'Let Us Protect Our Future' a culturally congruent evidenced-based HIV/STD risk-reduction intervention for young South African adolescents.

One of the worst HIV/AIDS epidemics in the world is occurring in South Africa, where heterosexual exposure is the main mode of HIV transmission. Young people 15-24 years of age, particularly women, account for a large share of new infections. Accordingly, there is an urgent need for behavior-change interventions to reduce the incidence of HIV among adolescents in South Africa. However, there are few such interventions with proven efficacy for South African adolescents, especially young adolescents. A recent cluster-randomized controlled trial of the 'Let Us Protect Our Future!' HIV/STD risk-reduction intervention for Grade 6 South African adolescents (mean age = 12.4 years) found significant decreases in self-reported sexual risk behaviors compared with a control intervention. This article describes the intervention, the use of the social cognitive theory and the reasoned action approach to develop the intervention, how formative research informed its development and the acceptability of the intervention. Challenges in designing and implementing HIV/STD risk-reduction interventions for young adolescents in sub-Saharan Africa are discussed.

Clinical depression and HIV risk-related sexual behaviors among African-American adolescent females: unmasking the numbers.

Clinically depressed and nondepressed African-American adolescent females aged 13-19 years (N=131) were interviewed and surveyed to determine the relationship between depression and HIV risk-related sexual behaviors. Narratives indicate that the psychopathology of depression may create situations where the target population could become exposed to HIV. Specifically, depressed participants described feelings of loneliness, isolation, and wanting somebody to "comfort them" as aspects of depression that affect the decisions they make about sex and relationships. In essence, sex was viewed as a stress reliever, an anti-depressant and a way to increase self-esteem. They shared that even if they did not feel like having sex, they might just "git it over wit" so their partners would stop asking. Some also discussed financial and emotional stability offered by older, more sexually experienced partners. These age-discordant relationships often translated into trusting that their partners knew what was best for their sexual relationships (i.e., having unprotected sex). Sixty-nine percent (n=88) of the sample reported engaging in sexual activity. Given their mean age (16 ± 1.9 years) participants had been sexually active for 2 ± 1.8 years. The adolescents reported an average of 2 ± 1.8 sexual partners within the past three months. Depressed participants reported a higher frequency of having ever had sex (78% vs. 59%, χ(2)=5.236, p=0.022), and had a higher mean number of sexual partners (2 vs. 1, t=-2.023, p= 0.048) and sexual encounters under the influence of drugs and alcohol (8 vs. 2, t=-3.078, p=0.005) in the past three months. The results of this study can guide the modification and/or development of tailored HIV/sexually transmitted infection (STI) prevention programs. The findings provide explicit, psychologically and culturally relevant information regarding the interaction between depression, self-medicating behaviors and risk for HIV/STIs among clinically depressed African-American adolescent females.

Theory of planned behaviour predictors of intention to use condoms among Xhosa adolescents in South Africa.

HIV/AIDS is taking a heavy toll on South African youth. Reducing their risk for HIV requires an understanding of the determinants of their HIV risk behaviours that are amendable to intervention-induced change. This study draws upon the theory of planned behaviour to identify the modifiable determinants of the intention to use condoms among Xhosa-speaking South African adolescents. The participants were 390 Xhosa-speaking 6th grade students (mean age = 12.1 years) in public schools in the township of Mdantsane, South Africa who completed an anonymous questionnaire. Multiple regression revealed that attitude and perceived behavioural control were significantly related to the intention to use condoms, whereas subjective norm was not, controlling for sexual experience, gender, and language preference. Consistent with this were additional analyses using beliefs as predictors: Hedonistic behavioural beliefs and control beliefs about condom-use negotiation and technical skills predicted intention, whereas normative beliefs did not. The theory of planned behaviour may be a useful model of condom use among Xhosa-speaking South African adolescents. An emphasis on beliefs about the adverse effects of condom use on sexual enjoyment, the ability to negotiate condom use, and the ability to use condoms correctly might improve the efficacy of HIV/STD interventions for such adolescents.

Borrowed theories, shared theories, and the advancement of nursing knowledge.

Despite the continued use of borrowed theories in nursing, little attention has been given to determining whether theories developed in another discipline are empirically adequate descriptions, explanations, or predictions of nursing phenomena. In this article, we demonstrate how a borrowed theory can be placed within a nursing context by linking it with two different conceptual models of nursing. We present our plans for research focused on condom use behavior and discuss how results from these studies will be used to determine whether the borrowed theory can be considered a shared theory.

The theory of planned behavior as a model of intentions for fighting among African American and Latino adolescents.

OBJECTIVES: To test the theory of planned behavior as a model for predicting and understanding behavioral intentions for fighting among inner-city adolescents and to determine whether its predictive power differs as a function of ethnicity (African American versus Latino). METHODS: Participants were 956 (511 females, 445 males) African American (n = 702) and Latino (n = 254) adolescents (mean age = 12.72 years; SD = 1.12) recruited from sixth, seventh, and eighth grade classes in public middle schools serving two inner-city communities in New Jersey who completed self-administered, confidential questionnaires. RESULTS: Consistent with the theory of planned behavior, hierarchical multiple regression analyses revealed that attitudes, subjective norms, and perceived behavioral control predicted intentions for fighting. Although the theory of planned behavior accounted for substantial variance in intentions to fight in both ethnic groups, it accounted for greater variance among Latinos than among African Americans. The strength of the relations of subjective norms and perceived behavioral control to intentions was similar in the two groups. but the relation of attitudes to intentions to fight was significantly stronger among Latinos. CONCLUSIONS: The findings strongly suggest that the theory of planned behavior provides a potentially useful conceptual framework for guiding the creation of interventions for African American and Latino adolescents that are designed to reduce violent behavior and the tragedies that such behavior leaves in its wake.

HIV risk reduction behavioral interventions with heterosexual adolescents.

This article provides a comprehensive review of research on the effects of behavioral interventions on heterosexual adolescents' HIV sexual-risk behavior. It details adolescents' risk of sexually transmitted HIV infection and describes challenges associated with adolescent intervention research, including obtaining school and parent approval and the validity of self-reported measures. It describes central characteristics of 36 controlled intervention studies assessing the HIV sexual-risk behavior of over 30,000 male and female adolescents 11-21 years of age. It summarizes the participants' race/ethnicity and age, the theoretical framework, and the intervention setting, duration and outcome. This review reveals that the most commonly assessed behavioral outcomes were condom use and abstinence, and the largest effects sized were on condom use and condom acquisition. Effect sizes for abstinence and number of sexual partners were the smallest. Perceived self-efficacy and behavioral interventions were the most commonly assessed theoretical mediators. Key questions this research engaged in included whether behavioral skills can be increased, whether intervention-induced behavior change can be sustained, whether matching the race/ethnicity and gender of facilitators and participants enhances the effectiveness of culturally sensitive interventions, whether classroom teachers can effectively facilitate interventions, whether the behavior of high-risk populations can be changed, and which kinds of interventions are most effective. This review concludes that carefully designed theory-based interventions that take into account the characteristics of the particular population or culture can cause positive changes in adolescents' HIV sexual-risk behavior, but boundary conditions for their effectiveness still need to be identified. Several suggestions for additional research are proffered.

HIV among people with mental illness: contributing factors, prevention needs, barriers, and strategies.

1. Findings suggest that PWMI, including those with serious mental illness, are sexually active although some individuals, including mental health professionals, perceive them to be asexual or not sexually active. 2. PWMI may be particularly susceptible to HIV risk-related behaviors due to poor judgment, limited impulse control, deficits in problem-solving skills, and suicidal intent and self-destructive behavior. 3. Nurses, due to their close interaction with PWMI, are in key positions to document HIV risk-related behaviors and to advocate for integrating HIV risk reduction strategies into the therapeutic milieu.

African American grandmothers' perceptions of caregiver concerns associated with rearing adolescent grandchildren.

In 1996, grandparents were the sole providers of care for 269,000 grandchildren. Research findings indicate that grandmothers are usually the primary caretakers of grandchildren. Previous issues associated with raising grandchildren vary, but usually relate to the grandparents' health, financial concerns, or lack of social support. This qualitative descriptive study was designed to describe African American grandmothers' perceptions about the burdens of raising adolescent grandchildren. Using this approach, the researchers were able to study the richness and diversity of the grandmothers' perceptions. Data were collected from 35 grandmothers through a focus group (n = 7) and during a 4-day intervention research study (n = 28) entitled "Grandmother-Grandchild Health Promotion Program." Numerous concerns were voiced by both groups, but those stated most frequently were associated with the well-being of grandchildren (grandchildren's sexual behavior, potential drug use, and potential risk of encountering violence) and relational conflicts with adult children. Unexpected findings were the absence of stated concerns associated with the grandmothers' financial situation or health. Recommendations for intervention, clinical practice, and research are discussed.

Saving our children: strategies to empower African-American adolescents to reduce their risk for HIV infection.

Adolescence is normally a healthy period of life. For some young people it is a period of experimentation with risky behavior. For others, it marks the development of habitual risk behaviors that persist into adulthood. Of special concern is adolescent involvement with sexual behaviors that increase the risk of infection with HIV and other sexually transmitted diseases (STDs). Nurses who work with adolescents are seeing an increase in STDs, including HIV infection occurring disproportionately among African-American adolescents. Although the use of condoms can reduce the risk of these sexually transmitted diseases, most sexually active adolescents do not consistently use condoms. This paper will discuss the scope of the problem of STDs, especially HIV infection among African-American adolescents. It will describe the Theory of Planned Behavior as a framework for designing interventions to reduce the sexual transmission of HIV and other STDs. Finally, it will provide strategies for nurses to intervene by empowering African-American adolescents to reduce their risk for sexually transmitted HIV infection.

Hearing our voices: assessing HIV prevention needs among Asian and Pacific Islander women.

The purpose of this study was to (a) assess the impact of HIV/AIDS on the Asian-Pacific Islander (API) community and changes in their behavior due to AIDS, (b) identify perception of risk, HIV risk behaviors, factors contributing to those behaviors, barriers to HIV prevention, and the types of prevention programs that would benefit their community, and (c) describe culturally appropriate considerations when designing HIV prevention strategies for API women. Thirty API adults participated in three different groups. Focus group interviewing methods were used, guided by the Health Belief Model. The women had numerous concerns about HIV that placed them at risk for infection, such as their inability to talk with their sexual partners about condom use due to the cultural and taboo nature of sexual topics. All groups concluded that for HIV prevention interventions to be successful, they must be tailored to the cultural and specific needs of API women.

Reducing HIV risk-associated sexual behavior among African American adolescents: testing the generality of intervention effects.

This randomized controlled trial tested the effects of a theory-based culture-sensitive HIV risk-reduction intervention among 496 inner-city African American adolescents (mean age = 13 years) and examined the generality of its effects as a function of the facilitator's race and gender and the gender composition of the intervention group. Adolescents who received the HIV risk-reduction intervention expressed more favorable behavioral beliefs about condoms, greater self-efficacy, and stronger condom-use intentions postintervention than did those who received a control intervention on other health issues. Six-month follow-up data collected on 93% of the adolescents revealed that those who received the HIV risk-reduction intervention reported less HIV risk-associated sexual behavior, including unprotected coitus, than did their counterparts in the control condition. Self-reported sexual behavior and changes in self-reported behavior were unrelated to scores on a standard measure of social desirability response bias. There was strong evidence for the generality of intervention effects. Moderator analyses testing eight specific interaction hypotheses and correlational analyses indicated that the effects of the HIV risk-reduction intervention did not vary as a function of the facilitator's race or gender, participant's gender, or the gender composition of the intervention group.

Abstinence and safer sex HIV risk-reduction interventions for African American adolescents: a randomized controlled trial.

CONTEXT: African American adolescents are at high risk of contracting sexually transmitted infection with human immunodeficiency virus (HIV), but which behavioral interventions to reduce risk are most effective and who should conduct them is not known. OBJECTIVE: To evaluate the effects of abstinence and safer-sex HIV risk-reduction interventions on young inner-city African American adolescents' HIV sexual risk behaviors when implemented by adult facilitators as compared with peer cofacilitators. DESIGN: Randomized controlled trial with 3-, 6-, and 12-month follow-up. SETTING: Three middle schools serving low-income African American communities in Philadelphia, Pa. PARTICIPANTS: A total of 659 African American adolescents recruited for a Saturday program. INTERVENTIONS: Based on cognitive-behavioral theories and elicitation research, interventions involved 8 1-hour modules implemented by adult facilitators or peer cofacilitators. Abstinence intervention stressed delaying sexual intercourse or reducing its frequency; safer-sex intervention stressed condom use; control intervention concerned health issues unrelated to sexual behavior. MAIN OUTCOME MEASURES: Self-reported sexual intercourse, condom use, and unprotected sexual intercourse. RESULTS: Mean age of the enrollees was 11.8 years; 53% were female and 92.6% were still enrolled at 12 months. Abstinence intervention participants were less likely to report having sexual intercourse in the 3 months after intervention than were control group participants (12.5% vs 21.5%, P=.02), but not at 6- or 12-month follow-up (17.2% vs 22.7%, P=.14; 20.0% vs 23.1%, P=.42, respectively). Safer-sex intervention participants reported significantly more consistent condom use than did control group participants at 3 months (odds ratio [OR]=3.38; 95% confidence interval [CI], 1.25-9.16) and higher frequency of condom use at all follow-ups. Among adolescents who reported sexual experience at baseline, the safer-sex intervention group reported less sexual intercourse in the previous 3 months at 6- and 12-month follow-up than did control and abstinence intervention (adjusted mean days over prior 3 months, 1.34 vs 3.77 and 3.03, respectively; P< or =.01 at 12- month follow-up) and less unprotected intercourse at all follow-ups than did control group (adjusted mean days, 0.04 vs 1.85, respectively, P<.001, at 12-month follow-up). There were no differences in intervention effects with adult facilitators as compared with peer cofacilitators. CONCLUSION: Both abstinence and safer-sex interventions can reduce HIV sexual risk behaviors, but safer-sex interventions may be especially effective with sexually experienced adolescents and may have longer-lasting effects.

Building community partnerships to improve HIV prevention efforts: implications for nurses.

Acquired immune deficiency syndrome (AIDS), caused by the human immunodeficiency virus (HIV), is a major and complex public health crisis. The Centers for Disease Control and Prevention (CDC) issued effective community-based HIV prevention planning in its 1993 "Supplemental Guidance on HIV Prevention Community Planning" through the formation of community planning groups (CPGs). These guidelines are reviewed along with behavioral and social science theories that are the crux of HIV prevention theory-based research and program development. Nurses' roles in community-based HIV prevention as community advocates, HIV prevention program planners, practitioners, and researchers are discussed. The article concludes with nursing implications for HIV prevention.

Effects of an HIV risk reduction project on sexual risk behavior of low-income STD patients.

A 10-hour small-group informational and skill-building intervention was tested among patients (N = 472) attending publicly funded sexually transmitted disease clinics in Maryland, Georgia, and New Jersey. After completing a 90-minute interview concerning HIV risk behaviors, condom use self-efficacy and condom outcome expectancies, participants were randomized to either an intervention or a control condition. Participants in both conditions displayed significant reductions in unprotected encounters and number of partners and increases in condom use. No differences between treatment conditions were observed, indicating that the motivational effects of the interview may have been stronger than the effects of the intervention in this population.

PIP: Sexually transmitted disease (STD) treatment services in low-income communities offer an effective arena for accessing those at greatest risk for HIV infection. This study evaluated an intensive HIV risk reduction program implemented in publicly funded STD clinics in Maryland, Georgia, and New Jersey (US). After completion of a 90-minute interview on HIV risk behaviors, condom use self-efficacy, and condom outcome expectancies, the 472 study participants were randomly assigned to either a 10-hour behavioral intervention designed to increase condom use self-efficacy through modeling and skill building or routine brief counseling. The average age of respondents was 30.1 years; they reported an average of 3.2 lifetime STDs. Participants in both the intervention and control groups reported significant reductions in the number of sexual partners and unprotected sexual encounters and significant increases in condom use at the 90-day follow-up interview, with no significant differences between groups. Four possible moderators of behavior change--gender, crack or heroin use, alcohol problems, and child sex abuse--were not significant. The possibility that the baseline interview, not the intervention, motivated the observed changes in sexual behavior merits consideration.

Effects of an institutional AIDS prevention intervention: moderation by gender.

AIDS risk reduction programs are being conducted in many institutional settings, but rigorous evaluations of their effectiveness are lacking. This is particularly unfortunate in that these programs are expensive, and tend to be of lower intensity than those that have been shown to be effective. Further, risk reduction is generally regarded as entailing greater difficulty for women, who do not use condoms themselves but must negotiate their use with male partners. We used a quasi-experimental design to evaluate an institutional AIDS prevention program on a New Jersey college campus. Sexual behavior was assessed via linked, anonymous mailed surveys at the beginning and end of an academic year among 1st-year students on the campus and others on a nearby control campus. Responses from the spring survey indicated that intervention campus students had been exposed significantly more than control students to intervention components. While MANCOVA analyses indicated no main effect of treatment group on outcome variable, we obtained a significant group by gender interaction, indicating a significant effect on number of risky encounters for men but not for women. In fact, relative to women on the control campus, women on the intervention campus displayed reduced self-efficacy to perform safe sex at the end of the year. These results may indicate that although men can be effectively reached by low-intensity risk reduction programs, women may not be. In fact, interventions without adequate intensity to provide substantial and individualized negotiation skill training may cause women to experience failure in these efforts.

AIDS risk among black male adolescents: implications for nursing interventions.

Acquired immunodeficiency syndrome (AIDS) is a devastating disease the incidence of which is increasing in the black heterosexual community. Only 12% of the nation's population is black, yet 28% of the people with AIDS are black. AIDS currently threatens black adolescents because of their high risk sexual behavior. No cure exists for AIDS nor is a vaccine available. However, AIDS is preventable. Presently, teaching people how to avoid becoming infected with the human immunodeficiency virus is the only strategy for reducing the spread of AIDS. Nurses can be an important link in the chain of AIDS prevention in this country. Minimal information is available to assist nurses in learning how to effectively intervene with adolescents, especially black male adolescents, regarding AIDS prevention. This article reviews research on AIDS knowledge, attitudes, and high risk sexual behavior among black male adolescents, suggests strategies for using the nursing process as an AIDS education model in working with black male adolescents, and provides guidelines for nurses to use when working with black male adolescents concerning the issue of sexuality education and AIDS prevention.

Increasing condom-use intentions among sexually active black adolescent women.

Whether a social cognitive theory AIDS prevention intervention would increase intentions to use condoms among 109 sexually active inner-city black female adolescents was tested. Analyses revealed that the women scored higher in intentions to use condoms, AIDS knowledge, outcome expectancies regarding condom use, and self-efficacy to use condoms after the intervention than before the intervention. Although increased self-efficacy and more favorable outcome expectancies regarding the effects of condoms on sexual enjoyment and sexual partner's support for condom use were significantly related to increased condom-use intentions, increases in general AIDS knowledge and specific prevention-related beliefs were not.

PIP: AIDS is the leading killer of black women of childbearing age in New Jersey and New York. Educating populations about AIDS and the risk factors for contracting HIV is often touted as sufficient to bring about risk-reducing behavioral change in a population. This study explored whether a social cognitive theory for AIDS prevention intervention would increase intentions to use condoms among a sexually active population. Instead of working to increase factual knowledge about HIV and AIDS, this approach seeks to improve subjectgs' sense of self-efficacy and perception that favorable outcomes will result from condom use. Levels of these 2 measures were tested before and after the intervention among 109 inner-city black female adolescents whose mean age was 16.79 years. Respondents were queried on intentions to use condoms in the next 3 months, perceived self-efficacy to use condoms, outcome expectancies regarding condom use, and knowledge about AIDS and sexually transmitted diseases. Following the intervention, higher scores were found in intentions to use condoms, AIDS knowledge, outcome expectancies about condom use, and self-efficacy to use condoms. Increased self-efficacy and more favorable outcome expectancies about the effect of condoms on sexual enjoyment and sexual partner's support for condom use were significantly related to increased condom use intentions. Increases in general AIDS knowledge and specific prevention-related beliefs, however, were not so related. The results of this study support the notion that education and information alone are not sufficient to bring about behavioral change.

Perceived risk of infection and attitudes toward risk groups: determinants of nurses' behavioral intentions regarding AIDS patients.

The relationship of perceived occupational risk of AIDS and attitudes toward AIDS risk groups to behavioral intentions regarding the care of AIDS patients was examined among nurses (N = 496) residing in a selected area of New Jersey, a state with a relatively high number of reported AIDS cases. Hierarchical multiple regression analyses on anonymous mail survey responses revealed that, controlling for AIDS knowledge and years of education, nurses who perceived that caring for AIDS patients increased their risk of HIV infection scored higher on an index of intentions to avoid AIDS patient care. In addition, nurses who expressed more negative attitudes toward intravenous drug users or homosexuals were more likely to report similar intentions to avoid AIDS patient care. The implications of these findings for efforts to increase nurses' ability and willingness to provide quality care to persons with AIDS are discussed.

Predicting AIDS patient care intentions among nursing students.

Predictors of intentions to care for AIDS patients were examined among 153 sophomore and senior nursing students. Multiple regression analysis revealed that students who had relatively less AIDS knowledge and who perceived greater occupational risk of HIV infection expressed stronger intentions to avoid caring for AIDS patients. However, avoidance intentions were not simply a function of concern about personal health and inadequate knowledge. Students who held more negative attitudes toward intravenous drug users also had stronger intentions to avoid caring for AIDS patients, even when the effects of AIDS knowledge and perceived occupational risk of HIV infection were controlled. AIDS content is incorporated in the nursing curriculum for these students beginning in the junior year. Multivariate analysis of variance performed to determine the effects of this content revealed a significant effect for year in school considering all the dependent variables simultaneously. Seniors had lower avoidance intentions, lower perceived occupational risk, and greater AIDS knowledge than did sophomores.