Loretta Sweet Jemmott, Ph.D., RN., FAAN

1. FROM RESEARCH TO PRACTICE TO POLICY: REDUCING HIV RISK AMONG AFRICAN AMERICAN ADOLESCENTS IN URBAN COMMUNITIES Loretta Sweet Jemmott, Ph.D., RN., FAAN van Ameringen Professor in Psychiatric Mental Health Nursing University of Pennsylvania - School of Nursing

2. John B. Jemmott III, Ph.D. Annenberg School of Communication Freida Outlaw, DNScSchool of Nursing M. Katherine Hutchinson, Ph.D, RNSchool of Nursing Larry Icard, Ph.D.School of Social Work Vivian Gadsden, Ph.D.Graduate School of Education David Metzger, Ph.D.Department of Psychiatry - Center for Studies Addiction Ann O’ Leary, Ph.D.Centers for Disease Control and Prevention Erica Gollub, Ph.D.Department of Psychiatry - Center for Studies Addiction Geoff Fong, Ph.D.Waterloo University, Canada CO-INVESTIGATORS

3. National Institute of Nursing ResearchNational Institute of Mental HealthNational Institute of Child Health and Human Development FUNDING SOURCES

4. A PROGRAM OF RESEARCH THAT SEEKS TO: • Elucidate the social psychological factors that underlie HIV risk associated sexual behavior. • Identify the particular conceptual variables that are most important to achieving intervention-induced sexual behavior change. • Identify theory-based, culture-sensitive, developmentally appropriate strategies to reduce HIV risk-associated sexual behaviors.

5. A PROGRAM OF RESEARCH THAT SEEKS TO:(continued) • Answer practical questions about the most effective way to implement HIV risk-reduction interventions with ethnic minority youth. • Test the effectiveness of such interventions using scientifically rigorous methodologies and experimental designs. • Disseminate effective research-based behavioral interventions to CBOs, schools, clinics, etc.

6. ADOLESCENTS ARE AT RISK FOR SEXUALLY TRANSMITTED HIV INFECTION • 17% of AIDS cases involve young adults 20 to 29 years of age. • 17% of HIV infections reported during 2000 were among people 13 to 24 years of age. • Adolescent pregnancy is a national concern. • High rates of sexually transmitted diseases. • Failure to use condoms

7. CHALLENGES IN HIV RISK-REDUCTION RESEARCH WITH ADOLESCENTS • Feelings of invulnerability • Resistance to abstinence messages • Negative beliefs about safer-sex practices • Inadequate confidence to negotiate safer sex • Legal or policy barriers • Sporadic sexual behavior

8. KEY RESEARCH QUESTIONS FOR ADOLESCENTS • Can the behavior of high-risk youth be changed? • Can culture-sensitive programs be effective when implemented by facilitators who do not share the ethnicity of participants? • Can abstinence-based interventions be effective? • How effective are peer educators? • Can evidenced-based practices be disseminated and evaluated when implemented by end users?

9. HOW DO WE CONDUCT OUR RESEARCH?

10. PHASES OF RESEARCH • 1. Elicitation (Focus Groups) • 2. Questionnaire Development • 3. Design Intervention • 4. Pilot Intervention • 5. Evaluation • 6. Dissemination

11. THEORETICAL MODELS • Social Cognitive Theory Self-efficacy, Outcome Expectancy, (Hedonistic, Partner Reaction, Prevention Beliefs) and Skills. • Theory of Reasoned ActionAttitudes, Beliefs, Subjective Norms and Intentions. • Theory of Planned BehaviorPerceived Behavioral Control and Control Beliefs

12. THEMES: (FAMILY, COMMUNITY, CULTURE & PRIDE) • “Respect Yourself, Protect Yourself...Because You Are Worth It” • “Let’s Work Together to Save Our People & Community.” • “Be Proud, Be Responsible...Respect Yourself, Protect Yourself!”

13. THE "BE PROUD! BE RESPONSIBLE!"THEME, ENCOURAGES ADOLESCENTS TO: • Be proud of themselves, their family and their community, • Behave responsibly for the sake of themselves their family and their community, and • To consider their goals for the future and how unhealthful behaviors might thwart the attainment of their goals and dreams.

14. Small Group Discussion Culturally Appropriate Themes & Strategies Developmentally Appropriate Strategies Interactive Activities Audiovisuals Knowledge Self-efficacy Attitudes/Beliefs Goals & Dreams Technical Skill Building Role Playing Practice and Feedback WHAT DO OUR INTERVENTIONS INVOLVE?

15. Randomized controlled trial 157 African American male adolescents at a weekend program Mean age was 14.6 years 83% reported ever having sexual intercourse Five hour cognitive-behavioral small group intervention Facilitator gender 96% 3-month follow-up return rate JEMMOTT, JEMMOTT, & FONG (1992, AJPH)--DESIGN

16. JEMMOTT, JEMMOTT, & FONG (1992, AJPH)--RESULTS • Reduced HIV risk-associated sexual behavior • Reduced frequency of sexual intercourse • Reduced unprotected sexual intercourse • Fewer sexual partners • No consistent effect of gender of facilitator • Self-reported sexual behavior change unrelated to social desirability bias

17. Randomized controlled trial 496 African American adolescents at a weekend program Mean age was 13.1 years 54% were female 55% reported ever having sexual intercourse 5-hour cognitive-behavioral small group intervention Facilitator race, facilitator gender, and group gender composition 96% 3-month follow-up return rate; 93% 6-month follow-up return rate JEMMOTT, JEMMOTT, FONG & MCCAFFREE (1999 AJCP) --DESIGN

18. JEMMOTT, JEMMOTT, FONG & MCCAFFREE (1999 AJCP) --RESULTS • Reduced HIV risk-associated sexual behavior • Reduced unprotected sexual intercourse • Self-reported sexual behavior change unrelated to social desirability bias • Intervention effects were the same irrespective of race of facilitator, gender of facilitator, and the gender composition of the group

19. Randomized controlled trial 659 African American adolescents at a weekend program Mean age was 11.8 years 53% were female 25% reported ever having sexual intercourse 8-hour abstinence-based, safer-sex, or general health promotion intervention Adult facilitator or peer co-facilitators 96% 3-month follow-up return rate JEMMOTT, JEMMOTT, & FONG (1998, JAMA)--DESIGN

20. JEMMOTT, JEMMOTT, & FONG(1998, JAMA)-- RESULTS • Abstinence intervention reduced the frequency of coitus and, in virgins, delayed initiation of coitus • Safer-sex intervention increased condom use • Safer-sex intervention reduced unprotected coitus • Adult and peer facilitators equally effective • Self-reported sexual behavior change unrelated to social desirability bias

21. HOW DO EFFECTIVE INTERVENTIONS GET DISSEMINATED TO END USERS, SUCH AS SCHOOLS, COMMUNITY BASED ORGANIZATIONS, OR HEALTH CLINICS?

22. CDC'S DISSEMINATION PROJECT "RESEARCH TO CLASSROOMS: PROGRAMS THAT WORK" • Scientifically valid evidence of effectiveness • User-friendly • Dissemination to educators and other advocates for youth • "Be Proud! Be Responsible! Strategies to Empower Youth to Prevent AIDS”(Jemmott, et al, 1994)

23. CDC'S DISSEMINATION PROJECT "RESEARCH TO CLASSROOMS: PROGRAMS THAT WORK" • "Making A Difference! An Abstinence Based Approach to Prevent HIV, STD, and Teenage Pregnancy" (Jemmott,et al., 2001). • "Making Proud Choices! A Safer Sex Approach to Prevent HIV, STD, and Teenage Pregnancy" (Jemmott, et al., 2001)

24. Teaches skills Emphasizes hedonistic beliefs Holds their attention Very interactive & fun Non judgmental, caring & supportive Culturally sensitive Videos are appropriate Excellent teacher-student interaction Age specific Good discussions Credible Promotes confidence Build pride/ responsibility WHY DOES OUR INTERVENTION WORK?

25. WHAT ROLE HAS POLICY PLAYED IN DISSEMINATING THESE EVIDENCED BASED PROGRAMS TO END USERS?

26. RESEARCH TO POLICY TO PRACTICE • CDC's National Training of Trainers Project for "Research to Classrooms - Programs That Work" Curricula. • CDC's Community Planning Group Initiative - A community level approach for providing evidenced-based strategies for reducing HIV risk associated behavior.

27. SISTER TO SISTER: THE BLACK WOMEN’S HEALTH PROJECT • Funded by The National Institute for Nursing Research

28. HIV PREVENTION FOR AFRICAN AMERICAN WOMEN IN PRIMARY CARE SETTINGS JEMMOTT, JEMMOTT & O'LEARY, et al., • Purpose of Study: To evaluate the effectiveness of HIV risk reduction intervention on self reported HIV sexual risk behaviors and incidence of sexually transmitted diseases (STDs) among inner-city African American women attending a primary care clinic in Northern New Jersey.

29. CHALLENGES IN HIV PREVENTION FOR AFRICAN AMERICAN WOMEN • Feelings of invulnerability • Resistance to condom use messages • Negative beliefs about safer-sex practices • Inadequate confidence to negotiate safer sex • Inadequate confidence in condom use skills • Concerns about partner reaction, poverty, violence, children, drug use, etc.

30. KEY RESEARCH QUESTIONS FOR WOMEN • Can the behavior of women be changed? • What type of HIV risk reduction intervention is best for African American women in a primary care setting? Group vs. Individual? Information alone vs. Skill based? • Can a single session, 20 minute 1-on-1 skill-based intervention reduce HIV risk-associated sexual behavior and the incidence of STDs?

31. Nurse-led randomized controlled trial 564 African American women attending a primary care clinic Mean age, 27 years Facilitators: 27 African American nurses 1 of 5 conditions 3, 6, 12 month follow-up Self reported sexual behavior STD clinical exam 86.9% retained at 12-month follow-up JEMMOTT, JEMMOTT, & O’LEARY DESIGN

32. THE 5 INTERVENTIONS • Contrasted two methods of delivery - group vs. individual • Two kinds of interventions content - information vs. skill-building • Health promotion control group

33. RANDOMLY ASSIGNED TO 1 OF 5 CONDITIONS • 20 minute skill-based 1-on-1 intervention. • 20 minute information-alone 1-on-1 intervention. • 3.5 hour skill based group intervention. • 3.5 hour information alone group intervention. • 3.5 hour health promotion control group.

34. MOTHERS AND SONS HEALTH PROMOTION PROJECT

35. Randomized controlled trial 42 housing developments in Philadelphia 16-hour cognitive-behavioral small group intervention over 4 Saturdays Homework assignments 630 single African American mothers and their sons ages 11-15 Facilitators - 84 women residing in the housing developments Mother's sexual behavior Son's sexual behavior 24-month follow-up MOTHERS AND SONS HEALTH PROMOTION PROJECT

36. PURPOSE The purpose of the study is to identify effective, theory - based, culturally sensitive behavioral interventions to help single African American mothers reduce their own and their son’s risk of sexually transmitted HIV infection.

37. MOTHERS AND SONS HEALTH PROMOTION PROJECT

38. MOTHERS AND SONS HEALTH PROMOTION PROJECT

39. MOTHERS AND SONS HEALTH PROMOTION PROJECT

40. MOTHERS AND SONS HEALTH PROMOTION PROJECT

41. WHAT ARE MY NEW RESEARCH PROJECTS?

42. CHURCH & FAMILY HEALTH PROMOTION PROGRAM TOGETHER WE CAN DO ALL THINGS

43. Randomized controlled trial 10 Black Baptist Churches in Philadelphia 12-hour small group intervention over 3 Saturdays 720 single African American parents and their children ages 11-14 1 of 3 conditions Facilitators - 18 adults from each church Parent-child communication Homework assignments & booster sessions Child's sexual behavior 24-month follow-up CHURCH-BASED PARENT-CHILD HIV RISK REDUCTION PROJECT

44. REDUCING SEXUAL RISK BEHAVIOR AMONG BLACK SUBSTANCE ABUSING WOMEN

45. Randomized controlled trial Presbyterian Medical Center Detox facility One of three conditions 869 African American women Facilitators: nurses and certified addiction counselors Sexual behavior Clinically documented STDs 3- & 6-month booster sessions 12- & 18-month follow-up REDUCING SEXUAL RISK BEHAVIOR AMONG BLACK SUBSTANCE ABUSING WOMEN

46. CONCLUSIONS THE RESULTS SUGGEST THAT: • Relatively brief but intensive culturally sensitive and developmentally appropriate HIV risk-reduction interventions can have significant impact on HIV risk behavior and theory-based mediators of such behavior among African American youth and women. • HIV Risk Reduction needs to consider partner approval, hedonistic expectancies, and skills when designing interventions for African American youth and women.

47. CONCLUSIONS THE RESULTS SUGGEST THAT: • By developing, testing and disseminating such interventions we can reduce the risk of sexually transmitted HIV infection among this population. • I am optimistic that continued work along these lines will curtail the spread of HIV.