1. Enhancing Evidence-based HIV Prevention
Interventions for African-American Youth:
Addressing Gaps through Review of the
Literature
Kari Gloppen, MPH
Lisa Romero, DrPH
Division of Adolescent and School Health
Division of Adolescent and School Health
August 24, 2009
August 24, 2009
Disclaimer:
Disclaimer:
The findings and conclusions in this presentation are those of the authors and do not necessarily represent the official position of the
The findings and conclusions in this presentation are those of the authors and do not necessarily represent the official position of the
Centers for Disease Control and Prevention.
Centers for Disease Control and Prevention.

2. Overview
 Study Rationale and Objectives
 Literature Review
 Unified Framework of Behavior-Change Constructs
 Content Analysis of EBIs
 Conclusions

4. Prevalence of “any STD” among
Sexually Experienced U.S. Female Adolescents,
14-19 years old by Race/Ethnicity
Race/ethnicity Prevalence of “any STD” (n= 587)
Non-Hispanic White 20.3%
Hispanic 19.7%
Non-Hispanic Black 47.7%
Source: 2008 National STD Prevention Conference Oral Presentation. Prevalence of Sexually Transmitted Infections and Bacterial
Source: 2008 National STD Prevention Conference Oral Presentation. Prevalence of Sexually Transmitted Infections and Bacterial
Vaginosis among Female Adolescents in the United States: Data from the National Health and Nutritional Examination Survey
Vaginosis among Female Adolescents in the United States: Data from the National Health and Nutritional Examination Survey
(NHANES) 2003-2004.
(NHANES) 2003-2004.

5. Study Rationale and Objectives
 Culturally relevant interventions are a promising
approach
 Efficacious behavioral interventions are tailored and
preceded by formative research
 To describe behavioral constructs most likely to
influence African American adolescents’ HIV prevention
behaviors
 To identify the degree to which behavioral constructs
are reflected in current EBIs

6. Three-Step Process
1. Review the HIV prevention literature to identify
variables associated with sexual risk behaviors among
African American adolescents
2. Map variables onto the unified framework of behavior-
change constructs
3. Analyze the content of HIV-prevention EBIs developed
for African-American youth using behavior-change
constructs

7. Literature Review Methods
 Literature search performed through
• Databases
• Manual search
• Reference lists
 Abstracts were identified (N=896)
 Articles meeting inclusion criteria were coded (N= 54)

8. Research Literature Review Inclusion Criteria
 Assess the association of a variable and at least one
sexual behavior outcome
 Be conducted in the United States
 Be published in peer-reviewed journals from 1995
through 2007
 Include multivariate analyses
 Have sufficiently large sample sizes (at least 100 for
significant results)
 Have participants younger than 19 years
 Have the majority of the sample (>50%) be African
American

9. Sexual Risk Behavior Outcomes
 Ever had sex
 Age at first sex
 Number of sexual partners
 Unprotected sexual intercourse (did not use a condom)
 History of STDs

10. Variables Most Frequently Correlated with
Sexual Risk Behavior Outcomes
 Sexual possibility situations
 Parental connectedness
 Parental involvement
 Communication with parents about sex-related issues
 Societal/cultural factors
 Perceived peer sexual behavior
 Perceived peer related risk behaviors

11. Constructs Identified in Unified Framework
Theorists’ Workshop, 1991
 Strong intentions
 Environmental conditions
 Skills
 Positive attitude
 Perceived norms
 Consistency between standards or values and practicing the
behavior
 Positive emotional reaction
 Self-efficacy

12. Construct Influence on Behavioral Outcomes
Theorists’ Workshop
 Environmental conditions, intentions, and skills, are
necessary and sufficient for producing behavior change
 The remaining five constructs, positive attitude, perceived
norms, consistency, positive emotional reaction, and self-
efficacy, are viewed as influencing the strength of intention
Interventions should address all three of the necessary
constructs
Focus on the one or two constructs from the remaining
five most likely to influence participants to engage in the
desired behavior

13. Constructs Influencing Behavior Change
Theorists’ Workshop, 1991
Constructs Identified by Leading Theorists Examples of Variables
Mapped Under Each
Strong intentions to perform a behavior Intentions to have sex
Environmental conditions--that foster feasible social, Parent connectedness, family
ecological, and structural influences to perform a behavior structure, societal factors
Having the skills necessary to perform the behavior Condom use, refusal
A positive attitude towards the behavior Towards buying condoms
Perceived norms about the behavior that are more positive Peer sexual norms, family
than negative norms
Consistency between an individual’s personal standards or Self concept, future
values and practicing the behavior aspirations, beliefs/values
Positive emotional reaction towards performing the Positive feelings about
behavior condoms
Self-efficacy, the individual’s belief that he or she can Self-efficacy to communicate,
complete the behavior use condoms

14. Constructs Influencing Behavior Change
Added From Literature Review and Content Analysis
Constructs Identified by Leading Theorists Examples of Variables
Mapped Under Each
Strong intentions to perform a behavior Intentions to have sex
Environmental conditions--that foster feasible social, ecological, and Parent connectedness, family
structural influences to perform a behavior structure, societal factors
Having the skills necessary to perform the behavior Condom use, refusal
A positive attitude towards the behavior Towards buying condoms
Perceived norms about the behavior that are more positive than negative Peer sexual norms, family norms
Consistency between an individual’s personal standards or values and Self concept, future aspirations,
practicing the behavior beliefs/values
Positive emotional reaction towards performing the behavior Positive feelings about condoms
Self-efficacy, the individual’s belief that he or she can complete the Self-efficacy to communicate, use
behavior condoms
Knowledge-- factual information about HIV transmission Awareness of where to
and prevention purchase condoms
Other related risky behaviors Substance use, lower school
performance

15. Relationship Between Constructs and Sexual
Risk Behavioral Outcomes
 Environmental conditions and perceived norms were
frequently associated with sexual risk behaviors among
African American adolescents
 Knowledge was not measured in the reviewed studies
• Knowledge is a necessary, but insufficient, construct in
changing behavior
 Skills were infrequently measured in the reviewed studies

16. Evidence-Based Interventions
Theoretical Number of sessions
Curriculum/intervention framework (dose per session)
Be Proud Be Responsible (Be Social Cognitive Theory 6 (50-min)
Proud!) Theory of Reasoned Action
Theory of Planned Behavior
Becoming a Responsible Teen Information Motivation 8 (90–120 min)
(BART) Behavior Model
Social Learning Theory
Focus on Youth with ImPACT Protection Motivation Theory 8 (100–125-min) for youth and
(formerly Focus on Kids) 1 (90 min) for parent
Making a Difference Social Cognitive Theory 8 (50-min)
Theory of Reasoned Action
Theory of Planned Behavior
Making Proud Choices Social Cognitive Theory 8 ( 50-min)
Theory of Reasoned Action
Theory of Planned Behavior
Sistas, Informing, Healing, Social Cognitive Theory 4 (125-188-min)
Living and Empowering Theory of Gender and Power
(SiHLE)
Street Smart Social Learning Theory 10 (100 min) and 1 (100 min)
individual session

17. Content Analysis Methods
 Coded activities to correspond with behavior-change
constructs
 Coded dosage (i.e. minutes spent on each type of
activity)
 2 people analyzed the content of each EBI
• Standardized coding
• Resolved coding discrepancies

18. Key Results from the EBI Content Analysis
 All 7 EBIs addressed the 10 identified theoretical
constructs
 EBIs devoted considerable time (higher dose) to
knowledge, skills, and self-efficacy
 EBIs devoted measurably less time (lower dose) to
environmental conditions, perceived norms, and
intentions

19. Programmatic Conclusions
To increase program impact on African American
adolescents, activities should
 Correct perceptions about peer sexual norms, and
promote healthy sexual norms and behaviors
 Promote environmental conditions that facilitate healthy
sexual behavior
• For example, parent education programs, family strengthening
programs, service learning, career planning, and increasing
access to STD and HIV testing, care, and treatment
 Consider how much knowledge dosage is necessary

20. Overall Conclusions
 Programs and science should match whenever possible
 Promote what works (environmental conditions and perceived
norms)
 Research and practice improve each other

21. Thank You!
Lisa Romero, DrPH
Jennifer Galbraith, PhD
Lyndsey Wilson-Williams, MPH
Kari Gloppen, MPH