parents as hiv educators: delay of first intercourse for both sons and daughters beatrice j. krauss,...

PARENTS AS HIV EDUCATORS: DELAY OF FIRST INTERCOURSE FOR BOTH SONS AND DAUGHTERS

Beatrice J. Krauss, Ph.D., and The Parent/Preadolescent Training for HIV Prevention (PATH) Research Team

5/28/09

Hunter College Center for Community and Urban Health 1

Acknowledgements

Cornell University/Cornell Cooperative Extension

Insituto Mexicano de Investigacion de Familia y Poblacion

University of Miami Albert Einstein College of

Medicine Lutheran Medical Center WHEDCO 163rd Street Improvement Association

The families of the Lower East Side

The PATH research team Our trainers Donald T. Campbell The work of Marilyn

Brewer Kim Miller, CDC The National Institute of

Mental Health, R01 MH 53834

The World AIDS Foundation

5/28/09

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Hunter College Center for Community and Urban Health

Goals

5/28/09Hunter College Center for Community and Urban Health

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Understand the importance of research designs that address selection biases

Review the potential role of parents – mothers and fathers – in gender-fair HIV education

Recognize the “common pathways” argument for responsible sexual and substance use behaviors

Stress the importance of early intervention

Don Campbell:Design question and answer session


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Who comes to HIV prevention interventions? Those who are interested? Are you then

preaching to the choir? Those who are very needy? Have you then set

yourself up to work with the most difficult clients? If so, what is your appropriate comparison group?

You will only know the answers if you do true random sampling and use a random invitation to treatment design to appropriately assess effects. The densely populated Lower East Side (LES) of New York City allowed such a design.

The Parent/Preadolescent Training for HIV Prevention (PATH) evaluation design


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Random dwelling unit sampling and, after baseline, a random invitation to enhanced treatment to evaluate the effects on children of an HIV prevention intervention aimed at parents

238 parents and their 238 children complete baselines|

All parents receive health and communication brochuresin English and Spanish/ \

161 (68%) randomly invited 77 (32%) not offered to group training group training (composed of

/ \ both potential decliners and accepters)

103 (43%) accept 58 (25%) decline|

238 parents and children measured at intervals post-baseline|

All drop-outs tracked

Parents as HIV educators


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In the best cases Available 24/7/365; communication can be

Continuous Sequential Timely Responsive

Communications can be adjusted to children’s Biographies Physical maturity Cognitive development Social circumstances

Communication can begin early (“off-time” and “on-time”)

In practice …


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Parents worry that if they talk about sex, drugs and HIV with their kids…

Youth are concerned…

My information is not accurate. I will give them the wrong information.

They [parents] are not up to date.

I will get too emotional. I will be embarrassed. They will get too emotional.I will find out something about my child that I don’t want to know.

If I ask about it, they will accuse me of doing it.

I will find out about all the risks there are out there now.

They’ll start talking about what it was like when they were growing up. They won’t understand what I face.My parents can’t keep a secret. Everyone will know what we talked about.[For boys] I am already supposed to know.

Even in a community where 10% of adults are living with HIV …


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Both children and adults have … Moderate levels of useful HIV knowledge,

including knowledge of prevention practices High levels of unrealistic HIV worry

Near-zero correlations between parent and child measures suggest little within-household sharing of Useful or practical HIV knowledge and skills Realistic or unrealistic HIV-related worry

Moderate scores on useful HIV prevention knowledge at baseline


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The effects of absent or ineffective communication – High worry


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Total mean scores on a measure ofunrealistic or controllable HIV-related worries

26436077

Baseline Mean Worry

parent

childDon't w orry

Worry a lot

Worry a little bit

But you can’t rely on schools to do it for you ...


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Percent of US elementary schools required to teach about how to prevent HIV (15.4%) how HIV is transmitted (14.8%) how HIV affects the body (12.2%) compassion for persons living with HIV (11.0%) signs and symptoms of HIV or AIDS (9.6%) how to find information about HIV services

including testing (7.6%) how HIV is diagnosed or treated (6.4%) (Kann, Telljohann & Wooley, 2007)

And it isn’t being done well …


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I was talking to him about the AIDS view

we were learning in school. You can’t get it by “friendly relations” [youth is quoting term]….I just wanted to speak to somebody who had experience with sex. (10-13 year old girl’s report of a conversation with the older brother who is raising her).

And it isn’t being done early enough…


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HIV-related health risks know no lower age boundary (e.g., a toddler can learn to non-verbally or verbally ask a parent or adult to pick up a sharp object or clean up blood; parents can be surveillant of toddlers, their activities and surroundings, Hagan, Shaw, & Duncan, 2008)

Early age-appropriate conversations lay the groundwork for later discussions about issues related to sex and substance use that may require more detail and more depth;

Data suggests that a substantial minority of US youth (7.1%) are sexually active before age 13, and 34.8% are by ninth grade, with rates varying by gender, geography and ethnicity (Eaton et al., 2008);

Values and expectations about the appropriate timing for sexual and drug risk may already be in place by preadolescence

But we know what to do …

Parent/child monitoring is one of the most robust predictors of safer sexual and substance use behaviors

Effective communication Accurate and in-depth Two-way and clarifying Concrete skills for addressing problems Responsive and rooted in child’s life Shares or clarifies emotions

The community-based Parent/Preadolescent Training for HIV Prevention (PATH) curriculum


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Four basic modules Useful and practical HIV knowledge and skills Child development and parent-child communication skill Recognizing, avoiding or negotiating risk Safe and sensitive socializing with PLwHIV, a

destigmatization module Two advanced

Transition to adolescence-1, internalized caring Transition to adolescence-2, lifelong learning

Participants: Mothers or fathers of 10-13 year old sons or daughters

Activities described in Pequegnat et al., 2000

Risk outcome of PATH—Delay of first male sexual intercourse


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Delay of intercourse for male youth sexually active by 40 months post- parent intervention

Risk outcome of PATH—Delay of first female sexual intercourse


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Delay of intercourse for female youth sexually active by 40 months post- parent intervention

Delay for every sexually activeyouth to date demonstrates longer delays, particularly for young men


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Multivariate predictors of delay for youth sexually active by 40 months post-intervention


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Expected age of first intercourse at baseline, p=.017

Age at baseline, p=.029 Age of first sexual partner, p<.001 The offer of training, p=.047

At 40 months post-intervention, there was a mean 5.5 month longer delay for sexually active children of parents offered training

Parent gender was not predictive Youth gender was not predictive

Why is gender-fair so important? Reviews of the literature indicate

Daughters receive more communications about sex and drugs than sons More of these communications emphasize

responsibility and limit-setting Daughters experience more parental monitoring

Sons experience more coercive control (e.g., yelling)

In PATH, there were no gender differences in reported content or style of communication by mothers or fathers.

Sexually active children of trained parents were more likely to say


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It is “like me” to not be too embarrassed to buy condoms, Chi-squared (1)=5.0, p=.026

It is “like me” to think it’s not cold and uncaring to keep using condoms after first intercourse, Chi-squared (1)=5.1, p=.023

The importance of early intervention:Estimated age of first intercourse at ages 10-13 is predictive of youth’s delay of intercourse


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Sexually active male youth’s estimated age of first intercourse at baseline and months delay to first intercourse

Why is delay of early intercourse important? Early intercourse has… Differential health effects (Kaestle et al., 2005)

Higher odds of STIs throughout adolescence for young men and women

Differential predictors Alcohol use, delinquency, school problems for intercourse by

age 15 with some predictors varying by gender and ethnicity (Zimmer-Gembeck & Helfand, 2007)

Family composition, parenting practices, parent characteristics, parent attitudes for early and middle adolescents

Youth’s ability to predict first intercourse one or more years in advance has been replicated by others (Forste & Haas, 2002; Miller et al., 1997; Whitaker, Miller, & Clark, 2000)

Replication of PATH in Miami

Added PATH to an early parenting training

Demonstrated a generalized protective effect

5/28/09Hunter College Center for Community and Urban Health25

Familias Unidas + Path vs ESOL + PATH, nsFamilias Unidas + Path vs ESOL+HEART p<.05Outcome is continuous measure of frequency of drug use in past 90 days

Results: Illicit Drug Use – Past 90 days

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

baseline 6 12 24 36

Months

Me

an

FamiliasUnidas+PATH

ESOL+PATH

ESOL+HEART


Familias Unidas + Path vs ESOL + PATH p<.002 Familias Unidas + Path vs ESOL+HEART p<.008

0

2

4

6

8

10

12

14

16

baseline 6 12 24 36

Months

Pe

rce

nt

FamiliasUnidas+PATHESOL+PATH

ESOL+HEART

Results: Smoking – Past 90 daysResults: Smoking – Past 90 days

What they walked away with… When asked to recall top of mind what influenced them

regarding “personal changes because of HIV” since the date of PATH project entry, the majority of intervention-arm respondents, parents and their youth, mentioned PATH and were able to recall, 7 years post-intervention, specific exercises or homework assignments that influenced them.

“She came home with the packet and she wanted me to show it to my friends. Made me think about if I wanted to live long or short. I had to choose my path. I chose the path to be clean.” (youth)

In selecting three top-of-mind recollected influences, parents divided their choices among exercises designed to raise awareness, promote concrete skills (putting on a condom), and improve communication, while youth focused on open communication and concrete skills.

“Teaching hands on, role playing.” (youth)


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Next steps

Thank you

parents as hiv educators: delay of first intercourse for both sons and daughters beatrice j. krauss,...

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