In the absence of effective vaccines or other biomedical interventions to prevent HIV infection, behavioral prevention remains the cornerstone of global efforts to control the HIV/AIDS epidemic.1
Approximately 40% of newly diagnosed HIV infections occur among persons aged 15 to 24 years,2–4
underscoring the importance of behavioral prevention interventions during early adolescence.
Central to HIV prevention efforts has been the use of theories of behavioral change to direct the design of the prevention program.5–7
Protection motivation theory (PMT), a social cognitive theory, has been used to guide intervention development regarding multiple health threats, including HIV/AIDS.8–14
PMT is based on 2 presumptive cognitive pathways: the threat-appraisal pathway and the coping-appraisal pathway. The threat-appraisal pathway includes 4 constructs and evaluates both the potential rewards from the maladaptive response (intrinsic and extrinsic rewards for engaging in maladaptive behaviors) and the perceived severity and vulnerability to the outcome of the maladaptive behavior. The coping-appraisal pathway (3 constructs) evaluates the individual’s perceptions of his or her ability to avert the threatened danger, including efficacy variables (the response efficacy of the maneuver and the individual’s self-efficacy to perform the maneuver) and the potential response cost (eg, disadvantages or untoward outcomes) of the protective maneuver. Balance between these 2 appraisal pathways determines the intention, or “protection motivation,” to initiate, continue, or inhibit an adaptive response. This intention may result in a protective action.15,16
Studies addressing HIV/AIDS prevention have generally found that PMT serves as a robust model for understanding and altering HIV-related health promotion and risk behaviors.17–22
In the 1990s, we developed and evaluated Focus on Kids (FOK), a prevention intervention based on PMT for children ages 9 through 15 years. Through a series of analyses, we found that the intervention did reduce sexual risk behavior for the short term (through 6 months of follow-up) but not through 12 months of follow-up.23
However, after a booster at 13 months postintervention, there was, again, a protective effect on sexual risk behavior at 18 months.24
Although we were encouraged by these short-term effects of the PMT-based intervention, we wished to identify an intervention approach of which the impact would be more enduring.
Existing research indicates that youth perceptions of parental monitoring and effective parent-child communication are inversely correlated with youth involvement in sexual risk and substance abuse behaviors.25–31
Accordingly, we developed and evaluated a parental monitoring, communication, and HIV education intervention, Informed Parents and Children Together (Im-PACT), to be given in combination with FOK. Through a randomized, controlled trial conducted among adolescents (all of whom received FOK) aged 13 to 16 years at baseline, we found that children whose parents received ImPACT exhibited more protective behaviors over 2 years than those whose parents received a career goal-setting intervention titled Goal for It (GFI). We concluded that a parental monitoring, communication, and HIV education intervention could enhance and sustain an effective prevention program based on PMT targeting midadolescents.24
Once again, however, this work had focused on adolescents rather than preadolescents. In many settings, the onset of sexual risk occurs during early adolescence,32–35
making it important to reach children with prevention messages during their preadolescent years. However, given that abstract thinking typically begins to develop in early adolescence and might be expected to be largely completed by midadolescence,36,37
an intervention based on a social cognitive model such as PMT would not necessarily be appropriate for children in their preadolescent years. That is, PMT requires the understanding of abstract concepts, such as long-term and indirect consequences of active and passive decisions made, perspective taking, individual responsibility, and concepts of probability. Consistent with this developmental perspective, although FOK had been developed for children as young as 9 years of age, the intervention seemed to be stronger among older youth23
; and, in our subsequent work with FOK and ImPACT, the median age of the children was 14 years.24,38
Therefore, when researchers and child health specialists from the Bahamas approached us about adapting FOK and ImPACT for use among preadolescents (sixth-grade students), the US and Bahamian teams felt it important to subject the intervention to a longitudinal, randomized, controlled trial.
In a previous publication, we described the process and short-term outcomes of the adaptation of FOK for sixth-grade Bahamian students (mean age at baseline: 10.4 years) and the adaptation of ImPACT for the parents of these preadolescents.39
At 6 months postintervention, the youth intervention, Focus on Youth in the Caribbean (FOYC), had positively impacted knowledge and condom-use skills, as well as several PMT perceptions and intentions to engage in safer behaviors.18
However, risk behaviors overall were very low, and there were no significant differences in behaviors. Accordingly, in the current study, we examined the effects through 24 months of follow-up of the PMT-based youth HIV-prevention intervention in combination with 1 of 2 parent interventions compared with a control condition on HIV/AIDS knowledge and sexual perceptions, intentions, and behaviors.