Long-term Effects of a Middle School– and High School–Based
Human Immunodeficiency Virus Sexual Risk Prevention Intervention
David M. Siegel, MD, MPH; Marilyn J. Aten, PhD, RN; Maisha Enaharo, MPH
Objective To determine the longer-term effect (mean SD, 41.2 15.3 weeks;
range, 14.1-80.5 weeks) of a middle school (MS)– and high school (HS)–based
human immunodeficiency virus and sexuality intervention (Rochester AIDS
Prevention Project for Youth [RAPP]) on knowledge, self-efficacy, behavior
intention, and behaviors.
Design Quasi-experimental design with 3 intervention groups and 1 control
group.
Setting Urban, predominantly ethnic, minority MS and HS health classes.
Participants Middle school and HS students (N = 4001) enrolled in health
classes in 10 schools. Fifty percent were African American; 16%, Hispanic; 20%,
white; and 14%, other. Less than 10% of the students refused participation.
Interventions There were 4 study conditions: (1) control, usual health education
curriculum taught by a classroom teacher; (2) RAPP adult health educator,
intervention curriculum implemented by highly trained health educators; (3)
RAPP peer educator, intervention implemented by extensively trained HS
students; and (4) a comparison of the RAPP intervention curriculum taught by
regular health teachers, implemented with MS students only.
Main Outcome
Measure A confidential
questionnaire was administered to all study subjects before and at long-term
follow-up after the intervention, containing scales to measure knowledge,
self-efficacy, behavior intention, and behaviors, including onset of sexual
intercourse experience and engagement in risky sexual behaviors.
Results Rates of baseline sexual activity in the sample were comparable to
those found in other urban school-based surveys. Long-term knowledge (MS
females, P<.001; and MS males,
P<.01) and sexual
self-efficacy (MS females, P<.05;
and HS females, P<.01) scores
were higher among the intervention groups (male and female are used in this
study to describe those aged 9½-23 years). Intention to remain safe regarding
sexual behavior was also greater among intervention groups in MS but not HS.
However, subjects who were already sexually active at pretest were less likely to
show a positive intervention effect. An intervention effect for the onset of
intercourse and risky sexual behavior was found most significantly among MS
females.
Conclusions A positive long-term effect from the RAPP intervention was
observed, particularly for youth who were involved in less risk (eg, not yet
sexually active) at study enrollment. Thus, we propose that the most
appropriate time for intervention implementation is earlier in adolescence,
before the onset of risky behaviors.
Arch Pediatr Adolesc Med.
2001;155:1117-1126
DESPITE MANY efforts directed at prevention,
adolescents continue to represent a significant proportion of Americans who are
diagnosed as having sexually transmitted diseases.1, 2 In addition,
unintended pregnancy among US teenagers persists and carries medical,
emotional, and social costs.3, 4 Although only a few of
those in the United States with the acquired immunodeficiency syndrome (AIDS)
are adolescents,5 given the long
incubation period for the human immunodeficiency virus (HIV), it is estimated
that one fifth of those with AIDS were infected as teenagers.6 Since neither a cure
nor an effective vaccination has yet been developed, primary prevention remains
the most powerful strategy for curbing this epidemic. Since behaviors determine
the likelihood of HIV infection, prevention programs must focus on maintaining
safer behaviors (such as abstinence from sexual intercourse or consistent use
of condoms and other barriers)7, 8 and interventions need
to include many participants to effectively reduce HIV risk in an adolescent
population.
In an effort to capture large groups of
teenagers for developing effective HIV, sexually transmitted disease, and
pregnancy prevention interventions, research9-12 has been based in
urban schools, where reported rates of having already experienced sexual
intercourse are relatively high. Because schools are structured to gather
students as a "captive audience," and some form of HIV and family
life education is already part of the curriculum, it is an ideal setting for
implementing and testing HIV and sexual risk prevention interventions. In an
earlier publication,12 the short-term
results of the Rochester AIDS Prevention Project for Youth (RAPP) were
presented. The intervention was successful in increasing not only knowledge but
also intentions to behave in sexually safer ways. The RAPP intervention, taught
by peer educators (Peer Eds) and, in middle school (MS), by regular health
teachers (RHTs), demonstrated a positive effect relative to the control and the
health educator (H Ed)–taught groups. Meaningful behavior change outcomes from
the RAPP intervention can only be described after sufficient follow-up. Little
published work in this area reports on follow-up beyond 3 to 6 months.10 The present report
describes the longer-term (mean SD follow-up,
41.2 15.3 weeks)
effect of RAPP on knowledge, self-efficacy, behavior intentions, and, most
important, behaviors related to sexual intercourse and risk for HIV infection.
SAMPLE
The subjects (N = 4001) (Table 1)
were drawn from 10 urban schools in a medium-sized northeastern city with a
population of approximately 250 000. The criteria for study inclusion were
that students were (1) enrolled in required health education classes and (2)
fluent in either English or Spanish. The ethnicity of the sample was diverse:
50% were African American; 16%, Hispanic; 20%, white, non-Hispanic; and 14%, other
(including Asians, Native Americans, and those who indicated that they were
biracial). Although the student population of the school district is generally
of low socioeconomic status (70% of the families have incomes less than the
federal poverty level), some differences might have confounded findings. For
confidentiality reasons, and because younger teenagers often do not know about
family income, employment, or education, we used a socioeconomic status proxy
based on median house value, rent, and family income and on educational level
of the adult population within each census tract. The proxy (socioeconomic area
[SEA]) consisted of subject-reported ZIP code and street address, and the mean
SEA was 5.2 (SD, 2.7), slightly lower for MS than high school (HS) students.
PROCEDURE
Intervention
Students were recruited (as classroom cohorts) within their regular school
health education classes to participate in RAPP, a quasi-experimental
classroom-based intervention designed to increase knowledge and skills aimed at
safe behavior regarding sexuality and HIV/AIDS. Passive parental consent for
student participation was obtained. The parents of all students scheduled to
take health in the upcoming school year are routinely sent a letter from the
district director of health and physical education informing them that family
life education, including sexuality, will be taught and they can request their
son or daughter not participate in that unit. During the study, a description
of the RAPP program was a part of this letter, and parents were given the
opportunity to inquire further about RAPP and/or refuse participation.
Questions were directed to the study principal investigator (D.M.S.), who met
with parents individually to address their concerns; few (<10 families)
withdrew their son or daughter. The opportunity to refuse study participation
was verbally offered in the classroom after the study description and before
the first session. In addition, students were told that they could withdraw
from the study at any time, and on the study instrument, instructions indicated
that a student could choose not to complete the questionnaire.
Classes were assigned within semesters to 1 of 3
conditions: (1) control, the usual health education curriculum taught by the
RHT; (2) RAPP adult H Ed, the RAPP intervention implemented by a male-female
ethnically diverse pair of highly trained adult educators; or (3) RAPP Peer Ed,
volunteer HS students who completed approximately 50 hours of preparation by
RAPP staff and taught the RAPP curriculum as pairs of educators. Health
education in MS was taught in seventh grade only, while in HS, students had the
option to take health in 10th, 11th, or 12th grade; most students chose 10th or
11th grade. The semester assignment of classes to the intervention condition
was based on feasibility issues and the availability of Peer Eds. However, by
study conclusion, all health classes in each of the participating MSs and HSs
had been assigned to each of the study groups (experimental and control). At no
time did intervention and control conditions take place in the same school
during a given semester. These design features enhanced generalizability by
ensuring that the study groups were spread across all different schools, while
avoiding contamination between intervention and control classes. Within the
year following the main study, regular MS teachers only were trained to
implement the curriculum. This fourth study condition tested the transfer of
the content and process of teaching to regular school personnel.
The RAPP intervention (H Ed, Peer Ed, or RHT)
consisted of 10 (HS) or 12 (MS) consecutive health class sessions (usually 2 or
3 sessions per week) delivered for 2 to 7 weeks. The intervention was
integrated into the regular school health education schedule to avoid
disruption within schools and to build an intervention that might generalize to
other schools in the future. The content was based on literature9 concerning school-based
interventions, the expertise of the RAPP H Eds, and principles from the Theory
of Reasoned Action13, 14 and normal adolescent
development. The intervention is most similar to the fourth generation of
"abstinence plus" interventions, which promote sexual abstinence but
also include safer sex messages.11 Early sessions
emphasized self-esteem and decision-making strategies, while later classes
progressed through in-depth discussion and skill-based activities concerning
sexuality, sexually transmitted diseases, pregnancy, and, finally, HIV/AIDS.
This last topic received particular emphasis, and all sessions included small-
and large-group activities such as games, role plays, and take-home exercises
often requiring parental input. Priority was placed on maximum engagement of the
students in a highly interactive and dynamic learning experience in both
intervention conditions.
Data Collection
Students completed a confidential survey at baseline (preintervention),
immediately after the intervention, and at long-term follow-up. The survey
instrument, available in English and Spanish, was read to students during a
40-minute health class by the project H Eds. The study was reviewed and
approved by the administration of the local school district and the university
institutional research review board. Students were assured that their answers
were confidential to the research staff, and that they could participate in the
health classes without completing the research instrument. More than 90% of the
students completed the survey preintervention. Those who declined participation
were provided alternate school activities. Subjects were tracked over time by
using (1) a school district–assigned identification (ID) number and (2) an RAPP
study ID number. Specifically, each health class teacher maintained a roster of
student names and associated school ID numbers. A separate study team list
associated the school ID numbers with unique RAPP-assigned subject numbers.
Surveys maintained by the study team were only labeled with the subject number,
while the school maintained the separate roster that contained the student name
and district ID number. This dual-list procedure confirmed that, despite
student mobility, duplicate subject enrollment did not occur and student
confidentiality was carefully preserved.
Study Instrument
The survey questionnaire, pilot tested on 450 students preceding the main
study, measured constructs determined to be important in assessing the impact
of the RAPP curriculum and has been described in detail elsewhere.12 Those variables
reported herein include demographics, knowledge, self-efficacy regarding sexual
matters, behavior intention within the next year, history of risk behaviors,
history of sexual experiences, and self-reports of behavior. The variable items
and their psychometric properties are summarized in Table 2.
VARIABLES MEASURED
In addition to demographics (age, sex, ethnicity, and the SEA proxy for
socioeconomic status), scales (summarized in Table 2)
were developed during a pilot phase, because of the lack of reliable and valid
scales reported in the literature. Existing literature was reviewed to include
variables represented in the Theory of Reasoned Action. Reliabilities were
computed separately for MS and HS students and ranged from 0.74 to 0.80 (n =
3800 students) for (internal
consistency) and from 0.66 to 0.84 for test-retest reliability (n = 450
students). Factor analyses for each construct revealed 1-factor solutions for
all constructs except "involvement in sexual risk behaviors," which
supported 3 factors ("somesex" represented the initiation of sexual
intercourse, and "risksex" represented some risk involvement). Variance
accounted for by the factors ranged from 10% to 36%.
Knowledge
Students responded to the 26 items with yes if they believed the statement to
be true; no, if false; and not sure (a choice scored as incorrect and included
to minimize guessing and inflation of correct response scores). To avoid a
ceiling effect, individual items were included only if they had less than 80%
correct responses during the pilot phase.
Sex Self-efficacy
This scale, developed from similar work by Misovich et al,15 asked how hard or
easy it would be to carry out each of 8 behaviors in relation to sexuality.
Behavior Intention
An index of intention to behave in safe ways12 included 9 items to
indicate student agreement or disagreement on 7-point scales with selected
statements concerning sexual behavior and substance use.
Life Risk History
Items from the Youth Risk Behavior Survey16 were used to tap 15
questions concerning school- and community-related risks. Furthermore, we asked
a panel of 25 experts in adolescent health (clinicians and behavioral
scientists) to rank the level of risk: 0 indicates no or minimal risk (eg,
missed school without permission); 1, some risk (eg, tried marijuana); and 2,
substantial risk (eg, used marijuana regularly).
History of Sexual Intercourse
Preintervention, students were asked about their history of sexual intercourse
as part of 7 different items addressing onset, frequency, and multiple partner
experience. The degree to which students were consistent across all 7 items in
which there was an opportunity to answer "I have never had sex" was
examined to be confident regarding the validity of responses. Particularly for
younger students, it was important that subjects understood the concept of
sexual intercourse before initiating the intervention. Students were categorized
as ever having had sexual intercourse (score of 1) or never having had sexual
intercourse (score of 0).
Involvement in Sexual Risk
Behaviors
To assess involvement in sexual behavior, students were queried as to their
initiation and engagement in 13 selected behaviors. Factor analyses resulted in
3 dimensions: (1) somesex or the initiation and onset of sexual intercourse
experience, which included 5 items (ever carry condoms, ever had sexual
intercourse, communication with a partner about sex, have had sex 1-5 times
within the past 3 months, and planning ahead to have sex), representing 33% of
the variance; (2) risksex or the engagement in some risky behaviors, which
included 5 items (tried to get pregnant or get a partner pregnant, actual
pregnancy involvement, having had sex when the teenager really did not want to,
having sex while using alcohol or other drugs, and having had sex >5 times
in the past 3 months), representing 10% of the variance; and (3) engagement in
high-risk sexual behaviors (history of sex with an intravenous drug user, anal
sex, oral sex, and a history of HIV testing), representing 8% of the variance.
The third dimension was not meaningful to further analyses as there were few
students who engaged in these most serious behaviors. The first 2 factors were
used as dependent variables in analyses of whether and how much engagement in
actual sexual behavior was reported at longer-term follow-up for all
intervention groups.
CLASS CLIMATE
To test for any differences across various learning settings, the existing
health education class environment was observed and scored by the adult RAPP
educators for all participating teachers/classrooms. Working independently,
each member of a pair of RAPP H Eds rated the physical environment and the
classroom health teacher's facilitation of the RAPP curriculum. The 18 items
were summed to form an overall "class climate" score (range, 0-36).
Rater agreement was high (r>0.80),
and the 2 scores were averaged.
DATA ANALYSES
Since the study design was a quasi experiment, it was important to consider
whether there were preintervention differences in study variables that might
confound findings in relation to long-term outcomes. Therefore, demographics
(age, sex, SEA, and ethnicity), the proportions of females and males (female
and male are used in this study to describe those aged 9½-23 years) who
reported sexual intercourse experience, and the study variables of interest
(knowledge, sexual self-efficacy, general life risk, sex safe behavior
intention, and the self-reports of behaviors concerning initiation of sexual
behavior and involvement in risky sexual behavior) were compared within the MS
and HS groups and by sex. Previous work17, 18 has documented
differences in sexual behavior by age and sex (eg, earlier sexual debut in
males vs females). Also, we compared the observation rating for the class
climate score among the MS and HS groups. Then, the major study analyses
concerning long-term outcomes were tested by repeated-measures analyses of
variance.
The study was a 3-factor design (4 by 2 by 4);
the factors were ethnicity (African American, Hispanic, non-Hispanic white, and
other), history of sexual intercourse experience (yes or no), and intervention
group (control, H Ed–taught, Peer Ed–taught, and, in MS, RHT-taught students).
The procedure for analyses was that demographics, the general life risk score,
the mean score for length of time from intervention, the class climate score,
and the relevant pretest score for each dependent variable were entered as
covariates. Then, each of the factors was entered with the intervention factor
considered last. The strategy was to delineate the long-term intervention
effect beyond other related variables. The interaction between sexual activity
status and intervention group was also examined to determine a given
intervention's differential effectiveness based on whether subjects were
sexually active. Since the sample was large and statistical significance is
easily reached with large sample sizes, effect sizes ( values) are reported for the intervention, as is the total
variance accounted for by the model (R2).
The mean SD duration of long-term follow-up in this study was 41.2 15.3 weeks
(range, 14.1-80.5 weeks); overall, two thirds of the subjects were present at
study conclusion (72% in MS and 55% in HS). Among 12th graders, 73% did not
complete long-term follow-up because of graduation or drop out, while the
attrition for 10th and 11th grade was 55% and 43%, respectively. The 4
intervention groups among the MSs (control, H Ed, Peer Ed, and RHT) and the 3
groups among the HSs (control, H Ed, and Peer Ed) were compared to determine
whether there were significant differences in demographic variables (Table 1)
and for the study variables of interest. While there were significant
differences for age, SEA, ethnicity, and the proportions of students who
reported a history of sexual intercourse experience preintervention, the
magnitude of the differences was, for the most part, small. The most important
differences were that, for MS students, the proportion of females who reported
having experienced intercourse preintervention ranged from 18.4% for RHT-taught
students to 34.2% for H Ed–taught students. In contrast, many more males among
the MS sample reported sexual experience preintervention, ranging from 53.2% of
RHT-taught students to 66.2% of Peer Ed–taught students. Overall, in MS, about
30% of females and 63% of males reported sexual experience at baseline. Among
the HS students, the range of sexual experience among females was from 60.6% of
Peer Ed–taught students to 73.2% of the controls, while the range among males
was from 69.3% of Peer Ed–taught students to 82.3% of controls. Demographics
and the self-reported history of sexual intercourse experience were entered as
covariates in all analyses.
Pretest scores for the major study variables
were also used as covariates in analyses of long-term intervention effects
since there were slight preintervention differences across study groups. It was
also important to control for each subject's pretest score before assessing the
intervention effect. Most differences, however, while statistically
significant, did not indicate meaningful distinctions. For example, MS sexual
self-efficacy scores were higher (safer) among H Ed–taught students (37.5),
Peer Ed–taught students (37.5), and RHT-taught students (37.9) compared with
control students (35.7) (P<.001).
Classroom climate scores represented the greatest preintervention differences
between control and intervention groups, with the largest discrepancy between
MS control (22.5) and RHT (29.9) groups (P<.001)
on a scale that ranged from 12 to 31.
Table 3,
Table 4,
Table 5,
and Table 6
present the analyses of variance models conducted for each of the dependent
variables. The format of these tables is the same as that used in an earlier
article.12 Using Table 3
as an example, the data presentation is as follows. Subjects were stratified by
school level and sex, with variables sequentially entered into the analysis of
variance, shown in the table as rows. In Table 3
(predicting knowledge at posttest), for MS females, the collective contribution
of the covariates to the model yielded an F value of 14.7, with a significance
of P<.001. Taking the
covariates separately, age was a meaningful predictor, with an F value of 11.4,
as was SEA, with an F value of 24.9.
Also in Table 3,
for MS females, the combined contribution of all main effects (to the posttest
knowledge score) was significant, with an F value of 12.2, while ethnicity
alone accounted for an F value of 10.1. In the lower half of the table, the
mean score from the study instrument for the dependent variable in question is
provided. In Table 3,
this would be the mean knowledge scale score. For example, among the MS
females, the F value for the contribution of intervention group membership to
knowledge score at posttest was 20.3, and the mean knowledge scale score for
the control group was 12.9 compared with 15.6, 15.9, and 15.5 for the H Ed,
Peer Ed, and RHT groups, respectively.
For long-term knowledge (Table 3),
covariates were important contributors to outcomes. Increasing age, a higher
SEA, a better class climate score, time from intervention (except HS males),
and the pretest knowledge score (except HS males) were significant. The
long-term knowledge means were consistently greater for the intervention groups
compared with the controls, and were significant for MS females and males.
There were some ethnic differences; white non-Hispanic students generally had
higher knowledge scores, followed by African Americans and Hispanics. The means
for self-efficacy (Table 4)
were higher for each of the intervention groups compared with the controls,
reaching significance for the MS and HS females. Ethnic differences were noted
in that Hispanic youth generally reported less self-efficacy than did other
groups. Covariate significance was almost entirely accounted for by the pretest
self-efficacy score and was highly significant (F values ranged from 80.0 to
175.0). There were no differences for either knowledge or self-efficacy in
relation to whether there was a history of sexual intercourse. Long-term values ranged
from 0.17 to 0.29 for knowledge and from 0.11 to 0.15 for self-efficacy. The
proportions of variance explained by the models (R2) ranged from 0.11 to 0.27 for knowledge and
from 0.12 to 0.35 for self-efficacy, with more variance explained in the HS
models.
Intention to remain safe in regard to sexual
behavior was the third variable considered for short-term outcomes,12 and tested again for
longer-term outcome in the present analyses (Table 5).
Among MS students, the means were lower (representing less intention to remain
safe, including remaining abstinent) for the controls than the intervention
groups. There was no intervention effect for HS students, likely reflecting the
high prevalence of sexual experience that preceded the intervention. In all
groups, the pretest score for intention was again the most significant and
powerful covariate (F values ranged from 98.2 to 223.7). Other covariates,
especially the general life risk score (F values ranged from 9.9 to 37.6), were
also significant. Unlike knowledge and self-efficacy, the means for intention
to be safe were lower for those students who reported a history of sexual
experience preintervention, especially for the MS males (P<.01). The values ranged from 0.11 to 0.26, and the R2 for the model ranged from
0.26 to 0.54; greater variance was explained among HS students.
Finally, we examined the long-term intervention
effect for the index scores described (in the "Variables Measured"
subsection of the "Participants and Methods" section), which
represented initiation of sexual activity (somesex [Table 6])
and engagement in more risky sexual behavior (risksex). For somesex, with the
exception of HS females, the means were in the expected direction for an
intervention effect, ie, the higher means (representing less involvement in
sexual exploration) were found for the intervention groups compared with the
controls. Significance, however, was reached only among the MS females, likely
because this group reported the least (30%) history of sexual experience
preintervention. There was also a significant interaction effect for sex
history by intervention for Peer Ed–taught males at the HS level. The pretest
covariate for somesex was highly significant (F values ranged from 207.4 to
320.9), and the history of sexual experience was also significantly related to
long-term sexual behavior (F values ranged from 30.3 to 45.4), with higher
(safer) scores among those not yet sexually active. Furthermore, the general
life risk covariate was also significant for all groups, suggesting that
preintervention risk (whether sexual or nonsexual) was significant in
predicting later sexual behavior. In relation to ethnicity, African American
youth had lower mean scores for this variable, indicating that they reported
greater engagement in sexual activity. The values were small (0.06-0.17), and the R2 values for the models ranged from 0.40 to
0.54.
Prediction of engagement in risky sex behavior
(risksex) was more difficult; significance for the intervention was not
demonstrated, as most students did not report these behaviors. However, the
means were in the expected direction for the intervention groups, with the
controls having slightly lower mean scores (representing less safety) than the
intervention groups among all students. There was a statistically significant
interaction for sex activity status by intervention for MS females, indicating
that sexually active (vs nonsexually active) females were more positively
affected by the intervention (P<.001).
Analogous to the other analyses, increasing age, greater life risk, a history
of sexual experience preintervention, and especially the pretest score for
risky behavior (F values ranged from 44 to 223) were highly significant. The
degree of variance explained by each of the 4 models for risksex ranged from an
R2 of 0.17 to an R2 of 0.43.
Numerous efforts to reduce behavioral risk
(especially sexual risk) have examined short-term change, while fewer studies
follow up subjects beyond 6 months. Findings describing 12-month after the
intervention follow-up in school-based studies are unusual.10, 19 The values for interventions are most often larger for
nonbehavioral outcomes (such as knowledge) and frequently lessen over time.19, 20 The sample in this
report, by virtue of the available school population, included students at
serious sexual risk and those youngsters who were at potentially no risk for
early life entry into sexual risk. Longer-term behavior values are usually small in such studies,19, 21 and in many instances
have not been considered at all. Our long-term values ranged from a medium effect of 0.25 (knowledge) to smaller
behavior values of 0.14
(somesex) and 0.13 (risksex), findings that are consistent with other
adolescent sex risk reduction studies and with behavior studies aimed at risk
reduction in other domains.
There was a positive, sustained, long-term
effect of the RAPP intervention when compared with the control intervention in
the areas of knowledge, self-efficacy regarding sexual matters, behavior intention,
and self-reported behaviors. While statistical significance was not universally
reached, when compared with control across intervention groups, mean scores
were consistently in the desired safer direction. This was especially true for
the Peer Ed– and (at MS) the RHT-taught groups. Since students' pretest
variable score heavily influenced their score on that same variable at
follow-up, this observation speaks to the need for development and testing of
school-based sexual risk reduction interventions among younger students, such
as those in the late elementary grades. In a preliminary analysis of our data
(not presented herein), we had not initially included sexual history as a
covariate and found that there was more significant effect of the intervention
compared with the control. When sexual history was entered into the analysis of
variance before examining for the intervention effect, the impact of the latter
was diminished. This is consistent with the association of a more positive
outcome in the presence of "safer" pretest scores, because the
initiation of sexual intercourse is included as a contributing item to the
somesex and risksex indexes.
Interpretations of school-based intervention
trials such as RAPP are bolstered by the inclusion of many subjects who are
representative of a general adolescent population. The prospects of
implementing programs found to be successful are also brighter compared with
community-based efforts since school structures already exist in every
community and are, in fact, obligated to provide curriculum time related to
family values and sexuality. At the same time, there are limitations to be
considered in evaluating RAPP. The quasi-experimental design we used was
necessary to carry out a large school-based study that would not disrupt the
usual class and grade structure to such an extent that the project would have
been rejected by the participating institutions. This resulted, however, in
lack of true subject randomization. Our analyses for group differences in baseline
characteristics revealed statistical significance across several variables, but
the magnitude of scale score differences was not clinically meaningful, and the
relevant variables were entered in the analysis of variance to further control
for their potential effect on the dependent variable. In addition, not all
subjects who enrolled in the study were present at longest follow-up. Such
attrition, greater in HS and particularly among 12th graders, presents
potential bias in results. We examined relevant pretest characteristics of
those students who did and did not participate in late follow-up, and there was
a slight overrepresentation of higher-risk (related to sexual behavior)
students among study dropouts. Their inclusion at follow-up might have diminished
the observed intervention effect, but again we expected and found that the most
intervention-responsive students were those who were yet to engage in risk
behaviors.
Another reality of this type of work is that the
most meaningful outcome, behavior, is measured by self-report. With this
potential source of error in mind, we asked subjects about sexual experience in
multiple ways (see the "Variables Measured" subsection of the
"Participants and Methods" section) and assessed their behavior only
based on consistent responses. Thus, we believe our index of sexual activity is
accurate. This and the other measures for the study were pilot tested at MS and
HS levels, and the instrument was not finalized until reliability and validity
were addressed.
It is clear that the goal for school-based
interventions of this type should be the primary prevention of risky sexual
behavior. Since this can only occur in younger, precoital populations, we
propose that late elementary school students, before the transition to sexual
activity, should be the target group for the next phase of study.
Author/Article Information
From the Department of Pediatrics (Drs Siegel and Aten) and the School of
Nursing (Dr Aten), University of Rochester, and the Department of Pediatrics,
Rochester General Hospital (Dr Siegel and Ms Enaharo), Rochester, NY.
Corresponding author and reprints: David M. Siegel, MD, MPH, Department of
Pediatrics, Rochester General Hospital, 1425 Portland Ave, Rochester, NY 14621
(e-mail: [log in to unmask]).
Accepted for publication April 10, 2001.
This study was supported by grant 49037 from the
National Institute of Mental Health, Rockville, Md.
We thank Barbara Thompson for her tireless
preparation of the manuscript; the staff of the Rochester AIDS Prevention
Project for Youth, including the health educators (Margaret Cain, BA; Raśl
Corujo-Molina; Desiree Voorhies, RN, MSEd; and Lennard Wedderburn, CSW) and the
research assistant (Terri Vaughn, CSW), for their dedication, commitment, and
hard work on behalf of the project; and the staff and students of the participating
schools.
What
This Study Adds A significant proportion of young adults with
AIDS became infected with HIV through sexual contact during adolescence. A
prior report showed that a school-based intervention was successful in the
short-term in improving knowledge and changing behavior. This study found that at an average of 10½
months after the intervention, MS and HS students still demonstrated a
positive effect of the program on several important measures related to safe
sex. Intensively trained HS Peer Eds can function as effective implementers
of an HIV sexual risk prevention program. |
1.
Cates W.
The epidemiology and control of sexually transmitted diseases in adolescents.
In: Schydlower M, Shafer M, eds. Adolescent
Medicine: State of the Art Reviews. Philadelphia, Pa: Hanley &
Belfus Inc; 1990:409-428.
2.
Burstein GR, Gaydos CA, Diener-West M, Howell MR, Zenilman JM, Quinn TC.
Incident chlamydia trachomatis infections among inner-city adolescent females.
JAMA.
1998;280:521-526.
ABSTRACT
| FULL TEXT
| PDF
| MEDLINE
3.
Epner JEG, ed.
Policy Compendium on Reproductive Health
Issues Affecting Adolescents.
Chicago, Ill: American Medical Association; 1996.
4.
Alan Guttmacher Institute.
Sex and America's Teenagers.
New York, NY: Alan Guttmacher Institute; 1994.
5.
Centers for Disease Control and Prevention.
HIV/AIDS Surveillance Report.
Atlanta, Ga: Centers for Disease Control and Prevention; 1998.
6.
Boyer CB, Kegeles SM.
AIDS risk and prevention among adolescents.
Soc Sci Med.
1991;33:11-23.
MEDLINE
7.
Rotheram-Borus MJ, Mahler KA, Rosario M.
AIDS prevention with adolescents.
AIDS Educ Prev.
1995;7:320-336.
MEDLINE
8.
Stanton B, Kim N, Galbraith J, Parrott M.
Design issues addressed in published evaluations of adolescent HIV-risk
reduction interventions: a review.
J Adolesc Health.
1996;18:387-396.
MEDLINE
9.
Kirby D, Short L, Collins J, et al.
School-based programs to reduce sexual risk behaviors: a review of
effectiveness.
Public Health Rep.
1994;109:339-360.
MEDLINE
10.
Kim N, Stanton B, Li X, Dickerson K, Gailbraith J.
Effectiveness of the 40 adolescent AIDS-risk reduction interventions: a
quantitative review.
J Adolesc Health.
1997;20:204-215.
MEDLINE
11.
Thomas MH.
Abstinence-based programs for prevention of adolescent pregnancies.
J Adolesc Health.
2000;26:5-17.
MEDLINE
12.
Siegel DM, Aten MJ, Roghmann KJ, Enaharo M.
Early effects of a school-based human immunodeficiency virus infection and
sexual risk prevention intervention.
Arch Pediatr Adolesc Med.
1998;152:961-970.
ABSTRACT
| FULL TEXT
| PDF
| MEDLINE
13.
Ajzen I, Fishbein M.
Understanding Attitudes and Predicting
Social Behavior.
Englewood Cliffs, NJ: Prentice-Hall International Inc; 1980.
14.
Fishbein M.
AIDS and behavior change: an analysis based on Theory of Reasoned Action.
Interamerican J Psychol.
1990;24:37-56.
15.
Misovich SJ, Fisher WA, Fisher JD.
Understanding and promoting AIDS preventive behaviors: measures of AIDS risk
reduction information, motivation, behavioral skills, and behavior.
In: Davis CM, Yarbor WH, Bauserman R, Scheer G, Davis SL, eds. Sexuality Related Measures: A Compendium.
Thousand Oaks, Calif: Sage Publications; 1998.
16.
Division of Adolescent and School Health, Center for Chronic Diseases
Prevention and Health Promotion, Centers for Disease Control and Prevention.
Youth Risk Behavior Survey.
Atlanta, Ga: Division of Adolescent and School Health, Center for Chronic
Diseases Prevention and Health Promotion, Centers for Disease Control and
Prevention; 1990.
17.
Siegel DM, Aten MJ, Roghmann KJ.
Self-reported honesty among middle and high school students responding to a
sexual behavior questionnaire.
J Adolesc Health.
1998;23:20-28.
MEDLINE
18.
Paikoff RL.
Early heterosexual debate: situations of sexual possibility during the
transition to adolescence.
Am J Orthopsychiatry.
1995;65:389-401.
MEDLINE
19.
Kalichman SC, Carey MP, Johnson BT.
Prevention of sexually transmitted HIV infection: a meta-analytic review of the
behavioral outcome literature.
Ann Behav Med.
1996;18:6-15.
20.
Walter HJ, Vaughan MS, Ragin DR, Cohall AT, Kasen S, Fullilove RE.
Prevalence and correlates of AIDS-risk behaviors among urban minority high
school students.
Prev Med.
1993;22:813-824.
MEDLINE
21.
Stanton B, Kim N, Galbraith J, Parrott M.
Design issues addressed in published evaluations of adolescent HIV risk
reduction interventions: a review.
J Adolesc Health.
1996;18:387-396.
Edward E.
Rylander, M.D.
Diplomat American
Board of Family Practice.
Diplomat American
Board of Palliative Medicine.