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Expanding the scope of HIV prevention for adolescents: beyond individual-level interventions
JOURNAL OF ADOLESCENT HEALTH 2000;26:377–378
FROM THE EDITORIAL BOARD
Expanding the Scope of HIV Prevention for Adolescents: Beyond Individual-level Interventions
Historically, the HIV epidemic has largely been viewed as a function adolescent’s behavior, most notably, their risky sexual and drug use behaviors. This individualistic perspective has dominated the field of HIV prevention. Consequently, interventions at this level aim to reduce adolescents vulnerability to HIV by enhancing theoretically-important intrapersonal and interpersonal mediators of preventive behavior such as HIV knowledge, attitudes, beliefs; foster the perception of peer norms as supportive of HIV-preventive practices; promote mastery of riskreduction skills; and motivate the adoption of preventive practices. Several individual-level interventions have demonstrated evidence of effectiveness in reducing adolescents’ HIV-associated risk behaviors (1). Although there is evidence that individual-level interventions are effective, these interventions may not be sufficient to sustain newly adopted behavior changes over protracted periods of time, particularly in the face of pervasive countervailing pressures that promote or reinforce risk behavior. Further, addressing behavior change at the individual-level lacks sufficient breadth to reach large segments of the at-risk adolescent population. Thus, there is need to expand the scope of HIV prevention interventions targeting adolescents to enhance their clinical and public health impact (2). Over the past few years, it has become evident that diverse socio-environmental, policy, and cultural influences significantly contribute to sustaining the HIV epidemic. Given the diversity of factors that may affect adolescents’ HIV-risk and preventive behavior, interventions at the individual-level as well as the family-, community-, and policy-level are needed to achieve meaningful behavior change (3,4). HIV Interventions targeted toward these larger levels of causality have the potential to reach broader adolescent audiences and hold promise for amplify-
ing and sustaining individual-level intervention effects. Family-level HIV interventions are designed to promote behavior change by utilizing the family as the target of intervention. This may include the nuclear family, a family of choice, or a network of individuals who are mutually committed to one another. Families can be mobilized to communicate important values, model appropriate behaviors, monitor adolescents’ behaviors, and encourage the adoption of HIV-preventive practices. Although there is a dearth of research exploring the impact of this promising intervention strategy, several studies funded by NIMH are currently underway evaluating the effect of family-level interventions on reducing adolescents’ HIV-associated behaviors (5). Community-level HIV prevention interventions are designed to promote behavior change by utilizing naturally occurring channels of influence (social/ friendship networks) and social institutions (media) while simultaneously providing a supportive environment that encourages HIV-preventive behavior. Several community-level HIV prevention interventions conducted among predominantly adult populations have observed reductions in HIV-risk behavior (6 – 8) as well as maintenance of low-risk behaviors over an extended period (9). One recent study, with young gay men, successfully increased condom use and decreased the proportion of men with more than one partner among gay men in several cities (10). This study used opinions leaders to direct the project. The initial group of opinion leaders recruited other opinion leaders. This process continued and established a self-perpetuating mechanism for changing community norms. A small media publicity campaign was developed to enhance awareness of the program, establish its legitimacy, invite young men to become involved in the program, and provide a continual reminder of the norm for safer sex. This approach effectively influenced
© Society for Adolescent Medicine, 2000 Published by Elsevier Science Inc., 655 Avenue of the Americas, New York, NY 10010
1054-139X/00/$–see front matter PII S1054-139X(00)00126-9
378
DICLEMENTE AND WINGOOD
community-level change through a process of informal communication and modeling by peers within interpersonal networks. Although these findings provide evidence of effectiveness, community-level interventions targeting adolescents remain an underutilized strategy. Policy-level interventions attempt to influence laws, policies, and legislative reform that may facilitate adolescents’ adoption and maintenance of HIVpreventive behaviors. Interventions at this level would promote the transfer of effective HIV-prevention curricula to schools, enhance adolescents’ ability to confidentially access reproductive and other health care services, reduce their access to drugs and alcohol, and enhance their access to drug and alcohol treatment. Policy-level changes have been used successfully to reduce adolescent morbidity and mortality associated with other risk behaviors. Interventions at this level, although effective in other areas of adolescent health promotion, remain fragmented in adolescent HIV prevention. It is pivotal that HIV interventions occur simultaneously across multiple levels of causality. Future HIV prevention programs will need to examine the effects of social, cultural, institutional, political, and economic forces as they promote or reinforce risky behavior and impede the adoption and maintenance of HIV-preventive behavior. By understanding these broader, pervasive influences it may be possible to develop community-level interventions, initiate policy changes, design institutionally-based programs, and promote the development of broader, macrolevel societal changes that can access many more adolescents and promote a social environment conducive to adopting and sustaining health-promoting behaviors while supporting the development and implementation of HIV-prevention activities. Reconceptualizing the HIV epidemic among adolescents from an individual-level to a broader, socioenvironmental-level phenomenon, requires designing multi-level interventions. This is not without methodologic challenges. Multi-level interventions are more complex. To facilitate the design, implementation and evaluation of these interventions, researchers will need to effectively transcend disciplinary boundaries, in terms of theory, methodology, and evaluation strategies. True interdisciplinary approaches and continued integration and collaboration between researchers and practitioners across diverse disciplines represents the best opportunity to develop multi-level HIV interventions.
JOURNAL OF ADOLESCENT HEALTH Vol. 26, No. 6
Our aim is to encourage prevention researchers to move beyond individual-level interventions, to embrace a broader array of HIV interventions and, optimally, to design multi-level interventions that complement each other and, hopefully, create preventive synergy (11) to effectively reinforce HIVprevention messages and skills and create an environment supportive of behavior change. Multi-level interventions, developed and implemented within a comprehensive and coordinated HIV prevention framework, represent a promising approach to impacting the HIV epidemic among adolescents. Respectfully, Ralph J. DiClemente* and Gina M. Wingood Emory University, Atlanta, Georgia
References 1. Centers for Disease Control and Prevention (CDC). Compendium of HIV Prevention Interventions with Evidence of Effectiveness. Atlanta, GA: CDC, November, 1999. 2. DiClemente RJ. Looking Forward: Future directions for HIV prevention research. In: Peterson JL, DiClemente RJ, eds. Handbook of HIV Prevention. New York: Kluwer/Plenum Publishing Corporation, 2000;311–24. 3. Sweat MD, Denison JA. Reducing HIV incidence in developing countries with structural and environmental interventions. AIDS 1995; 9(Suppl A):S251–S257. 4. Coates TJ. Reducing high-risk HIV behaviors: An overview of effective approaches. NIH Consensus Development Conference, February 11–13,1997. 5. Pequegnat W, Szapocznik J, eds. Working with Families in the Era of HIV/AIDS. Thousand Oaks, CA: Sage, in press. 6. The CDC AIDS Community Demonstration Projects Research Group. Community-level HIV intervention in five cities: Final outcome data from the CDC AIDS Community Demonstration Projects. Am J Pub Health 1999;89:336 – 45. 7. Kelly JA, St. Lawrence JS, Stevenson LY, et al. Community ADIS/HIV risk reduction: The effects of endorsements by popular people in three cities. Am J Pub Health 1992;82:1483– 89. 8. Kelly JA, Murphy D, Sikkema K, et al. Randomized, controlled, community-level HIV prevention intervention for sexual-risk behavior among homosexual men in US cities. Lancet 1997;350:1500 – 05. 9. St. Lawrence JS, Brasfield TL, Diaz YE, et al. Three-year follow-up of an HIV risk-reduction intervention that used popular peers. Am J Pub Health 1994;84:2027–28. 10. Kegeles SM, Hayes R, Coates TJ. The Mpowerment Project: a community-level HIV prevention intervention for young gay men. Am J Pub Health 1996;86;1129 –36. 11. DiClemente RJ. Looking forward: future directions for prevention of HIV among adolescents. In: Sherr L, ed. AIDS and Adolescents. Reading, Berkshire, United Kingdom: Harwood Academic Publishers, 1997:189 –99. *Denotes member of the Editorial Board.
FROM THE EDITORIAL BOARD
Expanding the Scope of HIV Prevention for Adolescents: Beyond Individual-level Interventions
Historically, the HIV epidemic has largely been viewed as a function adolescent’s behavior, most notably, their risky sexual and drug use behaviors. This individualistic perspective has dominated the field of HIV prevention. Consequently, interventions at this level aim to reduce adolescents vulnerability to HIV by enhancing theoretically-important intrapersonal and interpersonal mediators of preventive behavior such as HIV knowledge, attitudes, beliefs; foster the perception of peer norms as supportive of HIV-preventive practices; promote mastery of riskreduction skills; and motivate the adoption of preventive practices. Several individual-level interventions have demonstrated evidence of effectiveness in reducing adolescents’ HIV-associated risk behaviors (1). Although there is evidence that individual-level interventions are effective, these interventions may not be sufficient to sustain newly adopted behavior changes over protracted periods of time, particularly in the face of pervasive countervailing pressures that promote or reinforce risk behavior. Further, addressing behavior change at the individual-level lacks sufficient breadth to reach large segments of the at-risk adolescent population. Thus, there is need to expand the scope of HIV prevention interventions targeting adolescents to enhance their clinical and public health impact (2). Over the past few years, it has become evident that diverse socio-environmental, policy, and cultural influences significantly contribute to sustaining the HIV epidemic. Given the diversity of factors that may affect adolescents’ HIV-risk and preventive behavior, interventions at the individual-level as well as the family-, community-, and policy-level are needed to achieve meaningful behavior change (3,4). HIV Interventions targeted toward these larger levels of causality have the potential to reach broader adolescent audiences and hold promise for amplify-
ing and sustaining individual-level intervention effects. Family-level HIV interventions are designed to promote behavior change by utilizing the family as the target of intervention. This may include the nuclear family, a family of choice, or a network of individuals who are mutually committed to one another. Families can be mobilized to communicate important values, model appropriate behaviors, monitor adolescents’ behaviors, and encourage the adoption of HIV-preventive practices. Although there is a dearth of research exploring the impact of this promising intervention strategy, several studies funded by NIMH are currently underway evaluating the effect of family-level interventions on reducing adolescents’ HIV-associated behaviors (5). Community-level HIV prevention interventions are designed to promote behavior change by utilizing naturally occurring channels of influence (social/ friendship networks) and social institutions (media) while simultaneously providing a supportive environment that encourages HIV-preventive behavior. Several community-level HIV prevention interventions conducted among predominantly adult populations have observed reductions in HIV-risk behavior (6 – 8) as well as maintenance of low-risk behaviors over an extended period (9). One recent study, with young gay men, successfully increased condom use and decreased the proportion of men with more than one partner among gay men in several cities (10). This study used opinions leaders to direct the project. The initial group of opinion leaders recruited other opinion leaders. This process continued and established a self-perpetuating mechanism for changing community norms. A small media publicity campaign was developed to enhance awareness of the program, establish its legitimacy, invite young men to become involved in the program, and provide a continual reminder of the norm for safer sex. This approach effectively influenced
© Society for Adolescent Medicine, 2000 Published by Elsevier Science Inc., 655 Avenue of the Americas, New York, NY 10010
1054-139X/00/$–see front matter PII S1054-139X(00)00126-9
378
DICLEMENTE AND WINGOOD
community-level change through a process of informal communication and modeling by peers within interpersonal networks. Although these findings provide evidence of effectiveness, community-level interventions targeting adolescents remain an underutilized strategy. Policy-level interventions attempt to influence laws, policies, and legislative reform that may facilitate adolescents’ adoption and maintenance of HIVpreventive behaviors. Interventions at this level would promote the transfer of effective HIV-prevention curricula to schools, enhance adolescents’ ability to confidentially access reproductive and other health care services, reduce their access to drugs and alcohol, and enhance their access to drug and alcohol treatment. Policy-level changes have been used successfully to reduce adolescent morbidity and mortality associated with other risk behaviors. Interventions at this level, although effective in other areas of adolescent health promotion, remain fragmented in adolescent HIV prevention. It is pivotal that HIV interventions occur simultaneously across multiple levels of causality. Future HIV prevention programs will need to examine the effects of social, cultural, institutional, political, and economic forces as they promote or reinforce risky behavior and impede the adoption and maintenance of HIV-preventive behavior. By understanding these broader, pervasive influences it may be possible to develop community-level interventions, initiate policy changes, design institutionally-based programs, and promote the development of broader, macrolevel societal changes that can access many more adolescents and promote a social environment conducive to adopting and sustaining health-promoting behaviors while supporting the development and implementation of HIV-prevention activities. Reconceptualizing the HIV epidemic among adolescents from an individual-level to a broader, socioenvironmental-level phenomenon, requires designing multi-level interventions. This is not without methodologic challenges. Multi-level interventions are more complex. To facilitate the design, implementation and evaluation of these interventions, researchers will need to effectively transcend disciplinary boundaries, in terms of theory, methodology, and evaluation strategies. True interdisciplinary approaches and continued integration and collaboration between researchers and practitioners across diverse disciplines represents the best opportunity to develop multi-level HIV interventions.
JOURNAL OF ADOLESCENT HEALTH Vol. 26, No. 6
Our aim is to encourage prevention researchers to move beyond individual-level interventions, to embrace a broader array of HIV interventions and, optimally, to design multi-level interventions that complement each other and, hopefully, create preventive synergy (11) to effectively reinforce HIVprevention messages and skills and create an environment supportive of behavior change. Multi-level interventions, developed and implemented within a comprehensive and coordinated HIV prevention framework, represent a promising approach to impacting the HIV epidemic among adolescents. Respectfully, Ralph J. DiClemente* and Gina M. Wingood Emory University, Atlanta, Georgia
References 1. Centers for Disease Control and Prevention (CDC). Compendium of HIV Prevention Interventions with Evidence of Effectiveness. Atlanta, GA: CDC, November, 1999. 2. DiClemente RJ. Looking Forward: Future directions for HIV prevention research. In: Peterson JL, DiClemente RJ, eds. Handbook of HIV Prevention. New York: Kluwer/Plenum Publishing Corporation, 2000;311–24. 3. Sweat MD, Denison JA. Reducing HIV incidence in developing countries with structural and environmental interventions. AIDS 1995; 9(Suppl A):S251–S257. 4. Coates TJ. Reducing high-risk HIV behaviors: An overview of effective approaches. NIH Consensus Development Conference, February 11–13,1997. 5. Pequegnat W, Szapocznik J, eds. Working with Families in the Era of HIV/AIDS. Thousand Oaks, CA: Sage, in press. 6. The CDC AIDS Community Demonstration Projects Research Group. Community-level HIV intervention in five cities: Final outcome data from the CDC AIDS Community Demonstration Projects. Am J Pub Health 1999;89:336 – 45. 7. Kelly JA, St. Lawrence JS, Stevenson LY, et al. Community ADIS/HIV risk reduction: The effects of endorsements by popular people in three cities. Am J Pub Health 1992;82:1483– 89. 8. Kelly JA, Murphy D, Sikkema K, et al. Randomized, controlled, community-level HIV prevention intervention for sexual-risk behavior among homosexual men in US cities. Lancet 1997;350:1500 – 05. 9. St. Lawrence JS, Brasfield TL, Diaz YE, et al. Three-year follow-up of an HIV risk-reduction intervention that used popular peers. Am J Pub Health 1994;84:2027–28. 10. Kegeles SM, Hayes R, Coates TJ. The Mpowerment Project: a community-level HIV prevention intervention for young gay men. Am J Pub Health 1996;86;1129 –36. 11. DiClemente RJ. Looking forward: future directions for prevention of HIV among adolescents. In: Sherr L, ed. AIDS and Adolescents. Reading, Berkshire, United Kingdom: Harwood Academic Publishers, 1997:189 –99. *Denotes member of the Editorial Board.