Public Health Nursing Vol. 31 No. 5, pp. 414–427 0737-1209/© 2014 Wiley Periodicals, Inc. doi: 10.1111/phn.12128 POPULATIONS AT RISK ACROSS THE LIFESPAN:PROGRAM EVALUATIONS Factors Related to Risky Sexual Behaviors and Effective STI/HIV and Intervention Programs for African American Adolescents Young Me Lee, Ph.D., R.N. Adanisse Cintron, M.S., R.N., and Surinder Kocher, M.S., R.N. School of Nursing, DePaul University, Chicago, IL

Correspondence to: Young Me Lee, Assistant Professor, School of Nursing, DePaul University, 990 W. Fullerton Ave, Chicago, IL 60614. E-mail: [email protected]

ABSTRACT Objective: The purpose of this integrative literature review study was to investi- gate factors related to risky sexual behaviors among African American adolescents, to evaluate which of the factors are common across successful and effective STI/HIV and pregnancy interven- tion programs, and finally, to propose suggestions for future intervention programs for African American adolescents in West Englewood, Chicago. Design: An integrative literature review was conducted. Using CINAHL, PubMed, and ProQuest database, the following terms were searched: African American, Black, adolescents, teenagers, sexual behavior, cultural factors, pregnancy, STIs/HIV/AIDS, and intervention programs. Result: A total of 18 articles were reviewed, findings indicated there were five major contributing factors related to risky sexual behaviors: substance use, gender roles, peer influences, parental involvement, and level of knowledge and information on sex and STIs. Six successful STI/HIV and pregnancy programs that incorporated those factors to effec- tively reduce risky sexual behaviors were identified. Conclusion: After analyzing six national inter- vention programs proven to be effective, the findings suggest that future prevention programs should be designed with more emphasis on avoidance or limited substance use, increased parental involve- ment, integration of cultural teaching components such as storytelling and history as suggested from the Aban Aya Youth Project. This study also concluded that future prevention programs should con- sider the length of programs be longer than 1 year, as it has been shown to be more effective than shorter programs.

Key words: African American adolescents, intervention programs, pregnancy, sexually trans- mitted infections.

Background (STIs): human papillomavirus, , herpes Unplanned pregnancy and high rates of STI/HIV simplex virus, or . The rate of STIs transmission are still significant epidemics facing and unplanned pregnancy are consistently higher adolescents in America. The Centers for Disease among African American (non-Hispanic Black) ado- Control and Prevention (CDC, 2009) conducted a lescents as compared to non-Hispanic White adoles- survey that revealed 46% of U.S. high school stu- cents. Studies report it is because African American dents have engaged in . The survey adolescents are more likely to have sex at an earlier reported that one in four female adolescents (aged age and to have more sexual partners. Consequently, 14–19) have contracted one or more of the following these risky sexual behaviors put them at an most commonly sexually transmitted infections increased risk of pregnancy and contraction of STIs/

414 Lee et al.: STI/HIV and Pregnancy Prevention Programs 415

HIV (CDC, 2003; National Campaign to Prevent as the Illinois state rate (36.1 per 1,000 in 2009) Teen and Unplanned Pregnancy, 2011). The U.S. (City of Chicago, 2012). In addition, the rates of teen pregnancy rate for female adolescents ages 15– STI/HIV infections are significantly higher than 19 was 37.9 per 1,000 in 2009 and 34.2 per 1,000 in other communities, for example, 777.4 cases per 2010, while that of the African American adolescents 100,000 of in West Englewood com- ages 15–19 was 56.7 per 1,000 and 51.5 per 1,000, pared to 292.8 per 100,000 in Chicago and chla- respectively (Martin, Hamilton, Ventura, Osterman, mydia rates of 2,129.3 per 100,000 in West Wilson, & Mathews, 2012). The U.S. Department of Englewood compared to 938.1 per 100,000 in Chi- Health and Human Services (USDHHS) reported cago in 2009 (City of Chicago, 2011). that gonorrhea rates were highest in non-Hispanic Teen pregnancy and STI prevention are one of Black adolescents between the ages of 15 and 19 the CDC’s top priorities. The goals are to reduce (2012). Furthermore, African American adolescents, the rates within priority populations and promote ages 13–24 years, accounted for 65% (5,404) of the health equity among adolescents by implementing total incidence of HIV infection in the United States teen prevention programs (CDC, 2009). Various in 2009 (CDC, 2009). programs, including the Adolescent Health Program Teen pregnancy and STI. With the advent (APH) and the Family Planning Program, have and rigorous nationwide implementation of teen been developed and implemented on the commu- pregnancy and STI intervention programs, teach- nity level for vulnerable populations, such as Afri- ing and discussing practices, and adoles- can American adolescents living in West cents choosing to abstain from sex, the rates of Englewood. However, there is a persistent gap unplanned pregnancy and STI transmission among between best practices in sexual education and the general teenage population have decreased what is realistic for African American adolescents since 2009 (Bowers, 2007; Martin et al., 2012). In living in an economically and educationally disad- fact, the birth rate for the U.S. teenagers ages 15– vantaged community (Ott, Rouse, Resseguie, Smith, 19 fell 5% in 2010 to 34.2 per 1,000 (from 37.9 & Woodcox, 2011). Resources are often limited in per 1,000 in 2009), reaching the lowest level the West Englewood community, thereby, nega- reported in the United States in seven decades tively impacting the sustainability of programs, and (Martin et al., 2012). There has been a steady adaptations to local and national programs gener- decline in the number of birth rates from African ally must be made to target specific community American adolescents with a 17% decrease from health needs (Ott et al., 2011). Furthermore, there 2007 to 2010 (Martin et al., 2012). The steady is limited synthesis of published data describing declines in teen birth rates and STI rates have factors influencing African American adolescents’ been associated with the strong prevention mes- sexual behaviors, common factors across interven- sages directed toward adolescents (Martin et al., tion programs found to be effective in reducing 2012). Rates of both teen pregnancy and STIs are STI/HIV, and unplanned pregnancy rates for Afri- decreasing steadily among the African American can American adolescents. adolescent population, yet those rates in this pop- ulation still remain substantially higher than the Research questions U.S. teen population. The purpose of this study was to investigate factors The issues of STIs and teen pregnancy are of related to risky sexual behaviors among African serious concern on the south side of Chicago in the American adolescents to evaluate which factors are community known as West Englewood. This com- common across successful STI/HIV intervention munity is predominantly African American (97.6% programs and to propose suggestions for future of the total population for the area) and still reports intervention programs targeting African American high rates of teen births, infant morbidity and mor- adolescents living in West Englewood, Chicago. The tality, and STIs. Of Chicago’s 77 distinctive commu- findings of this study will be used to develop cultur- nities, West Englewood continues to have the ally sensitive and tailored intervention programs for highest teen birth rate, 116.9 per 1,000 adolescents African American Adolescents living in West Engle- (City of Chicago, 2012). This is almost twice as high wood and similar urban neighborhoods. 416 Public Health Nursing Volume 31 Number 5 September/October 2014

1. What contributing factors play an essential role public health resources, such as the CDC and the in the risky sexual behaviors of African American USDHHS. Peer reviewed articles were analyzed, adolescents? government resources were evaluated, and common factors within each discipline were used to answer 2. Which of the factors are common across success- each of the research questions. The search terms ful STI/HIV intervention programs that effec- included: African American adolescents, STI, HIV/ tively reduce the risky sexual behaviors, STI/ AIDS, STD (sexually transmitted disease), adoles- HIV, and pregnancy rates among this popula- cent pregnancy, teen pregnancy, intervention/pre- tion? vention programs, contributing factors, and cultural factors. 3. What effective curriculum components/factors can be suggested for future STI/HIV and preg- Analytic strategy nancy intervention program planning in West The first research question sought to identify fac- Englewood, Chicago? tors that play an essential role in risky sexual behavior of African American adolescents. Articles were reviewed to find relevant information that Methods addressed factors related to sexual behaviors among African American adolescents. The following crite- Design ria for articles used in this search included: An integrative literature review was conducted to • A study population that included African Ameri- provide a comprehensive search of the literature on can adolescents effective STI/HIV and pregnancy prevention pro- • Articles published from 1993 to 2013 grams developed for African American adolescents • Statistical acknowledgment of high-risk sexual in the United States. It also helped to identify con- behavior among African American adolescents tributing factors leading to the increasing rates of pregnancy and STI/HIV in African American ado- A total of 97 articles were found and of those, lescents in Chicago’s West Englewood community. 18 articles met the search criteria and were An integrative literature review is the broadest type selected. The rates of unplanned pregnancy and of research review method that includes the review STI/HIV transmission in African American adoles- of both experimental and nonexperimental research cents have been consistently high since the early on a given topic of concern (Whittemore & Knafl, 1990s. Thus, articles published from 1993 to 2013 2005). In this case, the topic included factors that were chosen and reviewed to determine the possi- influence sexual behavior of African American ado- ble recurrence of themes related to factors influenc- lescents and an investigation of effective STI/HIV ing sex behaviors of African American adolescents and pregnancy prevention programs focused pri- over two decades (Martin et al., 2012). Findings marily on African American adolescents. The from various surveys and interviews, as shown research method provides an accurate summary of within the reviewed articles, demonstrated a com- previously conducted research and plays an impor- monality of external factors contributing to African tant role in finding information that is fundamental American adolescent sexual behavior, which were to understanding the topic. categorized into five overarching factors. To address the second research question, a Measures study conducted by the USDHHS in 2012 was used A review of the available literature related to ado- to analyze the different components used in lescent sexual behavior in a predominantly African national intervention/prevention programs that American community was conducted using several have shown to be effective in reducing STI/HIV disciplines, including contributing factors, interven- transmission and pregnancy within the adolescent tion programs and nursing related to adolescent African American population. The HHS reported on STI/HIV and pregnancy rates. A search was per- 31 programs that were found to be effective in pre- formed using CINAHL and PubMed, as well as venting teen or births, reducing STIs, Lee et al.: STI/HIV and Pregnancy Prevention Programs 417 or reducing rates of associated sexual risk behav- among African American adolescents. These factors iors—defined by sexual activity, contraceptive use, include: substance use, gender roles, peer influ- or number of partners (2012). The following inclu- ences, parental involvement, and level of knowledge sion criteria were used to select the evidence-based and information on sex and STIs. programs for this study: Substance use. Substance use among adoles- • Intervention programs evaluated and articles cents is increasing. It is known that use of sub- published between 2002 and 2013 stances, such as alcohol, marijuana, and other • Intervention programs shown to be effective by drugs, yields impaired judgments and lowered inhi- the USDHHS bitions. When use of alcohol was reported, an • Intervention programs that focused on reducing increased probability of sexual activity was found in HIV/STI transmission and pregnancy in adoles- both African American males (96%) and African cent populations and implemented programs in American females (85%) (Perkins, Meilman, Leich- an urban area liter, Cashin, & Presley, 1999). This knowledge can • Total number of study participants greater than translate to an understanding of increased risky 450 sexual practices among adolescents while under the • African American study population comprising influence of substances, including alcohol and illicit greater than 50% of total study population drugs, leading to decreased contraceptive use. A Of the 31 programs that proved to be effective study conducted by Elkington, Bauermeister, and by HHS, six STI/HIV and pregnancy intervention Zimmerman (2011) also found that drug use, par- programs met the inclusion criteria and were ticularly alcohol use, was strongly related to sexual selected to address the second research question. activity. The probability of 15-year-old girls being Information about these six programs was compiled virgins decreased from nearly 100% for those who into a matrix that recorded the purpose of the pro- have never drank to less than 20% for those who gram, research design/sample/setting, theoretical drank every day. This decrease in probability of vir- framework, description of the interventions, pro- ginity status was similar for 15-year-old boys and gram outcomes on behavior changes, and factors 18-year-old girls (Elkington et al., 2011). Further- related to sexual practice (Table 1). more, Bachanas et al. (2001) found that adolescents The third research question sought to make in this study who engaged in substance use were suggestions for future STI/HIV and unplanned more likely to engage in sexual behaviors that put pregnancy prevention program planning in West them at greater risk for STI/HIV transmission and Englewood, Chicago. Identifying factors contribut- unplanned pregnancy. ing to African American adolescent sexual practices yielded understanding of aspects of African Ameri- Gender roles. Gender differences have been can culture and sexual influences. African American identified in previous research, noting that African cultural awareness, along with components incor- American adolescent males are more likely to sexu- porated in prevention programs that were found to ally debut at a younger age and have more part- be effective in reducing rates of STI/HIV and ners, whereas females are less likely to use unplanned pregnancy allowed for the suggestion of (CDC, 2003). Heatherington, Harris, Bau- components to be included in future programs tar- sell, Kavanagh, and Scott (1996) and Osmond et al. geting West Englewood, Chicago and its predomi- (1993) reported that women tend to feel powerless nantly African American adolescent population. in the negotiation of use during sexual intercourse with their partners. In addition, self- esteem enhancing reasons for engaging in risky sex- Results ual behavior have been studied and correlated with gender-specific sex behaviors and practices. Robin- Factors related to risky sexual practices son, Holmbeck, and Paikoff (2006) found that among African American adolescents males were more likely to report self-esteem Among 18 articles reviewed, five factors were iden- enhancing reasons for having sex, such as “to make tified as contributors to risky sexual practices yourself feel better” or “to feel proud of yourself” Table 1. Six Effective National Adolescent STI/HIV and Pregnancy Prevention Programs 418

Program and Theoretical Program outcomes on Factors r/t sexual

purpose Design/Sample/Setting framework Program description behavior practice 2014 September/October 5 Number 31 Volume Nursing Health Public Aban Aya Cluster randomized trial n/a School-based, Afro-centric SDC Increased use of Provided Youth Project Recruited N = 1,153 (5th–8th grade instructed over a 4-year period, condoms information about To promote participants) beginning in 5th grade. Reduced frequency of abstinence, abstinence from 91% African American and 50.5% SDC included 16–21 classroom- sexual intercourse in behavioral skills sex, to teach female, 49.5% male based lessons (40–45 min) per males development, students how to Recruited n = 12 high-risk year contraceptive avoid drugs and metropolitan schools in Chicago, SCI included SDC plus a parent/ Other education; self- alcohol and how IL at baseline, divided into three community element that focuses Reduced rate in efficacy/self- to resolve conditions: on all the social domains of violent behavior in esteem; Sexuality/ conflicts • Social development curriculum influence on children males HIV/AIDS/STI nonviolently (SDC; n = 4); HEC focused on general health, Reduced rate in Education • School/community intervention nutrition, and physical activity school delinquency in (SCI; n = 4); African teaching methods were males • – Control group health enhance- incorporated into content Reduced rate of drug ment curriculum (HEC; n =4) components. use in males Posttests and follow-ups in the fall and spring of 5th grade and annually in the spring of 6th, 7th, and 8th grades Be Proud! Be Cluster randomized trail Social cognitive Six session curriculum delivered Increased use of Provided Responsible! Recruited 86 community-based theory over the period of six 1 hr condoms information about To affect organizations (CBOs) at baseline, sessions in variety of settings HIV, STDs and knowledge, divided into treatment and (Building Knowledge about HIV pregnancy, and beliefs, and control conditions and AIDS; Understanding prevention intentions 3,445 adolescents aged 13–18 Vulnerability to HIV Infection; strategies related to received the intervention Attitudes and Beliefs about HIV, condom use and 90% African American and 56% AIDS, and Safer Sex; Building sexual behaviors female, 44% male Condom Use Skills; and Building 1,707 participants (863 in the HIV/ Negotiation and Refusal Skills). STD-intervention CBOs and 844 Delivered through group in the control intervention CBOs) discussions and exercises, videos, were randomly selected for the games, and role-play. follow-up sample Group size – ideally 6–12 per group Pre- and posttests; and follow-up at 3, 6, and 12 months postintervention

(continued) TABLE 1. (Continued)

Program and Theoretical Program outcomes on Factors r/t sexual purpose Design/Sample/Setting framework Program description behavior practice Children’s Aid Randomized controlled trial Developmental Uses a long-term, holistic approach Reduced frequency of Provided age Society- (Experimental design) assets/ After school program or sexual intercourse appropriated Carrera Recruited from six New York City Resiliency community-based organization and incidence of comprehensive sex Program youth agencies theory Recruits boys and girls aged 11–12 pregnancy within education To empower African American and Latino and follows them through high females and help youth aged 13–15 school and beyond. Increased use of in developing 55% female; 45% male and 56% Seven fundamental components – condoms within personal goals, African American; 42% Hispanic; Education; Job Club; Family Life females the desire for a 2% other and Sexuality Education (FLSE); Increased use of productive 484 youth at baseline, divided in Self-Expression; Lifetime hormonal method of future, and in half into treatment and control Individual Sports; Full Medical contraception developing their conditions and Dental Care; and Mental No difference between sexual literacy Health Services treatment and control Program activities run all five groups in sexual and e ta. STI al.: et Lee weekdays for about 3 hr per day reproductive behavior Heritage Quasi-experimental design n/a Classroom-based curriculum Less likely to report Provided Keepers 2,214 participants focused on benefits of remaining having ever had sex. information about Abstinence 7th–9th grade students from 34 abstinent until marriage and risky reproductive Education program schools and seven sexual activity systems and STIs To reduce the comparison schools 450 min interactive curriculum for Delay onset of first Benefits of sexual / number of 63% African American and 58% middle and/or high schools sexual intercourse abstinence in 419 Programs Prevention Pregnancy and HIV adolescents female, 42% male Presented in 45-min class periods terms of initiating sexual Recruited n = 2,214 at baseline, over 10 sequential school days or immediate risks, activity and divided into treatment in 90-min sessions for five such as unwanted increase the (n = 1,828) and control (n = 387) consecutive days. pregnancy and number of condition Five sections of content material: STDs, and in sexually active ; Family terms of helping adolescents Formation; STD Facts; Love, youth prepare for returning to Lust, Infatuation; and The SAFE family formation abstinence Plan in the future

(continued) 420 TABLE 1. (Continued)

Program and Theoretical Program outcomes on Factors r/t sexual purpose Design/Sample/Setting framework Program description behavior practice ulcHat usn oue3 ubr5SpebrOtbr2014 September/October 5 Number 31 Volume Nursing Health Public Promoting Randomized controlled trial Social Twelve modules delivered over two Reduced sexual Provided Health Among (experimental design) Cognitive to three consecutive Saturdays for initiation seen in information about Teens (PHAT) 662 participants and 53% female; Theory, a period of 8 or 12 hr. abstinence-only abstinence, safe To reduce the 47% male Theory of Intervention manual structured intervention sex practices, risk for HIV, Targeting African American Reasoned around group discussions, videos, Reduced recent sexual pregnancy STIs, and students in grades 6 and 7 Action, and games, brainstorming activities, intercourse in prevention, and unwanted Participants randomly assigned to Theory of skill-building, and experiential abstinence-only and the prevention of pregnancy one of five conditions: (1) 8-hr Planned exercise. 12-hr comprehensive HIV and STIs through abstinence-only intervention, (2) Behavior Four modules targeted to interventions behavior 8-hr safer sex-only intervention, encouraging abstinence; four Reduced number of modification (3) 8-hr comprehensive modules targeted to encouraging multiple sexual and building abstinence and safer sex condom use; and four cover partners in both knowledge intervention, (4) 12-hr general content related to HIV/ comprehensive comprehensive abstinence and STI knowledge. intervention groups safer sex intervention, or (5) 8-hr Survey before intervention general health promotion (baseline) and follow-up at 3, 6, program serving as a control 12, 18, and 24 months group postintervention Teen Health Randomized, controlled, multisite Diffusion of Community-level intervention that Increased use of Provided Project community-level intervention innovations helps adolescents develop skills to condoms information on To increase trial and social enact change, provides continued Delayed onset of first behavioral skills abstinence from Mean age 14.5 years and 50% cognitive modeling, peer norm, and social sexual intercourse development; sexual female, 50% male theory reinforcement for maintaining the contraceptive intercourse and 51% African American, 20% Asian, prevention of HIV risk behavior education; self- increase 29% other Control intervention consisted of a efficacy/self- condom use Recruited n = 1,172 participants at standard community HIV/AIDS esteem; Sexuality/ baseline from 15 housing education session HIV/AIDS/STI developments, divided into three Workshop intervention consisted Education conditions. Control intervention, of two 3-hr workshops conducted Workshop Intervention, separately for males and females. Community Intervention Free condoms were given to the adolescents. Baseline data and follow-up at 3 and 12 months after the workshops Lee et al.: STI/HIV and Pregnancy Prevention Programs 421 and those males reported more sexual partners over their adolescent children had adolescents that were their lifetime. Males were also more likely to more likely to be virgins (Elkington et al., 2011; endorse power-related reasons for having sex, Somers & Ali, 2011). On the other hand, adoles- including “to control partner” or “that you owed cents of families with less parental involvement or your partner or you had to have sex” and those familial cohesiveness, characterized by conflict, who did tended to sexually debut earlier (Robinson parental substance abuse, and neglectful or unsup- et al., 2006). Many researchers argue that the portive family relationships were more likely to social dynamics of African American male culture engage in risky sex practices (Donenberg et al., encourages sexual relationships and 2006). (Staples & Johnson, 1993). Level of knowledge and information on Peer influences. Adolescents are at a devel- sex and STI/HIV. The lack of appropriate infor- opmental stage in which relationships with peers mation regarding protected sexual behaviors and are of great importance. Teens tend to believe that low knowledge related to consequences of risky sex- what is observed of their peers is what defines nor- ual behavior, such as unplanned pregnancy and mal adolescent behavior. Researchers have found transmission of STIs, were found to be an accurate that perceived peer norms and behavior are also indicator of such risky sex practices among African strongly associated with risky sexual behavior American adolescents. According to a study by Re- (Elkington et al., 2011). Acceptance by peers is itman et al. (1996), males who reported lower con- widely sought, which can impact an adolescent’s fidence in initiating protective sex practices and judgment and decision making; therefore, adoles- perceived themselves at lower risk for contracting cents in peer groups whose members engage in STI/HIV were most likely to engage in high-risk risky behaviors, often engage in similar behavior. behaviors. The 2001 Youth Risk Behavior Surveil- African American adolescents whose peer groups lance found that 81.2% of Black males compared to demonstrated antisocial-like behavior such as illegal 63.6% of Black females reported using condoms at use of drugs and alcohol were more likely to engage last sexual intercourse (CDC, 2003). Furthermore, in early sexual intercourse and promiscuity (Leigh Beckman, Harvey, and Tiersky (1996) and Norris & Andrews, 2002). Furthermore, the fact of and Ford (1998) reported that teenagers often whether an adolescent has ever had sexual inter- report buying and/or using condoms is embarrass- course is strongly influenced by the sexual status— ing; some also note diminished physical pleasure of virgin or nonvirgin—of his or her friends (Leigh & sexual intercourse with the use of condoms. In a Andrews, 2002). study conducted regarding the awareness of HIV/ AIDS and the knowledge of the virus’s transmis- Parental involvement. Parental monitoring sion, only 2.8% (306) of the women who reported was found to be a significant predictor of adoles- both being aware of the virus and having knowl- cent sexual activity. Donenberg, Paikoff, and Pe- edge of its transmission had sex with a casual quegnat (2006) identified parental involvement and acquaintance or someone they just met (Booysen & family cohesion as strong influences in the develop- Summerton, 2002). ment of healthy romantic relationships and practice of safer sexual behavior among African American Effective National STI/HIV and Pregnancy adolescents. Closer family relationships and greater Prevention Programs parental involvement are associated with a number The following is a brief description of the six STI/ of low-risk sexual practices such as lower exposure HIV and abstinence intervention programs meeting to risky situations, greater rates of condom use, the inclusion criteria: Aban Aya Youth Project; Be and later sexual debut in adolescents (Donenberg, Proud! Be Responsible!; Children’s Aid Society-Car- Bryant, Emerson, Wilson, & Pasch, 2003). A study rera Program; Heritage Keepers Abstinence Educa- that identified the age of sexual debut of African tion; Promoting Health Among Teens; and Teen American adolescents and analyzed various contrib- Health Project. Table 1 indicates the components uting factors—including parental involvement— that each of the intervention programs imple- found that as parents who knew the whereabouts of mented to promote healthy sexual behaviors. 422 Public Health Nursing Volume 31 Number 5 September/October 2014

Table 2. Contributing Factors Integrated in the Selected Intervention Programs

Aban Aya Be Proud! Carrera Adolescent Heritage Keepers Promoting Health Teen Youth Be Pregnancy Prevention Abstinence Among Teens Health Project Responsible! Program Education (PHAT) Project National Intervention Programs Shown to be Effective Five contributing factors Substance X abuse Gender roles X X X X Peer influences X X X X Parental XX X involvement Level of sex/ XX X X X X HIV/STI knowledge

Table 2 presents the components that were com- curriculum (health enhancement curriculum). Stu- mon across the six successful STI/HIV intervention dents completed surveys in the classrooms at the programs. beginning and end of 5th grade and at the end of each subsequent year. Flay et al. (2004) found that Aban Aya Youth Project. The Aban Aya for boys, the SDC and SCI significantly reduced the Youth Project is an Afro-centric social development rates of violent behavior, provoking behavior, curriculum (SDC) designed to reduce rates of risky school delinquency, drug use, and recent sexual behaviors among African American children in intercourse, and improved the rate of increase in grades 5 through 8 (Flay, Graumlich, Segawa, condom use. The SCI showed to be more signifi- Burns, & Holliday, 2004). The name of the inter- cantly effective than the SDC alone. No significant vention derives from two symbols in the Akan effects were shown for girls. Overall, this program (Ghanian) language: Aban stands for fence and sig- reported that theoretically derived social-emotional nifies double/social protection, and Aya, an unfurl- programs that are culturally sensitive, developmen- ing fern signifying self-determination. This project tally appropriate, and offered in multiple grade lev- includes interventions that address all of the five els can reduce multiple risk behaviors for inner-city factors identified as related to risky sexual behav- African American adolescents (Flay et al., 2004). iors. The Aban Aya Youth Project was designed to administer in sixteen to twenty-one 40 to 45 min Be Proud! Be Responsible!. “Be Proud! Be lessons per year at 12 high-risk metropolitan Responsible!” is a six-module curriculum that is schools in Chicago, IL. It used African teaching designed to give adolescents the knowledge, motiva- methods, such as storytelling and African American tion, and skills necessary to change their behaviors history and literature, to promote abstinence, to in ways that will reduce their risk of contracting teach the avoidance of drugs and alcohol, and to HIV/STIs and getting pregnant (Jemmott, Jem- teach nonviolent conflict resolution; it was imple- mott, & Fong, 2010b; Jemmott, Jemmott, Fong, & mented over a 4-year span (USDHHS, 2012). The Morales, 2010a). The only factor related to risky 12 schools were selected for this project and ran- sexual behavior that this program addressed was domly divided into three study groups: four schools level of knowledge and information. It was imple- were chosen to implement the Aban Aya SDC; four mented in 43 community-based organizations schools implemented the Aban Aya curriculum plus (CBOs) and delivered through group discussions, additional school and community support programs exercises, videos, games, and role-play. Before [school/community intervention (SCI)]; and the implementing the program, the program facilitators other four schools served as the control group that were trained in the core content components of the implemented a general health curriculum focusing program. The components included: information on on nutrition, physical activity, and general health HIV/STIs, pregnancy, and prevention strategies; Lee et al.: STI/HIV and Pregnancy Prevention Programs 423 addressing behavioral attitudes and outcome expec- tance with college admissions process, (3) a com- tancies; building negotiation and problem-solving prehensive family life and sexuality education, (4) skills; building self-efficacy and desire to practice an arts component designed to help adolescents abstinence; and building individual’s confidence in discover and develop talent and confidence, and (5) skills by incorporating positive reinforcement (Jem- an individual sports component that emphasizes mott et al., 2010a,b). The control group received a activities requiring impulse control that can be general health promotion intervention. Surveys practiced at all ages (Philliber et al., 2002). The were administered before the intervention (base- two service components are providing mental line) and at 3, 6, and 12 months postintervention. health care and providing medical care. Results Results from this study showed that there was a sig- from the 3-year program evaluation found a gain in nificantly greater percentage of consistent condom knowledge in sexual, reproduction, and health care; use in the participants in the CBOs that imple- females were more likely to say they had chosen mented “Be Proud! Be Responsible!” (Jemmott not to have sex when pressured; females were less et al., 2010a,b). Overall, this study suggested that likely to have ever had intercourse; sexually active CBOs can achieve success when implementing evi- females were more likely to use a condom while on dence-based HIV/STI risk-reduction interventions an additional contraceptive method; and females in with adolescents. the CAS-Carrera Program showed significantly lower rates of pregnancies and births than the con- Children’s Aid Society: Carrera trol group females (Philliber et al., 2002). Overall, Adolescent Pregnancy Prevention Program the CAS-Carrera Program was successful in accom- (CAS-Carrera Program). The purpose of the plishing many goals by building long-term relation- CAS-Carrera program is to empower and help ado- ships with the students and reinforcing sexuality lescents in developing personal goals, developing education and academic skills. the desire for a productive future, and developing their sexual literacy. The program uses a philoso- Heritage Keepers Abstinence Education. phy that sees the adolescents as “at promise” Heritage Keepers Abstinence Education is a 450- instead of “at risk” and focuses on reducing preg- min interactive classroom-based curriculum that nancy by using a comprehensive youth develop- teaches students the benefits of remaining abstinent ment approach that includes sexuality education until marriage and the risks associated with pre- and contraceptive provision to those who become marital sexual activity (Badgley, Musselman, Casale, sexually active (Philliber, Kaye, Herrling, & West, & Badgley-Raymond, 2011). Three factors including 2002). It emphasizes the importance of sexual gender roles, peer influences, and level of knowl- health education and parental involvement to have edge and information were incorporated in the edu- positive program outcomes. The intervention is cational program. The material is presented during guided by six principles: (1) the staff treats the ado- required health classes on consecutive days in lescents as if they were their own, (2) adolescents either five 90-min or ten 45-min sessions. The cur- are viewed as having pure potential, (3) a holistic riculum content is grouped into five sections: Sex- approach is used to incorporate multiple services to ual Abstinence; Family Formation; STD Facts; meet comprehensive interests and needs, (4) con- Love, Lust, Infatuation; and The SAFE Plan. Each tact with each adolescent is continuous and long- section contains writing exercises, discussion, and term, (5) services aim to involve parents and other activities. Teachers are trained by Heritage Com- adults, and (6) services are offered under one roof munity Services to apply mediating constructs to in the community in a nonpunitive, gentle, gener- the delivery of the program, and to engage the stu- ous, and forgiving environment (Philliber et al., dents in active learning processes that foster com- 2002). These principles are instilled in the pro- mitment to abstinence (Weed, Birch, Ericksen, & gram’s seven critical components: five activity com- Olsen, 2011). The study found that a year after the ponents and two service components. program ended, students participating in the inter- The five program activities are as follows: (1) a vention were less likely to report having ever had work related intervention called Job Club, (2) an sex. Overall, the authors stated that this study pro- academic component including tutoring and assis- vided confirmation to the primary prevention/risk 424 Public Health Nursing Volume 31 Number 5 September/October 2014 elimination strategy for programs and policy by information. The Teen Health Project was adminis- demonstrating a reduction of sexual experience tered in 15 low-income housing developments among adolescents (Weed et al., 2011). across the United States by randomly assigning one of the three intervention components to each devel- Promoting Health Among Teens (PHAT). opment. Five developments were invited to attend PHAT uses two program approaches to reducing a standard community AIDS education session the risk for HIV, STIs, and unwanted pregnancy. (control intervention); five developments were The two approaches are PHAT – Abstinence-Only assigned to attend two 3-hr workshops that focused and PHAT – Comprehensive Intervention. The on HIV/STI education and skills training to avoid abstinence-only intervention is an 8-hr curriculum unwanted sexual activity (workshop intervention); that encourages abstinence to help eliminate the and the other five developments were assigned to risk of pregnancy and STIs (Jemmott, 2010b). attend the workshop intervention followed by a Three factors including gender roles, peer influ- multicomponent, community intervention that ences, and level of knowledge and information were included follow-up sessions, participation of opin- incorporated in the program. It was designed by ion leaders, activities to create social and environ- Jemmott et al. (2010a,b) to (1) increase HIV/STI mental supports for HIV risk avoidance, and HIV/ knowledge, (2) strengthen behavioral beliefs sup- AIDS workshops for parents (Sikkema & Kelly, porting abstinence including the belief that absti- 2005). Surveys were administered before the inter- nence can prevent pregnancy, STIs/HIV, and that vention and at follow-ups conducted 3 and abstinence can foster attainment of future goals, 12 months after the workshops. Compared to the and (3) increase skills to negotiate abstinence and control group, results showed that both of the treat- resist pressure to have sex. Facilitators were trained ment groups showed an increase in condom use to not portray sex in a negative light or to use a and an increase in abstinence. Sikkema and Kelly moralistic tone. The comprehensive intervention (2005) stated that the multicomponent, community combined the abstinence-only intervention, a safer intervention showed considerable promise and pro- sex intervention that encouraged condom use, and duced significant effects in relation to age of sexual HIV risk-reduction interventions. The intervention debut over time and also in condom use for sexu- is presented in either 8 or 12 hr, and both contain ally active adolescents. similar content. Results from this study showed (1) reduced sexual initiation was seen in abstinence- Suggestions for future prevention program only intervention, (2) reduced recent sexual inter- planning in West Englewood, Chicago course was seen in the abstinence-only and the 12- The investigation of six intervention programs hr comprehensive intervention, and (3) a reduced determined that only one—the Aban Aya Youth number of multiple sexual partners in both com- Project—incorporated components relative to all prehensive intervention groups (8-hr, 12-hr). Over- five factors identified as contributing to African all, the results from this study indicate that a American adolescent sexual behavior. This youth theory-based abstinence-only intervention reduced project was implemented over a 4-year span and self-reported sexual involvement among African used African teaching methods, such as storytelling American students in grades 6 and 7 (Jemmott, and African American history and literature, to pro- 2010b). mote abstinence, to teach the avoidance of drugs and alcohol, and to resolve conflicts nonviolently Teen Health Project. The Teen Health Pro- (USDHHS, 2012). Study findings included: ject is a community-based HIV prevention inter- increased use of condoms; reduced frequency of vention that helps high-risk adolescents develop sexual intercourse in males; reduced rate of violent skills to enact change, and provides continued behavior in males; reduced rate of provoking modeling, peer norm, and social reinforcement for behavior in males; reduced rate of drug use in maintaining the prevention of HIV risk behavior males; and reduced rate of school delinquency in (Sikkema & Kelly, 2005). This project addressed males (USDHHS, 2012). Incorporation with this four factors including gender roles, peer influences, program, the future program needs to include a few parental involvement, and level of knowledge and more components to develop an effective program Lee et al.: STI/HIV and Pregnancy Prevention Programs 425 targeting the African American population. The fre- pregnancy; increased use of hormonal methods of quency and length of the program should be con- contraception; delayed onset of sexual intercourse sidered. Programs developed to meet at regular, (recent and first time); and a reduced number of repeated intervals and for more than 1 year were sexual partners. It is apparent that health and sex- determined to be more effective than those with ual education in this population is vital to make shorter durations or less frequent meetings (US- healthy sexual decisions, which in turn, reduces DHHS, 2012). Furthermore, cultural competency is risky sexual behaviors and the consequences important when attempting to intervene in the life- involved in such behaviors. After knowledge and style and habits of any person or community. Espe- information on sex and STIs, gender roles and peer cially in a predominantly African American influences were consistently found in four of the six community, the need to understand the culture and STI/HIV intervention programs including Aban Aya be sensitive to relevant beliefs and traditions is vital Youth Project, Heritage Keepers Abstinence, PHAT, to the successful implementation of an intervention and Teen Health Project. Consideration of gender program. As aforementioned, the Aban Aya Youth role shared by African Americans may be another Project used African teaching methods, such as sto- key component for effective program outcomes. rytelling and African American history and litera- Three intervention programs included parental ture, to discuss topics with African involvement as a program component to help par- American adolescents was a great success. There- ents facilitate the ability to communicate more fore, the researchers suggest the development of a effectively with their children about family life and future intervention program should be imple- sexuality issues. Of the six programs, the Aban Aya mented for longer than 1 year and would include Youth Project was the only program that incorpo- culturally sensitive topics in its teaching compo- rated all five contributing factors into the curricu- nents. lum. The interesting finding discovered in this study Discussion was that program duration was found as another component that impacted program efficacy. Three In this integrative literature review, five major fac- programs (Aban Aya Youth Project, Carrera Pro- tors related to sexual behaviors among African gram, and Teen Health Project) lasted from American adolescents were identified. Those 6 months to 7 years, while the other three pro- included substance use, gender roles, peer influ- grams (Be Proud! Be Responsible!, Heritage Keep- ences, parental involvement, and knowledge and ers, and PHAT) lasted from 1 to 8 days. As information on sex and STIs. These factors contrib- demonstrated in Table 1, results showed that pro- ute to the increased risks of contracting a STI or grams implemented for over 6 months had more getting pregnant. Consideration of those elements positive findings than those lasting 1–8 days (US- should be taken when developing a future interven- DHHS, 2012). This finding suggests that future tion program for this population. As previous stud- programs must consider a frequency of regular and ies indicate, African American adolescents have repeated intervals with implementation of the pro- higher levels of substance use than any other gram more than 6 months. Increased frequency groups, which contribute to getting involved in and duration will help to retain STI knowledge and more risky sexual behaviors. Thus, in education information and enhance safe sex practice. These and prevention programs, it is very essential to findings established an overall understanding of address the impact of substance use in this popula- behaviors related to sexual practices among African tion. American adolescents and, subsequently, identified All six selected successful programs included culturally appropriate intervention programs and HIV/STI and sexual behavior education. These pro- program duration that can be recommended for grams reported an increase in knowledge regarding future intervention programs in Chicago’s predomi- sex and STI/HIV transmission among the partici- nantly African American West Englewood commu- pants. Behavioral outcomes reported in those pro- nity. grams included: increased use of condoms; reduced Based on the factors demonstrated in the six frequency of sexual intercourse; reduced rate of effective intervention programs, a new program can 426 Public Health Nursing Volume 31 Number 5 September/October 2014 be developed to address the five contributing fac- tural values in the sexual education process. In tors related to risky sexual behaviors seen among summary, after analyzing six national intervention African American adolescents. Implementation of programs proven to be effective, the findings sug- an improved, focused program will be essential in gest that future prevention programs be designed the reduction of high STI/HIV and pregnancy rates, with a greater emphasis on avoidance or limited as seen in West Englewood. After implementation, substance use; increased parental involvement; and follow-up surveys can be done to determine the integration of cultural teaching components such as effectiveness of the program based on these study storytelling and history as suggested from the Aban findings. Research on the current intervention pro- Aya Youth Project. In addition, the length of future grams implemented in Chicago and West Engle- programs should be over 1 year, as longer programs wood can also be done to analyze curriculum and have been shown to be more effective than shorter compare parallel contributing factors from this programs. study. The search for information associated with West Englewood from secondary sources provided factual References and statistical information, which allowed for the Bachanas, P. J., Morris, M. K., Lewis-Gess, J. K., Sarett-Cuasay, E. determination of needs related to African American J., Sirl, K., Ries, J. K., et al. (2001). Predictors of risky sex- ual behavior in African American adolescent girls: Implica- adolescent risky sexual behavior and the resultant tions for prevention interventions. Journal of Pediatric consequences. However, there was a lack of first- Psychology, 27(6), 519–530. Badgley, A., Musselman, C., Casale, T., & Badgley-Raymond, S. hand determinants of the community needs by key (2011). Heritage keepers abstinence education. Retrieved figures within West Englewood. Having information from http://www.hhs.gov/ash/oah/oah-initiatives/teen_ pregnancy/db/programs/heritage-keepers-v2.pdf from primary sources could potentially have led to Beckman, L. J., Harvey, S. M., & Tiersky, L. A. (1996). Attitudes a more thorough and culturally competent under- about condoms and condom use among college students. standing of the needs of West Englewood, yielding Journal of the American College of Health, 44, 243–250. Booysen, F., & Summerton, J. (2002). Poverty, risky sexual beha- an accurate compilation of factors to be included in vior, and vulnerability to HIV infection: Evidence from future intervention programs targeting urban Afri- South Africa. Journal of Health, Population and Nutrition, 20(4), 285–288. can American adolescents, particularly those at risk Bowers, R. (2007). U.S. teen pregnancy rates decline due to for unplanned pregnancy and STI/HIV transmis- improved contraceptive use. Contraceptive Technology Update. A Monthly Newsletter for Health Professionals, 28 sion, in West Englewood. (3), 25–36. The problems and findings reported in this study Centers for Disease Control and Prevention. (2003). HIV/AIDS sur- veillance report. Retrieved from http://www.cdc.gov/hiv/ are applicable to urban communities and neighbor- pdf/statistics_2003_HIV_Surveillance_Report_vol_15.pdf. hoods where the majority of the population is Afri- Centers for Disease Control and Prevention. (2009). Sexual risk can American and has reported high rates of STIs behavior: HIV, STD, & teen pregnancy prevention. Retrieved from http://www.cdc.gov/HealthyYouth/sexual- and teen pregnancy. Public health nurses working behaviors/ with similar high-risk populations on STIs and teen City of Chicago. (2011). Healthy Chicago STI/HIV Surveillance Report Fall 2011. Retrieved from http://www.cityofchicago. pregnancy should consider the five factors identi- org/content/dam/city/depts/cdph/policy_planning/Boar- fied in this study, especially gender roles, when d_of_Health/2011HIVSTISurveillanceReport120211.pdf City of Chicago. (2012). Healthy Chicago: Transforming the Health providing sexual health education to African Ameri- of Our City: Births in Chicago, 1999–2009. Retrieved from can adolescents. It may be a better approach to http://www.cityofchicago.org/content/dam/city/depts/cdph/ statistics_and_reports/BirthsInChicago1999thru2009May have separate sexual education programs for female 312013.pdf and male African American adolescents in an effort Donenberg, G., Bryant, F., Emerson, E., Wilson, H., & Pasch, K. to create an open environment that enhances active (2003). Tracing the roots of early sexual debut among adolescents in psychiatric care. Journal of the American discussion and participation in the gender segre- Academy of Child and Adolescent Psychiatry, 42, 594– gated education program. Furthermore, empower- 608. Donenberg, G. R., Paikoff, R., & Pequegnat, W. (2006). Introduc- ing female adolescents on how to say “no” and to tion to the special section on families, youth, and HIV: protect themselves from risky sexual behaviors is Family-based intervention studies. Journal of Pediatric Psychology, 31(9), 869–873. another consideration when teaching this popula- Elkington, K. S., Bauermeister, J. A., & Zimmerman, M. A. (2011). tion. To reduce risky sexual behaviors among the Do parents and peers matter? A prospective socio-ecological examination of substance use and sexual risk among Afri- African American adolescents, it is also essential to can American youth. Journal of , 34(5), 1035– involve peers and parents who share similar cul- 1047. Lee et al.: STI/HIV and Pregnancy Prevention Programs 427

Flay, B. R., Graumlich, S., Segawa, E., Burns, J. L., & Holliday, M. menting adolescent sex education programs. Maternal Y. (2004). Effects of two prevention programs on high-risk Child Health Journal, 15, 169–177. behaviors among African American youth. Archives of Pedi- Perkins, H. W., Meilman, P. W., Leichliter, J. S., Cashin, J. R., & atrics and Adolescent Medicine, 158(4), 377–384. Presley, C. A. (1999). Misperceptions of the norms for the Heatherington, S. E., Harris, R. M., Bausell, R. B., Kavanagh, K. frequency of alcohol and other drug use on college cam- H., & Scott, D. E. (1996). AIDS prevention in high risk puses. Journal of the American College of Health, 47, 253– African American women: Behavioral, psychological, and 258. gender issues. Journal of Sex and Marital Therapy, 22, Philliber, S., Kaye, J. W., Herrling, S., & West, E. (2002). Prevent- 9–21. ing pregnancy and improving healthcare access among Jemmott, J. B., Jemmott, L. S., & Fong, G. T. (2010b). Efficacy of a the- teenagers: An evaluation of the Children’s Aid Society-Car- ory-based abstinence-only intervention over 24 months: A rera program. Perspectives on Sexual and Reproductive randomized controlled trial with young adolescents. Archives Health, 34(5), 244–251. of Pediatrics and Adolescent Medicine, 164(2), 152–159. Reitman, D., St. Lawrence, J. S., Jefferson, K. W., Alleyne, E., Bras- Jemmott, J. B., Jemmott, L. S., Fong, G. T., & Morales, K. H. field, T. L., & Shirley, A. (1996). Predictors of African (2010a). Effectiveness of an HIV/STD risk-reduction American adolescents’ condom use in HIV risk behavior. intervention for adolescents when implemented by com- AIDS Education Prevention, 8(6), 499–515. munity-based organizations: A cluster-randomized con- Robinson, M. L., Holmbeck, G. N., & Paikoff, R. (2006). Self-esteem trolled trial. American Journal of Public Health, 100(4), enhancing reasons for having sex and the sexual behaviors 720–726. of African American adolescents. Journal of Youth Adoles- Leigh, W. A., & Andrews, J. L. (2002). Peer influence on sexual cence, 36, 453–464. behavior: what we know about African American Teens. Sikkema, K., & Kelly, J. (2005). Pregnancy prevention intervention Retrieved from http://www.aecf.org/upload/publication- implementation report: Teen Health Project. Retrieved from files/peer%20influence%20sexual%20behavior.pdf http://www.hhs.gov/ash/oah/oah-initiatives/teen_pregnancy/ Martin, J., Hamilton, B., Ventura, S., Osterman, M., Wilson, E., & db/programs/teen_health_project.pdf Mathews, T. J. (2012). Births: Final data for 2010. National Somers, C., & Ali, W. (2011). The role of parents in early adolescent Vital Statistics Reports, 61(1), 1–72. Retrieved from http:// sexual risk-taking behavior. Retrieved from http://bentham- www.cdc.gov/nchs/data/nvsr/nvsr61/nvsr61_01.pdf science.com/open/topsyj/articles/V004/88TOPSYJ.pdf National Campaign to Prevent Teen and Unplanned Pregnancy. Staples, R., & Johnson, L. B. (1993). Black families at the cross- (2011). Briefly...A Summary of effective interventions. roads. San Francisco, CA: Jossey-Bass. Retrieved from http://www.thenationalcampaign.org/resour U.S. Department of Health and Human Services. (2012). Office of ces/pdf/Briefly_Effective_Interventions.pdf adolescent health: Teen pregnancy prevention- evidence- Norris, A. E., & Ford, K. (1998). Moderating influence of peer based programs. Retrieved from http://www.hhs.gov/ash/oah/ norms on gender differences in condom use. Applied Devel- oah-initiatives/teen_pregnancy/db/programs.html opmental Science, 2, 174–181. Weed, S. E., Birch, P. J., Ericksen, I. H., & Olsen, J. A. (2011). Test- Osmond, M. W., Wambach, K. G., Harrison, D. F., Byers, J., Levine, ing a predictive model of youth sexual inter course initia- P., Imershein, A., et al. (1993). The multiple jeopardy of tion. Retrieved from http://instituteresearch.com/docs/ race, class, and gender for AIDS risk among women. Gen- IREPredictors_%281-17-2011%29.pdf. der and Society, 7,99–120. Whittemore, R., & Knafl, K. (2005). The integrative review: Ott, M. A., Rouse, M., Resseguie, J., Smith, H., & Woodcox, S. Updated methodology. Journal of Advanced Nursing, 52 (2011). Community-level successes and challenges to imple- (5), 546–553.