Parental underestimates of adolescent risk behavior: a randomized, controlled trial of a parental monitoring intervention.

OBJECTIVES: To develop and evaluate an intervention (ImPACT) seeking to increase monitoring (supervision and communication) by parents and guardians of African-American youth regarding high risk and protective behaviors; and to develop an instrument to assess parental monitoring, the Parent-Adolescent Risk Behavior Concordance Scale. DESIGN/INTERVENTION: This research was a randomized, controlled longitudinal study. Baseline (preintervention), and 2 and 6 months postintervention data were obtained via a talking MacIntosh computer regarding youth and parent perceptions of youth involvement in 10 risk behaviors, parental monitoring and youth-parent communication, and condom-use skills. Intervention parents and youth received the ImPACT program and a video emphasizing parental supervision and discussion, followed by a structured discussion and role-play emphasizing key points. Control parents and youth received an attention-control program on goal-setting, which also included an at-home video and discussion. PARTICIPANTS: A total of 237 parents and one each of their youth (ages 12-16 years) recruited from eight public housing developments located in a city in the mid-Atlantic region. RESULTS: Similarity of youth and parental reporting on the Parent-Adolescent Risk Behavior Concordance Scale was positively correlated with protective behaviors, perceived parental monitoring, and good parent-youth communication. At baseline, parents significantly underestimated their youth's risk behaviors. However, 2 and 6 months postintervention, the ImPACT program increased similarity of reports by youth and their parents of youth involvement in risk and protective behaviors. In addition, at 6 months postintervention, intervention (compared to control) youths and parents also demonstrated higher levels of condom-use skills. CONCLUSION: Parental monitoring interventions such as ImPACT should be given to parents in conjunction with more traditional youth-centered risk-reduction interventions.

Use of Western-based HIV risk-reduction interventions targeting adolescents in an African setting.

PURPOSE: To evaluate an intervention (based on one which had previously been successful in reducing adolescent human immunodeficiency virus (HIV) risk behaviors in the United States) among adolescents residing in Namibia, a country located in sub-Saharan Africa. METHODS: A randomized trial of a 14-session face-to-face intervention emphasizing abstinence and safer sex was conducted among 515 youth (median age 17 years; median grade 11) attending 10 secondary schools located in two districts in Namibia. Knowledge, attitudes, intentions, and HIV risk behaviors were assessed at baseline and in the immediate postintervention period. RESULTS: Knowledge increased significantly among intervention compared to control youth (88% vs. 82%; correct responses, p < .0001). At postintervention follow-up, more intervention than control youth believed that they could be intimate without having sex, could have a girlfriend or boyfriend for a long time without having sex, could explain the process of impregnation, knew how to use a condom, and could ask for condoms in a clinic. Fewer intervention than control youth believed that if a girl refused to have sex with her boyfriend it was permissible for him to strike her, and that condoms took away a boy's pleasure. More intervention than control youth anticipated using a condom when they did have sex, and fewer expected to drink alcohol. Finally, after intervention, there was a trend for increased condom use. There were significant gender-related differences at baseline, although intervention impact was generally equivalent. CONCLUSIONS: These findings provide support for the judicious adaptation of successful Western HIV prevention programs in other cultural settings. A single intervention approach appears to be effective in short-term follow-up with both genders.

HIV risk behaviors, intentions, and perceptions among Namibian youth as assessed by a theory-based questionnaire.

Considerable progress has been made in the United States and Europe regarding HIV risk prevention efforts targeting adolescents. However, in Africa less progress has been made to date. This article address three questions: Can risk assessment questionnaires developed in Western countries be modified so as to be appropriate for use in African countries? Are social cognitive models appropriate in African settings? Does covariation among risk behaviors occur among youth residing in African countries? The data was obtained from a cross-sectional survey conducted among 922 youth ages 12 to 18 years living in school-based hostels in Namibia. Data were collected using a theory-based risk assessment questionnaire. One third of the youth were sexually experienced, three quarters of whom had engaged in sexual intercourse in the previous 6 months. Over one third of these youth had had more that one sexual partner in the previous 6 months and over one half had not used a condom at last episode of intercourse. The psychometric properties of the questionnaire and the relationship between perceptions and behaviors provide evidence that theory-based questionnaires developed in Western countries can be modified for use in different cultural settings. The data also provide strong evidence of covariation between risk behaviors among Namibian youth.

PIP: Findings are presented from an investigation into whether risk assessment questionnaires developed in Western countries can be modified to be used appropriately in African countries. The authors also explored whether covariation among risk behaviors occurs among youth living in African countries. Data were obtained from a cross-sectional survey conducted among 922 individuals aged 12-18 years, of median age 15 years, living in school-based hostels in Namibia. 49% of the subjects were male. 37% overall and 56% of the boys had ever had sexual intercourse, of whom 70% had experienced such intercourse during the preceding 6 months. 29% of those who were sexually experienced reported having more than 1 sex partner in the previous 6 months and 50% used a condom during their most recent intercourse. Study findings suggest that theory-based questionnaires developed in Western countries can be modified for use in different cultural settings. Study data also provide strong evidence of covariation between risk behaviors among Namibian youth.

Increased protected sex and abstinence among Namibian youth following a HIV risk-reduction intervention: a randomized, longitudinal study.

OBJECTIVE: To evaluate an HIV risk-reduction intervention among Namibian adolescents. METHODS: A randomized trial of a 14-session face-to-face intervention emphasizing abstinence and safer sexual practices conducted among 515 youths (median age 17 years and median grade 11) attending 10 secondary schools located in two districts in Namibia. Youths were randomly assigned to the intervention or control condition at the level of the individual. HIV risk behaviours, intentions and perceptions were assessed at baseline, immediately post-intervention and at 6 and 12 months post-intervention. RESULTS: Among all 515 youths who enrolled in the programme, rates of either abstinence or sex with a condom were not different between control and intervention youths at baseline or in the follow-up period. However, analyses conducted among the subset of youths who were sexually inexperienced at baseline (n = 255) revealed that a higher percentage of intervention youths (17%) than control youths (9%, P<0.05) remained sexually inexperienced one year later. Moreover, in the immediate post-intervention period, among baseline virgins who subsequently initiated sex, intervention youths were more likely than control youths to use a condom (18 versus 10%, P<0.05). Additional HIV-related risk behaviours (failure to discuss previous HIV risk exposure with one's sexual partner and alcohol use), intentions to use condoms, and perceptions of the ability to use condoms were positively affected by the intervention. CONCLUSIONS: There is evidence that the 'My Future is My Choice' (MFMC) intervention is reducing HIV risk behaviours among sexually inexperienced participants aged 15-18. Related risk behaviours and perceptions are also positively impacted by the intervention.

A randomized, controlled effectiveness trial of an AIDS prevention program for low-income African-American youths.

BACKGROUND: Some interventions to reduce the risk of the acquired immunodeficiency syndrome (AIDS) that target youths have resulted in short-term increases in self-reported condom use. However, long-term intervention effects have not been assessed. STUDY QUESTION: Can a theoretically and culturally based, AIDS-risk reduction intervention delivered to naturally formed peer groups increase self-reported condom use among African-American early adolescents at 6 and 12 months of follow-up? METHOD: A randomized, controlled trial of a community-based intervention delivered in eight weekly sessions involved 76 naturally formed peer groups consisting of 383 (206 intervention and 177 control) African-American youths 9 to 15 years of age. A theory-based, culturally and developmentally tailored instrument that assessed perceptions, intentions, and self-reported sexual behaviors was administered to all subjects at baseline (preintervention) and 6 and 12 months later. RESULTS: At baseline, 36% of youths were sexually experienced, and by 12 months of follow-up, 49% were sexually experienced. Self-reported condom use rates were significantly higher among intervention than control youths (85% vs 61%; P<.05) at the 6-month follow-up. However, by 12 months, rates were no longer significantly higher among intervention youths. The intervention impact at 6 months was especially strong among boys (85% vs 57%; P<.05) and among early teens (13 to 15 years old) (95% vs 60%; P<.01). Self-reported condom use intention was also increased among intervention youths at 6 months but not at 12 months. Some perceptions were positively affected at 6 months, but the change did not persist at 12 months. CONCLUSIONS: High rates of sexual intercourse underscore the urgent need for effective AIDS-risk reduction interventions that target low-income urban, African-American preteens and early teens. A developmentally and culturally tailored intervention based on social-cognitive theory and delivered to naturally formed peer groups recruited from community settings can increase self-reported condom use. The strong short-term improvements in behaviors and intentions followed by some relapse over longer periods argue for a strengthened program and research focus on sustainability.

Sexually transmitted diseases, human immunodeficiency virus, and pregnancy prevention. Combined contraceptive practices among urban African-American early adolescents.

OBJECTIVE: To evaluate the success of efforts to educate youth not only to use prescription contraceptives to avoid pregnancy, but also to use condoms to avoid sexually transmitted diseases, including infection with the human immunodeficiency virus. METHODS: Longitudinal study of 383 African-American youth aged 9 to 15 years enrolled in a randomized, controlled trial of an acquired immunodeficiency syndrome (AIDS) risk reduction intervention. Data about contraceptive practices were obtained at baseline and 6, 12, and 18 months later using a culturally and developmentally appropriate risk assessment tool administered with "talking" computers (Macintosh, Apple Computer Inc, Cupertino, Calif). RESULTS: Approximately three fourths of sexually active youth used some form of contraception in each 6-month round, with almost half of the youth using combinations of contraceptives. Among all youth at baseline and among control youth throughout the study, more than half used condoms and more than two thirds who used oral contraceptives also used condoms. Receipt of an AIDS education intervention was associated with use of more effective contraceptive practices (eg, condoms and another prescription or nonprescription method of birth control). After receiving the intervention, more than 80% of the youth who used oral contraceptives also used condoms. Contraceptive practices showed considerable stability. Knowledge about AIDS was positively associated with use of more effective contraceptive methods. CONCLUSIONS: Many youth are using condoms and prescription birth control simultaneously, and these use rates can be increased through AIDS education interventions.

Longitudinal stability and predictability of sexual perceptions, intentions, and behaviors among early adolescent African-Americans.

PURPOSE: To assess the stability and predictability of perceptions, intentions, and behaviors regarding intended sexual intercourse and condom use. METHODS: One hundred and nineteen African-American youth aged 9-15 years living in urban public housing provided information at baseline and 6 months later using a theory-based and culturally- and developmentally-tailored instrument assessing perceptions, intentions, and sexual behaviors. RESULTS: Over the 6-month study interval, individual behaviors, intentions, and perceptions demonstrated considerable stability. Intentions regarding sexual intercourse in the next half-year were predictive of subsequent coitus among the entire cohort and among the subset who were virgins at baseline. Youth who thought it likely that they would be sexually-active in the next 6 months were at significantly elevated risk of doing so, compared to youth who were uncertain or thought coitus unlikely. However, intentions regarding future coitus among the subset of youth who were sexually-experienced at baseline were not predictive of future coital behavior. CONCLUSIONS: These data suggest that social cognitive behavioral models that incorporate intentions and perceptions are appropriate as the theoretical basis for interventions targeting these young adolescents.

PIP: A longitudinal study conducted among low-income African-American early adolescents identified the salience of intentions and perceptions regarding sexual intercourse to subsequent behavior. The 119 boys and girls 9-15 years of age were recruited from public housing project recreation centers in Baltimore, Maryland, in 1993. Each youth completed the Youth Health Risk Behavioral Inventory; the instrument was re-administered 6 months later. At baseline, 71 respondents (60%) were virgins; 6 (9%) became sexually active during the 6-month study period. 27 (56%) of the 48 subjects who were sexually experienced at baseline engaged in intercourse during the ensuing 6 months. Overall, the predictiveness of intention to have sex in the next 6 months and actual behavior was very strong, especially among younger youth; nearly half of young people who thought it likely they would have sex did so, while only one-fifth of those who were uncertain and one-seventh of those who considered it unlikely had sex. Condom intention, on the other hand, was not predictive of subsequent use. Youth who engaged in sexual intercourse during the study period had more perceived peer support and internal rewards for sexual activity and perceived the sequelae of intercourse as less severe than their abstinent counterparts. Overall, these findings suggest that social cognitive behavioral models that incorporate intentions and perceptions should form the theoretical basis for interventions aimed at young adolescents.

Urban adolescent high-risk sexual behavior: corroboration of focus group discussions through pile-sorting. The AIDS Youth Research Team.

Risk activities for acquisition of the human immunodeficiency virus (HIV) remain prevalent among urban adolescents. While interdisciplinary approaches to examine the variables contributing to risk/protective behaviors have been promoted, strategies for such explorations require further formulation. Recently we employed focus group discussions to explore factors placing urban adolescents at risk for engaging in HIV risk behaviors. The focus group format enables substantial interaction on a topic in a limited time period, but does not always provide expression of the full range of behavioral options. In this study we investigated the use of pile-sorts for confirmation of impressions from focus group discussions among 57 urban youths aged 10-14. The pile-sorts revealed some support for most of the views expressed in the group discussions. However, the sorts revealed more variability in views than was expressed in the group discussions. Substantial gender and age-based differences in perceptions were revealed with potentially important intervention implications.

Addressing national and regional health needs: a framework for health planning.

Completion of the first decade since the Alma-Ata Declaration of 'health for all' (1978) has led to numerous appraisals, in international forums, of progress achieved by the current primary health care strategy. Although this strategy appears to have contributed to improvements in selected health outcomes, changing circumstances in many developing countries may now require a more flexible and country-specific approach to health care programming. This article argues for the development of a pragmatic framework: to articulate problems which should be addressed in the development of national health programs; and, to organize concepts and methodologies to address these problems. Such a framework should enable an assessment of currently implicit value judgments, and enable strategies to be considered that assess several input and output variables simultaneously. Moreover, this framework would, we believe, further the goal of improved health delivery at a national level, and serve as a guide for further methodologic and conceptual development.

Methodological considerations in defining chronic diarrhoea using a distributional approach.

Attempts to develop effective treatment and preventive strategies for chronic diarrhoea have been confounded by inconsistencies in defining the disorder. In the present paper, we illustrate some of the methodological considerations encountered in using a distributional approach to define chronic diarrhoea. We employ data obtained from 3470 children aged less than six years residing in Dhaka, Bangladesh, between January 1985 and January 1986. The importance of defining the age of the target population is demonstrated by the inverse correlation between age and duration of episodes required to reach or exceed the 95th percentile, ranging from 27 days in children aged less than 12 months to 18 days in children aged over four years. Altering the percentile cut-off qualifying as 'chronic' from the 95th percentile to the 90th percentile changed the minimum qualifying duration from 24 to 16 days. We also demonstrate the impact of altering criteria for termination of an episode and of altering the duration of the monitoring period on the resultant length of episodes classified as 'chronic'.

Breast feeding and the risk of severe cholera in rural Bangladeshi children.

The association between breast feeding and the risk of severe cholera was examined in a case-control study of rural Bangladeshi children under 36 months of age who were studied in 1985-1986 during a field trial of killed oral cholera vaccines. A total of 116 cases who were treated for severe cholera were compared with 464 age-matched community controls without severe cholera. Overall, the odds ratio relating breast feeding to severe cholera (0.30, p less than 0.0001) reflected a 70% reduction in the risk of severe cholera among breast-fed children. The estimated reduction of risk declined with age, but was clearly evident in children up to 30 months of age. Although the association between breast feeding and a reduced risk of severe cholera was not significantly greater in children of mothers who had received cholera vaccine than in children whose mothers had received placebo during the trial, maternal vaccination per se was suggestively associated with a reduced risk of severe cholera in their nonvaccinated children (odds ratio = 0.53, p = 0.05). These results indicate that breast feeding was associated with a substantial reduction of the risk of severe cholera and raise the possibility that vaccination of mothers may provide protection to their young children in endemic settings.

Exclusion of clinically atypical or microbiologically mixed diarrhoeal episodes from outcome events in a field trial of oral cholera vaccines.

We investigated whether alternative clinical and microbiological criteria for outcome events affected estimates of vaccine efficacy in a randomized, double-blind field trial of B subunit-killed whole cell (BS-WC) and killed whole cell-only (WC) oral cholera vaccines among 62,285 rural Bangladeshi participants. At one year of follow-up estimates of vaccine protective efficacy (PE = 60%, P less than 0.0001 for BS-WC; PE = 54%, P less than 0.0001 for WC) against all treated diarrhoeal episodes associated with V. cholerae 01 were similar to estimates of efficacy against only those episodes which were clinically typical and unassociated with additional enteric pathogens (PE = 62%, P less than 0.0001 for BS-WC; PE = 52%, P less than 0.0001 for WC). In contrast, estimates of vaccine cross-protection against episodes associated with each of several agents antigenically related to V. cholerae 01 (LT-ETEC, non-cholera Vibrio sp, Aeromonas sp) were substantially reduced when mixed infections with V. cholerae 01 were excluded. We conclude that restrictive criteria intended to improve the specificity of the definition of cholera did not increase the detectability of vaccine efficacy against V. cholerae 01, but that exclusion of mixed infections with V. cholerae 01 was necessary to avoid false-positive conclusions about vaccine cross-protection against other potential target pathogens.

Oral cholera vaccines containing B-subunit-killed whole cells and killed whole cells only. II. Field evaluation of cross-protection against other members of the Vibrionaceae family.

Because of demonstrable cross-reactivity of cellular antigens contained in B subunit-killed whole-cell (BS-WC) and killed whole-cell-only (WC) oral cholera vaccines with antigens of various non-cholera species of the family Vibrionaceae (NCV), the protection conferred by the vaccines against diarrhoea associated with NCV was evaluated during a randomized, double-blind field trial in Bangladesh. Children aged 2-15 years and women aged greater than 15 years (62,285 in number) received three doses of BS-WC vaccine, WC-only vaccine, or a placebo consisting of Escherichia coli K12 strain (K12). During 1 year of follow-up, the incidence of treated episodes of diarrhoea associated with non-cholera vibrios known to be enteric pathogens (non-01 Vibrio cholerae, V. fluvialis, V. parahaemolyticus, V. mimicus) in the placebo group was low (1.9 cases per 10,000 recipients) and identical to that for the two vaccine groups combined. The incidence (per 10,000 recipients) of treated diarrhoeal episodes associated with Aeromonas species was considerably higher, but nearly identical in the three groups (26.1 cases for BS-WC, 26.0 cases for WC; 25.9 cases for K12). Pleisiomonas shigelloides was not isolated from any participant. It is concluded that NCV other than Aeromonas were rarely isolated from diarrhoeal patients in our study population and that killed oral vaccines which were effective against cholera exhibited no detectable cross-protection against diarrhoea associated with NCV organisms.

Measles vaccination and childhood mortality in rural Bangladesh.

To ascertain whether measles vaccination was associated with reduced mortality rates in rural Bangladeshi children, the authors conducted a case-control study in four contiguous areas, two of which had participated in an intensive measles vaccination program which began in the spring of 1982. Cases were 536 children who had died in the four-area region at the age of 10-60 months between April 1982 and December 1984. Two age- and sex-matched controls were selected from the four-area region for each case; each control had survived at least through the date of death of the matched case. Measles vaccination was associated with a 36% (95% confidence interval 21%-48%) proportionate reduction in the overall rate of death and a 57% (95% confidence interval 43%-67%) reduction in the rate of deaths directly attributed to measles or ascribed to diarrhea, respiratory illness, or malnutrition. The association of measles vaccination and reduced mortality remained unchanged after the authors restricted controls to children who had survived at least one year after the deaths of their matched cases. Moreover, children vaccinated in 1982 exhibited a sustained reduction in the rate of death in 1983 and 1984. The authors concluded that measles vaccination was associated with a pronounced and sustained reduction in the rate of death among children in this study.

Educational intervention for altering water-sanitation behavior to reduce childhood diarrhea in urban Bangladesh: impact on nutritional status.

We evaluated whether an educational intervention that was effective in reducing childhood diarrhea also improved childhood nutritional status. Fifty-one communities of 38 families each were randomized to receive the intervention or no intervention. During 1 y of follow-up the rate of diarrhea (per 100 wk) in children less than 6 y in the intervention group was 5.89 episodes whereas that in the nonintervention group was 7.55 episodes (protective efficacy 22%; p less than 0.0001). During the same follow-up period children in both groups exhibited comparable patterns of weight gain; 1 y after the intervention the mean weight for age of children in both groups was 76% of the NCHS standard. No significant differences were observed in the proportion of each group that experienced a major deterioration or improvement of nutritional status. We conclude that an intervention that reduces rates of childhood diarrhea may not necessarily also improve nutritional status.

Field trial of oral cholera vaccines in Bangladesh: results of one year of follow-up.

We assessed the protective efficacy (PE) of three doses of B subunit-killed whole cell (BS-WC) and killed whole cell-only (WC) oral cholera vaccines in a randomized, double-blind trial among 62,285 children and women residing in rural Bangladesh. After one complete year of surveillance, 110 cases of cholera were detected in the placebo group, 52 in the WC group (PE, 53%; P less than .0001), and 41 in the BS-WC group (PE, 62%; P less than .0001). Protection was greater for BS-WC recipients than for WC recipients only during the initial eight months of observation. Both vaccines conferred equivalent protection against cholera associated with life-threatening dehydration and against less severe cholera. High-grade, sustained protection was observed in persons vaccinated when older than five years; in younger persons protection was transient. We conclude that BS-WC and WC vaccines confer significant protection against cholera, particularly in persons vaccinated when older than five years.

Impact of B subunit killed whole-cell and killed whole-cell-only oral vaccines against cholera upon treated diarrhoeal illness and mortality in an area endemic for cholera.

The impact of B subunit killed whole-cell (BS-WC) and killed whole-cell-only (WC) oral cholera vaccines was assessed in a randomised double-blind trial in rural Bangladesh. 62,285 children aged 2-15 years and women aged over 15 ingested three doses of one of the vaccines or placebo. During the first year of follow-up there was a 26% reduction of all visits for treatment of diarrhoea in the BS-WC group and a 22% reduction in the WC group. The reduction of all admissions for fatal or severely dehydrating diarrhoea was 48% in the BS-WC group and 33% in the WC group. Overall mortality rates were 26% lower in the BS-WC group and 23% lower in the WC group during the first year, and reductions of mortality were observed only in women vaccinated at ages over 15 years. However, no differences in cumulative mortality were evident at the end of the second year of surveillance.

The influence of gender on determinants of urban childhood mortality in Bangladesh.

To assess sociodemographic characteristics predicting childhood mortality in urban Bangladesh, we conducted a case-control study of subjects selected from 51 low and middle class areas of urban Dhaka between 14 October 1984 and 13 October 1985. Cases were the 38 children who died aged under six years during the study interval; six surviving controls aged under six years were selected for each case. Factors associated with childhood deaths included being under one year of age (OR (odds ratio) = 11.80; p less than 0.0001), and several direct and indirect indicators of poor economic status: ie head of household earning a daily wage rather than a salary (OR = 2.63; p less than 0.01); residence in a single-room dwelling (OR = 2.63; p less than 0.05); or residence in a structure of inferior construction (OR = 2.58; p less than 0.05). There were important gender-specific differences in the risk factors. Having one or more male siblings was associated with an increased risk of death for male children (OR = 2.78; p less than 0.05), while having at least one female sibling was suggestively associated with the risk of death for female children (OR = 2.47; p less than 0.10). Family dependence on daily wages rather than on a salary was associated with male deaths (OR = 6.24; p less than 0.001) but not with female deaths (OR = 1.38). Other indices of poverty (poor construction of house and single-room dwellings) were also associated with an increased risk of male but not female deaths.(ABSTRACT TRUNCATED AT 250 WORDS)