number of partners). Secondary outcomes include daughters' STI rates, mothers' beliefs
      regarding parenting behaviors and daughters beliefs regarding sexual risk behaviors.
    

Detailed description: 
      Caribbean nations, including Jamaica, exhibit HIV rates that are second only to sub-Saharan
      Africa. Jamaican young women and adolescent girls are at particularly high risk for HIV and
      other sexually transmitted infections (STIs) due to a number of cultural factors (including
      male-dominated gender norms and older male partners) and lack of knowledge and skills related
      to sexual communication, refusal and HIV prevention. Reducing the sexual risk behaviors of
      Jamaican adolescent females is critical to reducing their risk for HIV/STIs. U.S. studies
      have shown that parents, particularly mothers, may act as key influences of their daughters'
      sexual risk beliefs and behaviors. However, no studies have documented these parental effects
      outside of the U.S. and no studies have evaluated the effectiveness of family-based HIV
      risk-reduction interventions with international populations, including Jamaican adolescents.
      Further, it is not yet known whether the instruments used to assess the theoretical
      constructs of interest are culturally sensitive or appropriate for use with Jamaican
      adolescents and adults. Hence, the broad objective of this proposal is to develop and test a
      culturally sensitive, theory-based, gender-specific Jamaican mother-daughter HIV
      risk-reduction intervention by using community-based participatory research methods and
      existing collaborative relationships between investigators from the New York University, the
      University of Pennsylvania Center for Health Disparities Research (PENN) and the University
      of the West Indies (UWI), Mona Campus. Building upon already completed preliminary
      elicitation research with Jamaican adolescents, parents, teachers and stakeholders, the
      investigative team proposes to a) conduct in-depth elicitation research into the social,
      cultural and family factors that influence HIV-related sexual risk behaviors among Jamaican
      adolescent girls; b) collaboratively develop a culturally appropriate, gender specific,
      theory-based mother-daughter HIV risk reduction intervention for Jamaican adolescent girls
      and their mothers; c) enhance the research capacity of the UWI School of Nursing and the
      sustainability of the intervention program; d) assess the cultural appropriateness of study
      instruments and adapt and refine as needed; and e) evaluate the effectiveness of the
      mother-daughter HIV/STI risk reduction intervention through a randomized pilot study.
      Although the term "mother" is used throughout the application, it is defined based upon the
      preliminary elicitation research already completed in Jamaica. The term "mother" will be used
      to represent the primary female guardian or caregiver; this may be the mother, step-mother,
      aunt, grandmother or other related or unrelated female guardian or caregiver. In the proposed
      pilot study, the plan is to recruit 360 Jamaican adolescent females, ages 13 - 17 years, and
      their mothers from non-governmental community-based organizations (CBOs) in and around
      Kingston, Jamaica and randomly assign them to either a mother-daughter HIV/STI risk-reduction
      intervention condition or a "no intervention" waitlist control condition that includes only a
      brief educational activity addressing heart disease. The HIV risk-reduction intervention will
      be implemented by trained adult Jamaican women (nurses and CBO staff). The adolescent
      component is designed to reduce HIV-related sexual risk behaviors (e.g., sexual intercourse,
      unprotected intercourse, multiple partners); the mother component is designed to increase
      those parenting behaviors (e.g., monitoring and parent-teen sexual risk communication
      [PTSRC]) associated with reduced adolescent sexual risk-taking. A "no intervention" waitlist
      control condition is being employed as the proposed project is a pilot study of the HIV/STI
      risk-reduction intervention. Should the pilot study find evidence of intervention
      effectiveness, a full RCT study with long-term follow-up and examination of moderation of
      intervention effects will be proposed in a subsequent application.

      There are four specific aims for the proposed project. Aim 1 is to conduct broad, in-depth
      elicitation research using community-based participatory research (CBPR) methods in order to
      elucidate the social, cultural and family factors that influence Jamaican adolescent girls'
      sexual risk-taking during Years 01 and 02. Aim 2 is to develop a culturally appropriate,
      gender specific, theory-based, skill-building mother-daughter HIV/STI risk-reduction
      intervention during Year 02. Aim 3 is to evaluate the cultural appropriateness of our
      commonly used measures and research instruments using both qualitative and quantitative
      methods in Year 02. The remaining Aims evaluate the effectiveness of the Jamaican
      Mother-Daughter HIV/STI Risk-Reduction Project through a randomized pilot study. Aim 4A is to
      examine whether mothers in the HIV/STI risk-reduction intervention condition show a greater
      increase in intentions and actual parenting behaviors (monitoring and PCSC) at 3- and 6-month
      follow-ups compared with mothers in the control group. Aim 4B is to examine whether
      adolescent girls in the HIV/STI risk-reduction intervention condition show a greater increase
      in intentions and reduction in actual sexual risk behaviors (sexual intercourse, unprotected
      intercourse, number of sexual partners) at 3- and 6-month follow-ups compared with girls in
      the control group. Aim 4C is to examine whether adolescents in the HIV/STI risk-reduction
      intervention exhibit a lower incidence of clinically documented STIs at 6-month follow-up
      compared with the adolescents in the control condition. Aim 4D is to identify why and how the
      mother-daughter HIV/STI risk-reduction intervention works (i.e., mediation of effects). The
      mother-daughter intervention is based on a family expansion of the Theory of Planned
      Behavior. The intervention is intended to affect the adolescents' sexual risk behaviors
      (abstinence, intercourse, unprotected intercourse, condom use, number of partners) by
      affecting their behavioral, normative and control beliefs and intentions toward safer sex and
      sexual risk behaviors. It is also designed to affect mothers' key parenting behaviors
      (monitoring and PTSRC) by affecting their behavioral beliefs, normative beliefs, control
      beliefs, and intentions toward those parenting behaviors. Parenting behaviors should, in
      turn, indirectly affect adolescents' sexual risk beliefs, intentions and behaviors. Thus,
      these theoretical mediators will be assessed in order to understand why the intervention is
      effective or not. Findings from this study will contribute to the development of effective
      HIV/STI risk-reduction programs for Jamaican adolescent girls. Significant information will
      also be gained regarding the design of effective family-based interventions, how to partner
      with international organizations and communities, and how to develop culturally appropriate
      instruments and effective HIV risk-reduction interventions for use with international
      populations at highest risk for HIV/AIDS.
    

Intervention name(s): Behavioral Intervention
Intervention type(s): Other
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: Mother-daughter dyads were randomly assigned to either HIV risk-reduction intervention group or control group
Masking: Single (Outcomes Assessor)
Primary purpose: Prevention