¡ Cuídate! An HIV Prevention Intervention for Latino Youth

1. ¡Cuídate!An HIV Prevention Intervention for Latino Youth Antonia M. Villarruel, PhD, RN, FAAN University of Michigan School of Nursing National Hispanic Science Network 2004

2. Co-Investigators Loretta S. Jemmott, PhD, RN, FAAN University of Pennsylvania School of Nursing John B. Jemmott, III PhD University of Pennsylvania Annenberg School of Communication Funded by National Institute of Nursing Research R01

3. Background • Rates of HIV are inceasing among US Latinos. • HIV/STD/pregnancy rates indicate the concern of unprotected intercourse. • Latinos are less likely than all adolescents to use condoms.

4. Behavioral Interventions for Latino Adolescents • Few controlled intervention studies (6 published) • No significant effects on behavior (3/6) • No significant differences in intervention effects among diverse adolescents (5/6) • No long-term evaluation of behavior effects (5/6) • No inclusion of culturally relevant variables (5/6)

5. Purpose To test the efficacy of a culturally tailored, theory-based HIV risk-reduction intervention designed to reduce the risk of sexually transmitted HIV infection among inner-city Latino adolescents.

6. Designing Culturally Specific Interventions • Building on “what” “works” • Theoretical framework • Intervention design • Overcoming biases and stereotypes • Only culturally-specific interventions will work • Latinos won’t participate in research • Understanding how “culture” works to support healthy behaviors

7. Designing Culturally Specific Interventions • Literature review • Preliminary studies • descriptive studies • questionnaire pilots • intervention pilots • Focus groups • identification of salient attitudes and beliefs • determine feasibility and generate support • Considering content and style • style – facilitators, music, videos, themes

8. Theory of Planned Behavior Attitudes Toward Behavior Subjective Norms Intentions Behavior Perceived Behavioral Control Theoretical Model Moderating Factors Latino Ethnicity Generational Distance, Acculturation, Ethnic Identity Latino Cultural Variables Familialism, Gender Roles, Religiosity Individual Variables Age, Gender, Sexual Experience

9. Research Design • Experimental, randomized control • Safer sex or health promotion conditions. • Pre, post-test - intervention with 3, 6, 12 – month follow ups.

10. Research Setting and Subjects • Schools and communities in Philadelphia with highest concentration of Latinos. • Latino adolescents, 13 and 18 years, English and Spanish speaking, in and out of school. • Retention rates: • 98% - day 2; • 87% - 3 month; • 85% - 6 month; • 81% - 12 month.

12. Experimental Conditions • Six 50 minute modules • Education and skill building • Videos, small group discussions, interactive exercises • Generate cultural pride • Consider decision making within a cultural context • Delivered by trained adult bilingual community members

13. Safer Sex Condition • Latino cultural values and protection from HIV • HIV/AIDS facts • Vulnerability to and consequences of HIV • Cultural values, attitudes, beliefs about HIV, AIDS, safer sex (condom use, abstinence) • Condom use skills • Communication and negotiation skills

14. Demographics(n=553) 45% 28% 26% 46% 29% 25% 48% 29% 24%

15. Demographics(n=553)

16. Comparison of Groups • No significant differences between groups on key demographic or outcome variables. • Spanish dominant speakers, those with a greater number of days of sex and days of unprotected sex were more likely to attrit. • No significant differences in attrition between groups.

17. Analysis • GEE analyses • Predictors: baseline sexual experience, gender, time, intervention • Interactions between intervention condition and each predictor, variables related to attrition, social desirability

18. 3 month 6 month 12 month Safer Sex Health Safer Sex Health Safer Sex Health Group total 42.1 57.9 43.0 57.0 43.4 56.7 experienced 44.4 55.6 47.7 52.3 43.7 56.3 no experience 31.8 68.2 27.3 72.7* 42.3 57.7 *P=.007 Sexual IntercoursePast 3 Months(percent)

19. Sexual IntercoursePast 3 monthsGEE analysis • Significant main effects • Sexual activity increased across time • Adolescents who were in the Safer Sex group were less likely to have had sex in the past 3 months (p = .02). • No significant interaction effects

20. Frequency of SexPast 3 Months(mean number of days) 3 months 6 months 12 months * P=.031 **p=.033

21. Frequency of SexPast 3 Months GEE analysis • Significant main effects • Adolescents who participated in the Safer Sex intervention had significantly fewer days of sex than those in the control group (p = .01). • No significant interactions

22. 3 months 6 months 12 months Safer Sex Health Safer Sex Health Safer Sex Health Group total 51.9 48.2 50.8 49.3 56.3 43.8* experienced 56.1 43.9** 57.8 42.2 56.3 43.8 no experience 40.0 60.0 31.5 68.4 53.3 46.7 * P=.027 **P=.048 Consistent Condom UsePast 3 Months(per cent)

23. Consistent Condom Use Past 3 MonthsGEE analysis • Significant main effect • Adolescents in the safer sex group were more likely to consistently use condoms than the control group (p = .009) • No significant interaction

24. 3 months 6 months 12 months SaferSex Health Safer Sex Health Safer Sex Health Group total 4.31 (1.70) 4.10 (1.52) 4.5 (1.65) 4.39 (1.53) 4.72 (1.46) 4.30 (1.46)* experienced 4.37 (1.66) 4.04 (1.49) 4.45 (1.66) 4.27 (1.50) 4.68 (1.47) 4.19 (1.49)** No experience 3.8 (1.93) 4.11 (1.66) 4.73 (1.68) 4.6 (1.63) 4.77 (1.50) 4.6 (1.38) * P=.051 **P=.058 Frequency of Condom Use Past 3 Months 1= never – 5 = always

25. Frequency of Condom UsePast 3 Months GEE analysis • Significant main effects • Adolescents who participated in the Safer Sex intervention had a higher frequency of condom use (p = .02) • No significant interactions

26. Proportion of Days of Unprotected SexPast 3 Months 3 months 6 months 12 months

27. Proportion of Days of Unprotected Sex GEE analysis • No significant main effects • Significant interaction effects between intervention and language (p=.005) • Spanish speakers in the Safer Sex group have a lower mean proportion of days of unprotected sex than those in the control group

28. Number of Partners in the Past 3 Months(% with more than 2 partners) * P=.024

29. Number of Partners Past 3 Months GEE analysis • No significant main effect • Significant interaction with condition, sexual experience and gender (p = .02) • Spanish speakers, females, and the sexually inexperienced in the Safer Sex group, had fewer partners than those in the control group

30. Summary • One of the few randomized controlled studies to demonstrate the long-term effectiveness of an intervention for Latino adolescents • The intervention was effective in increasing both condom use and abstinence behaviors • Some evidence of differential intervention outcomes by language dominance, sexual experience, and gender

31. Assumptions • Beginning assumptions • Aspects of Latino culture influences sexual risk and protective behavior • Culturally specific/tailored interventions will be most effective • Assumptions supported • TBD • Only a measurement issue? • Changed assumptions • See “beginning assumptions”