Vietnam has experienced rapid social and political-economic changes over the past few decades. Within the context of these changes, adolescents and emerging adults have significantly greater access to knowledge and resources than their parents' generation, and sexual norms and the social constructs of gender continue to evolve within often conflicting contexts of “traditional” and “modern” values and beliefs [18
]. Our baseline data reveal low rates of engagement in sexual behaviors among our cohort of 15–20 year olds. Recent research suggests that sexual debut among Vietnamese youth occurs at 22.7 years for females and 21.3 for males [35
]. Among males, data indicate rapidly increasing rates of engagement in nonmarital sexual behaviors from under 9% at 20 years to over 33% at 24 years. In addition, young men are engaging in casual and transactional sexual relations and inconsistent condom use [41
]. Furthermore, data on HIV prevalence as well as STIs and unwanted pregnancy among Vietnamese youth indicate a clear need for both early prevention programming before sexual debut as well as interventions for older adolescent and emergent adults.
We have presented the outcomes of a cluster-designed randomized evaluation for three HIV risk and sexual health interventions for Vietnamese adolescents. Changes within the PMT coping appraisal constructs include self-efficacy for both condom use and abstinence and response efficacy for condoms. These positive changes are sustained through 12-month postintervention followup. Among threat appraisal pathway constructs, across each intervention, there was a 12-month sustained decrease in extrinsic rewards. There were also sustained increases in perceived vulnerability to HIV. Other outcomes within the threat appraisal pathway constructs are less conclusive. Across all interventions, there is an increase from baseline to postintervention followups for “intrinsic rewards.” These data could reflect a need to reassess the scale items to better reflect cultural perceptions of “intrinsic rewards” and/or suggest that participation in a program in which sexual behaviors are openly discussed could empower youth to be more open about their sexual feelings. In both VFOK and EWA+, there are decreases in perceived severity of HIV/AIDS. Again, these changes could reflect a need for reassessing the scales and/or indicate at postintervention less HIV-associated stigma and therefore less severe perceived social consequences. Overall, these findings indicate more robust and sustained changes among constructs within the PMT coping appraisal pathway compared to the threat appraisal pathway. Such findings may indicate a need to strengthen programmatic content focused on rewards, severity, and vulnerability. Alternatively, these data may also reflect the coping appraisal constructs as more salient within Vietnamese culture—future cross-cultural data analysis may help determine patterns of construct relevancy outside of western contexts.
Outcomes data show decreased intention to have sex in the next three months for EWA+ participants at immediate postintervention (3 months); however, through 12 months participants across interventions show increases in intention to have sex. Without an assessment-only control group, this increase is difficult to interpret though it could reflect aging and maturity of the participants. With a control group, we would be able to compare if the increase among intervention participants was significantly less than control.
Comparison of VFOK and EWA indicates a 12-month sustained increase in HIV/AIDS knowledge among VFOK participants. This greater impact among VFOK participants could reflect more concentration on fact-based activities and less abstract concepts, for example, regarding gender roles and relationships, within the VFOK curriculum. Comparison of VFOK and EWA+ indicates a significantly greater increase in pregnancy and contraceptive knowledge among EWA+ participants at 3, 6, and 12 months and greater change in STI knowledge at 12 months. These data could indicate that parents participating in the EWA program became more communicative about sexual health knowledge. A lack of significant differences between EWA+ and VFOK in PMT constructs may reflect Vietnamese parents' greater comfort level sharing with their child new fact-based information compared to skill-based information (e.g., condom use). The EWA+ intervention included both a parent curriculum and a sexual health workshop for commune health center staff. Analysis of the parent evaluation data (reported elsewhere) indicates that parents improved significantly on knowledge about HIV, STIs, and pregnancy after intervention and level of comfort communicating with youth about sexual issues [43
]. While it is not possible to discriminate if the parent and/or the health staff intervention may have contributed to the increases in knowledge among EWA+ participants, the data suggest that a multiple-level intervention including parents and/or broader community institutions has potential for the sexual health education of Vietnamese youth. A majority of Vietnamese youths live with both parents, and parents remain an untapped source for sexual health education. In addition, commune health workers have regular contact with residents and are engaged in intervention activities. Ensuring health workers have accurate information are comfortable communicating about sexual issues, and are essential components for improving sexual health of youth and the broader community.
At this time, there are limited numbers of evidence-based sexual health and HIV risk reduction programs for adolescents and emerging adults throughout low- and middle-income countries [44
]. For Vietnamese youth, sexual health and HIV prevention resources remain limited in accessibility and scope. In order to facilitate future dissemination and implementation of efficacious programming, strides need to be made both in the adaptation and/or development of interventions and in the conduct of randomized-control evaluations of promising interventions. Overall, evaluation data indicate that each of these programs has promise; however, the EWA and EWA+ programs improve on the VFOK both in terms of sustainability and evidence of positive planned changes. The EWA adolescent curricula for males and females included gender-specific activities and issues which may have more effectively targeted the PMT constructs which can be affected by social contexts and constructs, for example, gender roles and relationships.
There is an unmet need for longer-term follow-up intervention assessments for adolescents in Vietnam and elsewhere in Asia. Extended follow-up assessment could provide data on whether or not the changes sustained through 12 months would be further sustained over time and delay sexual debut or increase engagement in safer sexual practices among young Vietnamese men and women. Further research is also needed on evidence-based program implementation and dissemination to increase youth and parent program participation within the contexts of school and work obligations, as well as cultural constructs and social norms which deny the need for sexual health knowledge prior to marriage.