标题：Assessing the Effects of a Complementary Parent Intervention and Prior Exposure to a Preadolescent Program of HIV Risk Reduction for Mid-Adolescents
摘要：Objectives. We (1) evaluated the impact of an evidence-based HIV prevention program with and without a parent component among mid-adolescents living in the Caribbean and (2) determined the effect of prior receipt of a related intervention during preadolescence on intervention response. Methods. A randomized, controlled 4-cell trial of a 10-session, theory-based HIV prevention intervention involving 2564 Bahamian grade-10 youths (some of whom had received a comparable intervention in grade 6) was conducted (2008–2011). Randomization occurred at the level of the classroom with follow-up at 6, 12, and 18 months after intervention. The 3 experimental conditions all included the youths’ curriculum and either a youth–parent intervention emphasizing adolescent–parent communication, a parent-only goal-setting intervention, or no parent intervention. Results. An intervention delivered to mid-adolescents in combination with a parent–adolescent sexual-risk communication intervention increased HIV/AIDS knowledge, condom-use skills, and self-efficacy and had a marginal effect on consistent condom use. Regardless of prior exposure to a similar intervention as preadolescents, youths benefited from receipt of the intervention. Conclusions. Preadolescents and mid-adolescents in HIV-affected countries should receive HIV prevention interventions that include parental participation. Evidence acquired over the course of the global HIV epidemic conclusively demonstrates that risk reduction can be achieved through interventions delivered in various venues at the individual, group, class, and community levels using a wide range of intervention approaches. 1,2 Prevention researchers agree that even greater impact could be achieved by employing approaches that are multidimensional (defined here as delivered in different settings, using differing approaches or occurring at multiple times in an individual’s life, and integrated into a wide array of public health and educational efforts). 3,4 Consequently, the next generation of prevention efforts will need to be correspondingly “highly active” 5 and appropriately targeted. Adolescents are of primary importance in curtailing the epidemic. The Joint United Nations Programme on HIV/AIDS (UNAIDS) has estimated that nearly one half of the world’s HIV infections have occurred among individuals aged 15 to 24 years. 6 In the United States, individuals 15 to 29 years old, who represent one fifth of the total population, account for two fifths of new infections. 7 Adolescence is a time of remarkable change in neural development, cognition, physical maturity, and social exposure. These changes have great impact on youths’ mood and impulse control, potential exposure to risk, and ability to comprehend the consequences of their actions. 8–10 Adolescents are variably affected by family, peers, community (including neighborhood and school), and the wider sociocultural context in which they live, 11–13 all of which can exert protective or risk influences. 14 The relative impacts of these social forces change during adolescence, but parents remain prominent throughout. 15–17 Accordingly, prevention efforts targeting adolescents require emphasis on parental involvement. Moreover, intervening with adolescents and parents together has been shown to reduce risk behaviors, 18,19 leading intervention researchers to call for efforts to bring parents and adolescents together for at least 1 session. 20 Although there is consensus regarding the importance of the multiple phases of adolescence in terms of HIV prevention, 8 there is no consensus as to when adolescent interventions should be delivered: in preadolescence or early adolescence (ages 10 to 13 years, prior to the onset of most risk behavior, including consensual sexual activity), during mid-adolescence (ages 14 to 16 years, when some risk taking and experimenting has been initiated), or later in adolescence (ages 17 to 20 years, when many of the situations confronting youths are no longer theoretical). 8,21–23 Some have argued that prevention interventions should not be conceptualized as something that can be completed as a stand-alone intervention; rather, they will need to be repeated over time. 3 Repetition may be especially important for adolescents, given the rapid changes they are experiencing across multiple biological, social, and cognitive fronts. HIV prevention efforts of the 21st century call for multidimensional interventions 24,25 ; mounting such interventions in a fashion that permits assessment of effectiveness presents a formidable challenge. Settings with vibrant biomedical and community-based prevention and treatment efforts may offer the opportunity to examine the potential augmentative effects of school-based programs (with and without a parent component) offered across the adolescent period. One such setting is the Commonwealth of The Bahamas, with the second-highest prevalence of HIV/AIDS in the Caribbean area, peaking at 5.5% in 1994. In partnership with the World Health Organization, the Pan American Health Organization, UNAIDS, and the President’s Emergency Plan for AIDS Relief, The Bahamas has reduced this rate to an estimated 3%, with a 39% decrease in new HIV and AIDS cases from 2001 to 2011, 26 placing it among the 25 nations with the greatest decrease. 25 This substantial decrease required a multidisciplinary, interagency approach. In 2009, the Bahamian Ministry of Health initiated a new National Health Systems Strategic Plan for 2010 through 2020, based on 7 strategic elements that include collaboration across public and private sectors working with communities to improve health and well-being, health care services focusing on prevention at all stages of life, and an emphasis on improved outcomes through an evidence-based approach to decision-making. The country hosts an aggressive educational, testing, and treatment program using multiple sources, including multimedia and a community-outreach service system. In this setting, the Bahamian Ministries of Health and of Education have been collaborating with US investigators in the development and evaluation of school-based prevention efforts. As described in The Bahamas’ 2012 UN General Assembly Special Session report, the goal of the original collaborative effort was to reach youth before the onset of sexual risk behavior. . . . The US–Bahamian research team evaluated the Bahamian adaptations of Focus on [Youth] which resulted in a 10-session adolescent HIV prevention program entitled “Focus on Youth in The Caribbean” (FOYC) and the 1-hour adapted parental monitoring intervention entitled “Caribbean Informed Parents and Children Together” (CImPACT). These adapted programs were evaluated through a randomized, controlled trial involving 1360 6 grade youth and 1175 of their parents. . . . The intervention effects across 3 years for knowledge, condom-use skills, perceptions and intentions regarding condoms and condom-use behavior are strong, with increases among FOYC youth showing significant improvements in most categories compared with youth receiving the control condition. 26 (pp24–25) Accordingly, the Bahamian Ministry of Education incorporated FOYC plus CImPACT into the grade-6 curriculum in government schools throughout The Bahamas 27 and decided to test an adapted version of FOYC (Bahamian Focus on Older Youth, or BFOOY) for use among grade-10 students. As a result of these actions, The Bahamas offers a unique opportunity to examine the impact of an HIV curriculum, delivered at either the grade-6 or grade-10 level or at both, in the context of a country with a robust HIV prevention and treatment program. We examined the effect of a grade-10 HIV prevention program among participating youths overall and by gender, and according to prior exposure to a similar intervention in grade 6, in a country with substantial prevention efforts. We addressed 3 questions of significant public health relevance, both in The Bahamas and globally: (1) Does a school-based intervention targeting mid-adolescents improve knowledge, skills, perceptions, and practices about sexual-risk reduction overall? (2) What is the impact on sexual-risk knowledge, skills, perceptions, and practices of a parent component added to the youth intervention? (3) Does prior receipt of a similar intervention during early adolescence affect intervention effects among mid-adolescents, and if so, how?
