Behavioral and Socioemotional Outcomes of the Legacy for Children™ Randomized Control Trial to Promote Healthy Development of Children Living in Poverty, 4 to 6 Years Postintervention.

OBJECTIVE: The objective of this article was to assess the impact on behavioral and socioemotional development, 4 to 6 years postintervention (depending on the curriculum), of Legacy for Children™, a public health approach to improve child developmental outcomes among families living in poverty. METHODS: Mothers who were recruited prenatally or at the time of childbirth participated in a set of Legacy parallel design randomized control trials between 2001 and 2009 in Miami, Florida, or Los Angeles, California. Of the initial 574 mother-child dyads, 364 completed at least 1 behavioral or socioemotional outcome measure at the third-grade follow-up. Intention-to-treat analyses compared Legacy and comparison groups on behavioral and socioemotional outcomes. RESULTS: Children of Legacy mothers in Los Angeles were at lower risk for externalizing behaviors and poor adaptive skills than children whose mothers did not participate in the intervention. No significant outcome differences by group assignment were found in Miami. CONCLUSION: Group-based positive parenting interventions such as Legacy may have a sustained impact on children's behavioral and socioemotional development several years after intervention completion.

Role of team dynamics in the learning process: a mixed-methods evaluation of a modified team-based learning approach in a behavioral research methods course.

Health sciences education is increasingly focusing on building students' skills to work collaboratively. Therefore, instructors must intentionally incorporate team-based skill building into their courses, using teaching strategies like team-based learning (TBL). An assumption of TBL is that team dynamics facilitate learning; however, limited research has examined this connection. The primary purposes of this mixed-methods evaluation were: (a) to describe the characteristics of team dynamics in a graduate-level research methods course that employs a modified TBL approach, and (b) to examine the association between team dynamics and student grades. Given the importance of preparing health professional students to work collaboratively in their careers, a secondary aim was to examine how team skills developed through a team-based learning approach could be transferred to other courses and to future jobs. We conducted surveys on team dynamics at mid-semester (n = 64) and the end of the semester (n = 66), collected students' grades for the final paper and overall course, and conducted 4 focus groups with Master of Public Health students (n = 25). Paired t tests were used to examine change in team dynamics and correlations were conducted to assess the relationship between team dynamics and grades. Thematic analysis was used to identify themes related to team dynamics from the focus group data. Overall, students reported experiencing positive and beneficial team dynamics. The findings support two main underlying categories of team dynamics, interpersonal team processes and task orientation, and the linkages between the categories that allow teams to function. Team dynamics scores were not associated with student grades. However, students recognized the value of practicing team skills in preparation for future group work and jobs. These findings suggest that active learning approaches, such as TBL, can help to facilitate the acquisition of collaborative skills.

Allowing cigarette or marijuana smoking in the home and car: prevalence and correlates in a young adult sample.

Given the increased marijuana use, negative health consequences of marijuana secondhand smoke exposure (SHSe) and dearth of research regarding marijuana SHSe in personal settings, we examined the prevalence and correlates of allowing marijuana versus cigarette smoking in personal settings among 2002 online survey respondents at two southeastern US universities in 2013. Findings indicated that 14.5% allowed cigarettes in the home, 17.0% marijuana in the home, 35.9% cigarettes in cars and 27.3% marijuana in cars. Allowing cigarettes in the home was associated with younger age, racial/ethnic minority status, living off campus, personal marijuana use, parental tobacco use and positive perceptions of cigarettes (P < 0.05). Correlates of allowing marijuana in the home included older age, not having children, living off campus, positive perceptions of marijuana and personal, parental and friend marijuana use (P < 0.05). Correlates of allowing cigarettes in cars included personal cigarette and marijuana use, parental tobacco and marijuana use, more cigarette-smoking friends and positive perceptions of cigarettes (P < 0.05). Correlates of allowing marijuana in cars included being non-Hispanic black; positive perceptions of marijuana; and personal, parental and friend marijuana use (P < 0.05). Interventions must target distinct factors influencing policies regarding cigarette versus marijuana use in personal settings to address the consequences of marijuana and cigarette SHSe.

Correlates of Inconsistent Refusal of Unprotected Sex among Armenian Female Sex Workers.

This cross-sectional study assessed the prevalence and correlates of inconsistent refusal of unprotected sex among female sex workers (FSWs) in Armenia. One hundred and eighteen street-based FSWs between the ages of 20 and 52 completed a questionnaire assessing FSWs' demographic, psychosocial, and behavioral characteristics. A total of 52.5% (n = 62) of FSWs reported inconsistent refusal of unprotected sex with clients in the past 3 months. Logistic regression analysis controlling for participants' age and education revealed that perceiving more barriers toward condom use (AOR = 1.1; P < 0.01), reporting more types of abuse (AOR = 2.1; P < 0.01), and setting lower fees for service (AOR = 0.9; P = 0.02) significantly predicted inconsistent refusal of unprotected sex. HIV-risk-reduction behavioral interventions tailored to FSWs working in Yerevan Armenia should address the factors identified in this study toward the goal of enhancing refusal of unprotected sex and ultimately preventing acquisition of sexually transmitted infections (STIs) including HIV.

Efficacy of a telephone-delivered sexually transmitted infection/human immunodeficiency virus prevention maintenance intervention for adolescents: a randomized clinical trial.

IMPORTANCE: Behavioral change interventions have demonstrated short-term efficacy in reducing sexually transmitted infection (STI)/human immunodeficiency virus (HIV) risk behaviors; however, few have demonstrated long-term efficacy. OBJECTIVE: To evaluate the efficacy of a telephone counseling prevention maintenance intervention (PMI) to sustain STI/HIV-preventive behaviors and reduce incident STIs during a 36-month follow-up. DESIGN, SETTING, AND PARTICIPANTS: In a 2-arm randomized supplemental treatment trial at 3 clinics serving predominantly minority adolescents in Atlanta, Georgia, 701 African American adolescent girls aged 14 to 20 years received a primary treatment and subsequently received a different (supplemental) treatment (PMI) to enhance effects of the primary treatment. INTERVENTIONS: Participants in the experimental condition (n = 342) received an adapted evidence-based STI/HIV intervention (HORIZONS) and a PMI consisting of brief telephone contacts every 8 weeks over 36 months to reinforce and complement prevention messages. Comparison-condition participants (n = 359) received HORIZONS and a time- and dose-consistent PMI focused on general health. MAIN OUTCOMES AND MEASURES: The primary outcomes were percentage of participants with a laboratory-confirmed incident chlamydial infection and percentage of participants with a laboratory-confirmed gonococcal infection during the 36-month follow-up. Behavioral outcomes included the following: (1) proportion of condom-protected sexual acts in the 6 months and 90 days prior to assessments; (2) number of sexual episodes during the past 90 days in which participants engaged in sexual intercourse while high on drugs and/or alcohol; and (3) number of vaginal sex partners in the 6 months prior to assessments. RESULTS: During the 36-month follow-up, fewer participants in the experimental condition than in the comparison condition had incident chlamydial infections (94 vs 104 participants, respectively; risk ratio = 0.50; 95% CI, 0.28 to 0.88; P = .02) and gonococcal infections (48 vs 54 participants, respectively; risk ratio = 0.40; 95% CI, 0.15 to 1.02; P = .06). Participants completing more telephone contacts had a lower risk of chlamydial infection (risk ratio = 0.95; 95% CI, 0.90 to 1.00; P = .05). Participants in the experimental condition reported a higher proportion of condom-protected sexual acts in the 90 days (mean difference = 0.08; 95% CI, 0.06 to 0.11; P = .02) and 6 months (mean difference = 0.08; 95% CI, 0.06 to 0.10; P = .04) prior to assessments and fewer episodes of sexual acts while high on drugs and/or alcohol (mean difference = -0.61; 95% CI, -0.98 to -0.24; P < .001). CONCLUSIONS AND RELEVANCE: Sustaining the long-term impact of an STI/HIV intervention is achievable with brief, tailored telephone counseling. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00279799.

Efficacy of an HIV intervention in reducing high-risk human papillomavirus, nonviral sexually transmitted infections, and concurrency among African American women: a randomized-controlled trial.

OBJECTIVE: This trial evaluated the efficacy of an HIV-intervention condition, relative to a health-promotion condition, in reducing incidence of nonviral sexually transmitted infections (STIs; Chlamydia, gonorrhea, and trichomoniasis), oncogenic human papillomavirus (HPV) subtypes 16 and 18, sexual concurrency, and other HIV-associated behaviors over a 12-month period. DESIGN: Randomized-controlled trial. Data analysts blinded to treatment allocation. SETTING: Kaiser Permanente, GA. SUBJECTS: A random sample of 848 African American women. INTERVENTION: The two 4-hour HIV intervention sessions were based on Social Cognitive Theory and the Theory of Gender and Power. The intervention was designed to enhance participants' self-sufficiency and attitudes and skills associated with condom use. The HIV intervention also encouraged STI testing and treatment of male sex partners and reducing vaginal douching and individual and male partner concurrency. MAIN OUTCOME MEASURE: Incident nonviral STIs. RESULTS: In generalized estimating equations' analyses, over the 12-month follow-up, participants in the HIV intervention, relative to the comparison, were less likely to have nonviral incident STIs (odds ratio [OR] = 0.62; 95% confidence interval [CI]: 0.40 to 0.96; P = 0.033) and incident high-risk HPV infection (OR = 0.37; 95% CI: 0.18 to 0.77; P = 0.008) or concurrent male sex partners (OR = 0.55; 95% CI: 0.37 to 0.83; P = 0.005). In addition, intervention participants were less likely to report multiple male sex partners, more likely to use condoms during oral sex, more likely to inform their main partner of their STI test results, encourage their main partner to seek STI testing, report that their main partner was treated for STIs, and report not douching. CONCLUSIONS: This is the first trial to demonstrate that an HIV intervention can achieve reductions in nonviral STIs, high-risk HPV, and individual concurrency.

Efficacy of SISTA South Africa on sexual behavior and relationship control among isiXhosa women in South Africa: results of a randomized-controlled trial.

BACKGROUND: The HIV epidemic has a devastating impact among South African women. The current study evaluated the efficacy of SISTA South Africa, a culturally congruent HIV intervention for isiXhosa women in South Africa, which was adapted from SISTA, an HIV intervention for African American women. METHODS: A randomized-controlled trial recruited 342 isiXhosa women aged 18-35 years. Participants were randomized to the general health comparison or the SISTA South Africa intervention. Xhosa-speaking peer health educators tailored the SISTA South Africa curriculum, while maintaining the core elements of the original SISTA intervention. Participants completed assessments at baseline and 6 months follow-up. RESULTS: Relative to participants in the comparison, participants in the HIV intervention reduced the frequency of unprotected vaginal intercourse acts (adjusted mean difference = 1.06; P = 0.02), were more likely to report not desiring dry sex (adjusted odds ratio = 0.229; 95% confidence interval = 0.10 to 0.47; P = 0.0001), and were more likely to perceive that their main sexual partner did not desire dry sex (adjusted odds ratio = 0.24; 95% confidence interval = 0.11 to 0.52; P = 0.0001). In addition, women randomized to the intervention also reported an increase in HIV knowledge, greater relationship control, and had more opposing attitudes toward HIV stigma. The HIV intervention did not reduce sexually transmitted infection incidence. CONCLUSIONS: This trial demonstrates that an HIV intervention, which is adapted to enhance its gender and cultural relevance for rural isiXhosa women, can reduce self-reported sexual risk behaviors and enhance mediators of HIV among this vulnerable population.

Gender based violence as a risk factor for HIV-associated risk behaviors among female sex workers in Armenia.

This cross-sectional study identified the prevalence of gender based violence (GBV) and examined its association with sexual risk behavior among female sex workers (FSWs). Among 120 participants between ages 20 and 52, a total of 56.7 % reported lifetime GBV. Multivariate analyses revealed that GBV was significantly associated with inconsistent condom use, unprotected sex, condom misuse, fear of client reaction to requests of condom use, self-reported history of STIs, and earlier age of initiation of sex work. GBV must be considered an urgent public health priority among FSWs in Armenia. Interventions addressing FSWs, in addition to targeting skill-based, sexual risk reduction must also introduce a discourse among FSWs, sexual partners, clients and community members about the role of GBV in HIV-associated risk behaviors and infection. Structural level initiatives must address economic opportunities for women, health-sector policies and responses to FSWs' health needs, law enforcement training and societal norms toward women.

Multi-level factors associated with pregnancy among urban adolescent women seeking psychological services.

The purpose of this study was to examine the prevalence of pregnancy as well as multi-level factors (i.e., individual, family, and environment) associated with history of pregnancy among a sample of urban adolescent women seeking psychological services. Data were collected from a total of 264 sexually active, 13-18-year-old, adolescent women who participated in a larger HIV prevention study. Adolescents and one participating parent completed an audio computer-assisted self-interviewing survey. A total of 17.4% of participants reported a history of pregnancy. A multivariable logistic regression model suggests that after controlling for empirically derived sociodemographic and behavioral covariates, absence of father in the home, family support and cohesion, and neighborhood risk were positively related to pregnancy. This study is among the first to examine multi-level factors associated with pregnancy among adolescent women diagnosed with psychological disorders. Consideration of such factors is crucial both in terms of clinical practice and in the design of pregnancy prevention programs. Collaboration between physicians and mental health providers working with adolescent women is crucial and represents an ideal opportunity to promote parental involvement and access to supportive community resources, including pregnancy prevention programs for this vulnerable population of adolescents.

Gender differences in sexual risk behaviours and sexually transmissible infections among adolescents in mental health treatment.

BACKGROUND: Adolescents with a history of psychiatric disorder(s) are particularly vulnerable to contracting sexually transmissible infections (STIs) as a result of psychological and emotional states associated with higher rates of risky sexual behaviour. The present study examined gender differences in sexual risk behaviours and STI among adolescents in mental health treatment. METHODS: Three hundred and seventy nine sexually active adolescents, aged 13-18 years, from a larger multisite study, who received mental health treatment during the past year, completed an audio computer-assisted self interview assessing sociodemographics, psychiatric symptomatology and HIV/STI risk behaviours, and provided urine specimens tested for STI. RESULTS: After controlling for covariates, multivariate logistic regression models indicated that female adolescents were more likely to have had an HIV test (adjusted odds ratio (AOR)=3.2, P=0.0001), obtain their HIV test results (AOR=2.9, P=0.03), refuse sex out of fear for STI acquisition (AOR=1.7, P=0.04), or avoid a situation that might lead to sex (AOR=2.4, P=0.001), and were less likely to have a casual sex partner (AOR=0.40, P=0.002). Additionally, females were more likely to report inconsistent condom use (AOR=2.60, P=0.001) and have a STI (AOR=9.1, P=0.0001) than their male counterparts. CONCLUSIONS: Female adolescents receiving mental health treatment were more than nine times as likely to have an STI and more likely to use condoms inconsistently. The standard of care for mental health practice for adolescents should include referrals for STI screening and treatment as well as assessment and discussion of risky sexual behaviours as part of the treatment plan when indicated. Effective programs should address gender-specific communication and behavioural skills.

The mediating role of partner communication frequency on condom use among African American adolescent females participating in an HIV prevention intervention.

OBJECTIVE: Although effective HIV prevention interventions have been developed for adolescents, few interventions have explored whether components of the intervention are responsible for the observed changes in behaviors postintervention. This study examined the mediating role of partner communication frequency on African American adolescent females' condom use postparticipation in a demonstrated efficacious HIV risk-reduction intervention. METHODS: As part of a randomized controlled trial, African American adolescent females (N = 715), 15-21 years, seeking sexual health services, completed a computerized interview at baseline (prior to intervention) and again 6 and 12 months follow-up post-intervention participation. The interview assessed adolescents' sexual behavior and partner communication skills, among other variables, at each time point. Using generalized estimating equation (GEE) techniques, both logistic and linear regression models were employed to test mediation over the 12-month follow-up period. Additional tests were conducted to assess the significance of the mediated models. RESULTS: Mediation analyses observed that partner communication frequency was a significant partial mediator of both proportion of condom-protected sex acts (p = .001) and consistent condom use (p = .001). CONCLUSION: Partner communication frequency, an integral component of this HIV intervention, significantly increased as a function of participating in the intervention, partially explaining the change in condom use observed 12 months postintervention. Understanding what intervention components are associated with behavior change is important for future intervention development.

Determinants of multimethod contraceptive use in a sample of adolescent women diagnosed with psychological disorders.

OBJECTIVE: Despite recommendations for concurrent use of contraceptives and condoms to prevent unintended pregnancy and STIs, multimethod contraceptive use among women is poor. This study examined individual-, interpersonal-, and environmental-level factors that predict multimethod use among sexually active adolescent women diagnosed with psychological disorders. METHODS: This multisite study analyzed data from 288 sexually active adolescent women who provided sociodemographic, psychosocial, and behavioral data related to birth control and condom use. RESULTS: 34.7% of the participants reported multimethod use in the past three months. Controlling for empirically and theoretically relevant covariates, a multivariable logistic regression identified self-efficacy, multiple partners, pregnancy history, parental communication, parental norms about sex, and neighborhood cohesion as significant predictors of multimethod use. CONCLUSIONS: While continued targeted messages about multi-method contraceptive use are imperative at the individual level, an uptake in messages targeting interpersonal- and environmental-level factors such as adolescents' parents and the broader community is urgently needed.

Efficacy of a health educator-delivered HIV prevention intervention for Latina women: a randomized controlled trial.

OBJECTIVES: We developed and assessed AMIGAS (Amigas, Mujeres Latinas, Inform andonos, Gui andonos, y Apoy andonos contra el SIDA [friends, Latina women, informing each other, guiding each other, and supporting each other against AIDS]), a culturally congruent HIV prevention intervention for Latina women adapted from SiSTA (Sistas Informing Sistas about Topics on AIDS), an intervention for African American women. METHODS: We recruited 252 Latina women aged 18 to 35 years in Miami, Florida, in 2008 to 2009 and randomized them to the 4-session AMIGAS intervention or a 1-session health intervention. Participants completed audio computer-assisted self-interviews at baseline and follow-up. RESULTS: Over the 6-month follow-up, AMIGAS participants reported more consistent condom use during the past 90 (adjusted odds ratio [AOR] = 4.81; P < .001) and 30 (AOR = 3.14; P < .001) days and at last sexual encounter (AOR = 2.76; P < .001), and a higher mean percentage condom use during the past 90 (relative change = 55.7%; P < .001) and 30 (relative change = 43.8%; P < .001) days than did comparison participants. AMIGAS participants reported fewer traditional views of gender roles (P = .008), greater self-efficacy for negotiating safer sex (P < .001), greater feelings of power in relationships (P = .02), greater self-efficacy for using condoms (P < .001), and greater HIV knowledge (P = .009) and perceived fewer barriers to using condoms (P < .001). CONCLUSIONS: Our results support the efficacy of this linguistically and culturally adapted HIV intervention among ethnically diverse, predominantly foreign-born Latina women.

Rape victimization and high risk sexual behaviors: longitudinal study of african-american adolescent females.

OBJECTIVES: African-American women are affected by disproportionately high rates of violence and sexually transmitted infections (STI)/human immunodeficiency virus (HIV) infection. It is imperative to address the intersection of these two urgent public health issues, particularly as these affect African-American adolescent girls. This study assessed the prevalence of rape victimization (RV) among a sample of African-American adolescent females and examined the extent to which participants with a history of RV engage in STI/HIV associated risk behaviors over a 12-month time period. METHODS: Three hundred sixty-seven African-American adolescent females ages 15-21, seeking sexual health services at three local teenager-oriented community health agencies in an urban area of the Southeastern United States, participated in this study. Participants were asked to complete an audio computer-assisted self-interview (ACASI) at baseline, 6- and 12-month follow-up. We assessed sociodemographics, history of RV and sexual practices. At baseline, participants indicating they had experienced forced sex were classified as having a history of RV. RESULTS: Twenty-five percent of participants reported a history of RV at baseline. At 6- and 12-months, victims of RV had significantly lower proportions of condom-protected sex (p=.008), higher frequency of sex while intoxicated (p=.005), more inconsistent condom use (p=.008), less condom use at last sex (p=.017), and more sex partners (p=.0001) than non-RV victims. Over the 12-month follow-up period, of those who did not report RV at baseline, 9.5% reported that they too had experienced RV at some point during the 12-month time frame. CONCLUSION: African-American adolescent females who experience RV are engaging in more risky sexual behaviors over time than non-RV girls, thereby placing themselves at higher risk for contracting STIs. In light of the results from this unique longitudinal study, we discuss considerations for policies and guidelines targeting healthcare, law enforcement and educational and community settings. The complexities of RV screening in healthcare settings are examined as is the need for tighter collaboration between healthcare providers and law enforcement. Finally, we consider the role of prevention and intervention programs in increasing awareness about RV as well as serving as an additional safe environment for screening and referral.

Application of condoms on male clients by female sex workers in Yerevan, Armenia: prevalence and correlates.

This study sought to assess the prevalence of consistent condom application on male clients by female sex workers (FSWs) in Armenia and its association with demographic, psychosocial and behavioural factors. In this cross-sectional study, 120 street-based FSWs aged 20-52 completed an interviewer-administered questionnaire. The primary outcome measure was consistent application of condoms by FSWs on their male clients. A total of 21.7% of participants reported consistently applying condoms on clients. Logistic regression analysis demonstrated that higher condom use self-efficacy (Adjusted Odds Ratio, AOR=1.1; p=0.01), lower perceived condom use barriers (AOR=0.9; p=0.04) and not using douching as a method to prevent STI/HIV (AOR=4.8; p=0.04) significantly predicted consistent condom application. Higher HIV/AIDS knowledge was a marginally significant predictor of condom application (AOR=1.3; p=0.05). Future interventions should address these modifiable factors to encourage FSWs to apply condoms on clients themselves, which may reduce condom failure and exposure to HIV transmission.

Neighborhood environment, sexual risk behaviors and acquisition of sexually transmitted infections among adolescents diagnosed with psychological disorders.

The association between neighborhood environment and prevalence of STIs, sexual partner variables and condom use among adolescents with psychological disorders was examined. Cross-sectional data in three urban areas of the US (Southeast, Northeast and Midwest) were obtained from 384 sexually active male and female participants who provided urine samples for laboratory-confirmed testing of Neisseria gonorrhoeae, Chlamydia trachomatis and Trichomonas vaginalis. A total of 15.4% of participants tested positive for one of the three STIs. Results indicated that relative to adolescents living in low risk neighborhood environments, those living in high risk environments were significantly more likely to have a STI and to report having casual partners. Findings suggest that in high risk neighborhoods, STI acquisition may be less dependent on condom use and more dependent on other contextual factors. The importance of expanding public health research to include assessment of neighborhood context as a determinant of sexual risk-taking is emphasized.