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1.  Fidelity of implementation of an evidence-based HIV prevention program among Bahamian sixth-grade students 
The Bahamian Ministry of Education has elected to implement at a national level in all Bahamian government grade six classes an evidence-based HIV prevention intervention [Focus on Youth in the Caribbean (FOYC)]. This study explores fidelity of implementation of the intervention, factors that may influence implementation fidelity, and the impact of variations in implementation fidelity on student outcomes. Data were collected in the first wave of national implementation in 2011, involving 35 government primary schools and 110 teachers and 2811 students. Structural equation modeling was performed to examine the relationships among factors which facilitated or impeded teachers’ implementation of FOYC. Results indicate that teachers taught 16.3 out of 30 core activities, 24.9 out of 46 total activities and 4.4 out of 8 sessions on average. The strongest predictor of implementation fidelity was teacher comfort level with the FOYC curriculum. Teachers who did not perceive the FOYC intervention to be important for their students or who had attended only part of a FOYC training workshop were more likely to change the curriculum. Increased duration of experience as a teacher (>10 years) was negatively associated with fidelity of implementation. Teacher’s perception of the importance of the FOYC intervention and implementation fidelity had direct positive effects on students’ HIV/AIDS knowledge, reproductive health skills, protective intentions and self-efficacy. Youth did not appear to benefit from FOYC if two or fewer sessions were delivered. We concluded that an evidence-based HIV prevention intervention can be implemented at a national level. Prior training of teachers in the intervention curriculum, teacher perception of the importance of the intervention, and fewer years as a teacher are associated with implementation fidelity. Implementation fidelity is associated with improved student outcomes.
doi:10.1007/s11121-014-0486-y
PMCID: PMC4199933  PMID: 24736950
Implementation research; HIV prevention; fidelity; adolescents; Bahamas
2.  A quarter century of HIV prevention intervention efforts among children and adolescents across the globe 
In 1988 a group of pediatricians, developmental, clinical, child and social psychologists, anthropologists and health educators began researching in Baltimore, Maryland on an HIV prevention intervention, Focus on Youth. Over the next 25 years the questions being addressed by Focus on Youth, reflected those of the global HIV research experience.
During the first phase, the questions being addressed by the broader research community included: Can HIV risk behaviors be purposefully impacted by behavioral interventions? If so, how do successful interventions differ from those that are not effective? Are theory-based interventions more likely to be effective than information-only based interventions? Can theories be translated into culturally and developmentally appropriate interventions including those that are appropriate for children and adolescents? Should parents be involved--and if so, how?
During its next phase, the Focus on Youth team increasingly became concerned with a disturbing reality. A large number of interventions had been developed and some had been shown to have evidence of impact. But virtually all of these interventions had been conducted in the USA or Europe. The questions facing researchers included: With the global burden of HIV disproportionately impacting Low and Middle Income Countries (LMIC), especially those in southern Africa, the Caribbean and parts of Asia, what is known about the effectiveness of western-based interventions in these culturally, racially and economically disparate settings?
With the exciting proliferation of interventions, federal agencies in the USA and international agencies including UNAIDS realized the importance of assessing the research portfolio and developing metrics of effectiveness. The questions during this phase included: What is an “effective” intervention? How are effective interventions implemented in a new setting? This phase merged with the next phase as researchers and public health workers realized that the dissemination to a new community of an intervention developed and found to be effective in one community requires change. The central questions during this time included: What changes or kinds of changes can be made to an intervention without undermining its effectiveness? What aspects of an intervention cannot be changed without potentially undermining its effectiveness? What constitutes a “change”? Who should be involved in this decision-making?
These efforts culminated in our current phase, one focused on implementation. We must learn more about the factors that allow an intervention to survive and thrive and selectively target these critical factors. The main objective of this paper is to review our experiences and lessons learned in developing, implementing, and evaluating Focus on Youth in a wide range of socio-cultural settings over the past a quarter of century.
doi:10.1080/21642850.2014.889572
PMCID: PMC4020185  PMID: 24839584
3.  The impact of parent involvement in an effective adolescent risk reduction intervention on sexual risk communication and adolescent outcomes 
Parent involvement in prevention efforts targeting adolescents increases the impact of such programs. However, the majority of risk-reduction intervention programs that are implemented through schools do not include parents, in part because most existing parental interventions require significant time commitment by parents. We designed a brief parent-adolescent sexual risk communication intervention to be delivered with an effective HIV prevention intervention as part of a randomized, controlled trial among 2564 grade 10 students and their parents in The Bahamas. Mixed effects modeling analysis was conducted to evaluate the effect of the brief parent-adolescent communication intervention using four waves of longitudinal data. Results indicate that a brief parent-adolescent communication intervention is effective in improving parent-adolescent communication on sex-related issues and perceived parental monitoring as well as the youth's condom use skills and self-efficacy. There is a marginal effect on consistent condom use. In addition, there is an apparent dose effect of the brief parent intervention on perceived parent-adolescent sexual risk communication and adolescent outcomes. These findings suggest that adolescent risk reduction interventions should include a brief parent-adolescent communication intervention which should be reinforced by periodic boosters in order to enhance the impact of adolescent HIV prevention programs.
doi:10.1521/aeap.2014.26.6.500
PMCID: PMC4261929  PMID: 25490732
adolescent; condom use skills; self-efficacy; parent-adolescent communication; brief parental intervention; risk behaviors; The Bahamas
4.  Withdrawal (Coitus Interruptus) as a Sexual Risk Reduction Strategy: Perspectives from African-American Adolescents 
Archives of sexual behavior  2008;38(5):779-787.
This study examined adolescents’ beliefs about the benefits and risks of withdrawal (coitus interruptus) with respect to both pregnancy and sexually transmitted infections (STIs). In the course of qualitative interviews with African-American youth aged 14–19 (n = 124) about sexuality and risk, 24 adolescents spontaneously introduced the subject of withdrawal as a sexual risk reduction strategy. Eighteen percent of the sexually experienced adolescents mentioned their own use of withdrawal as a contraceptive method. From adolescents’ accounts of their own and their peers’ use of withdrawal, we learned that the cultural meanings of withdrawal within the context of adolescent relationships were multifaceted. Using withdrawal could signal sexual prowess in male youth, was seen as promoting trust and caring within a stable relationship, and was seen as mitigating the risk of pregnancy. However, adolescents also recognized that withdrawal did not protect against most STIs. Beliefs about withdrawal as a gendered skill and as a sign of trust may undermine some adolescents’ attempts to negotiate condom use for protection against STIs.
doi:10.1007/s10508-007-9304-y
PMCID: PMC4218729  PMID: 18293076
Sexually transmitted infections; HIV/AIDS; Adolescents; Withdrawal; Contraception; African-American
5.  The influence of parental monitoring and parent-adolescent communication on Bahamian adolescent risk involvement: A three-year longitudinal examination 
The literature suggests that parental monitoring can best be conceptualized and measured through the domains of parental knowledge, youth disclosure, parental solicitation, and parental control. Using longitudinal data on 913 grade-six Bahamian students followed over a period of three years, we examined the unique and independent roles of these domains of parental monitoring and parent–adolescent communication in relation to adolescent involvement in delinquency, substance use, and sexual risk behaviors. The results obtained with mixed-effects models indicate that parental knowledge, youth disclosure, and parental control are negatively associated with both delinquency and substance use. Open parent—adolescent communication was associated with decreased sexual risk behavior, whereas problematic parent–adolescent communication was associated with increased sexual risk behavior. The results obtained with path models indicate that youth disclosure is a significant longitudinal predictor of reduced adolescent delinquency and that parental control during early adolescence predicted reduced substance use in middle adolescence. The findings suggest that parental knowledge, youth disclosure and parental control differ in their impacts on substance use, delinquency and sexual risk behaviors. Problematic parent–adolescent communication is consistently associated with increases in all three types of adolescent risk behaviors. Future parental monitoring interventions should focus on enhancing parents’ interpersonal communication skills and emphasize the differences in and importance of the unique components of parental monitoring.
doi:10.1016/j.socscimed.2013.08.013
PMCID: PMC4049067  PMID: 24161101
adolescent; parental knowledge; youth disclosure; parental solicitation; parental control; parent–adolescent communication; risk behaviors; Bahamas
6.  Adolescent Age at Time of Receipt of One or More Sexual Risk Reduction Interventions 
Purpose
Age of the target audience at time of intervention is thought to be a critical variable influencing the effectiveness of adolescent sexual risk reduction interventions. Despite this postulated importance, to date studies have not been designed to enable a direct comparison of outcomes according to age at time of intervention delivery.
Methods
We examined outcomes of 598 youth who were sequentially involved in two randomized controlled trials of sexual risk prevention interventions, the first one delivered in grade 6 [Focus on Youth in the Caribbean (FOYC)] and the second one in grade ten [Bahamian Focus on Older Youth (BFOOY)]. Four groups were examined, including those who received: 1) both treatment conditions, FOYC and BFOOY; 2) FOYC in grade 6 and the control condition in grade 10; 3) the control condition in grade 6 and BFOOY in grade 10; and 4) both control conditions. Intentions, perceptions, condom-use skills as well as HIV-related knowledge were assessed over 60 months.
Results
Data showed that those who received both interventions had the greatest increase in condom-use skills. Youth who received FOYC in grade 6 had greater scores in knowledge and intention.
Conclusion
These results suggest that youth receive the most protection with early and repeated exposure to interventions. These findings suggest that educators should consider implementing HIV prevention and risk reduction programs as a fixed component of education curriculum beginning in the pre-adolescent years and if possible also during the adolescent years.
doi:10.1016/j.jadohealth.2014.01.016
PMCID: PMC4108619  PMID: 24656447
HIV Prevention Intervention; Adolescence; Condom-use skills; Randomized Controlled Trials; Risk Reduction Behavior
7.  Psychological Fears among Low-Paid Female Sex Workers in Southwest China and Their Implications for HIV Prevention 
PLoS ONE  2014;9(10):e111012.
Commercial sex plays a critical role in rapidly increasing heterosexual transmission of HIV in China. Low-paid female sex workers (FSWs) are especially vulnerable to HIV/AIDS. Because of the illegality and stigma associated with sex work, FSWs may constantly live with fears in their daily life. Based on cross-sectional study of 794 low-paid FSWs in China we described their psychological fears related to commercial sex and examined the associations between fears and HIV-related behaviors. Fear of HIV infection was significantly associated with consistent use of condoms with clients. However, fear of breaching sex worker identity significantly prevented the FSWs from consistently using condoms with clients and taking HIV tests. Fear of being arrested by the police was positively associated with consistent use of condoms but negatively associated with accessing HIV prevention services. Our findings underlined the importance of examining the triadic interaction of behavioral, psychological and environmental factors in HIV prevention interventions among low-paid FSWs.
doi:10.1371/journal.pone.0111012
PMCID: PMC4201579  PMID: 25330242
8.  National Implementation of an Evidence-Based HIV Prevention and Reproductive Health Program for Bahamian Youth 
A wide range of behavioral prevention interventions have been demonstrated through longitudinal, randomized controlled trials to reduce sexual risk behaviors. Many of these interventions have been made available at little cost for implementation on a public health scale. However, efforts to utilize such programs typically have been met with a range of problems to be addressed, leading to the recognition that new processes must be identified and integrated into the emerging field of implementation science. A randomized, controlled trial conducted among Bahamian grade six students attending fifteen elementary schools found the sexual risk-reduction intervention “Focus on Youth in the Caribbean (FOYC) and Caribbean Informed Parents and Children Together (CImPACT)” to be effective through three years of follow-up. Based on these results, the Bahamian Ministry of Education decided to implement FOYC-CImPACT throughout all government grade six classes in The Bahamas. This manuscript describes the considerations, approaches, and actions taken regarding national implementation of this evidence-based intervention. The implementation process included active data-gathering, observation and feedback components to inform subsequent intervention phases. This manuscript reviewed the success and challenges to date within this framework and described changes made to enable next stages of the national implementation effort.
PMCID: PMC4153366  PMID: 25197265
HIV/AIDS Prevention; Reproductive Health Education; Implementation Research
9.  Predictors of responsiveness among early adolescents to a school-based risk reduction intervention over 3 years 
AIDS and behavior  2013;17(3):1096-1104.
This study assesses potential predictive factors for unresponsiveness to the “Focus on Youth in the Caribbean (FOYC)” intervention using longitudinal data from 1360 Bahamian sixth-grade youth. Results from hierarchical logistic regression analyses indicate that the intervention had a greater impact on knowledge, skills, self-efficacy, and condom use intention among low and medium initial scorers. High initial scores in knowledge, skills, self-efficacy, and intention were predictive of relative unresponsiveness to the intervention. Advanced age and male sex were predictive of unresponsiveness to the intervention for HIV/AIDS knowledge. Female gender was predictive of unresponsiveness to the intervention for self-efficacy. High academic self-evaluation was predictive of unresponsiveness to the intervention for condom use intention. The greatest intervention impact was observed at the six-month post-intervention follow-up; these intervention-related gains were sustained over the subsequent follow-up periods. Youth with higher risk attributes (lower knowledge, skills and self-efficacy) were more likely to respond to a risk reduction intervention.
doi:10.1007/s10461-012-0144-y
PMCID: PMC4136491  PMID: 22311147
HIV/AIDS knowledge; condom use skills; self-efficacy; condom use intention; intervention; unresponsiveness
10.  Disclosure of parental HIV infection to children and psychosocial impact on children in China: a qualitative study 
This qualitative study aims to investigate parental HIV disclosure and psychological impact from the perspectives of their children. In-depth individual interviews with 47 children who had lost one or both parents to AIDS were conducted in China. All transcripts were coded using the software ATLAS.ti 5. Results showed that few of children knew of parental HIV status before the death of their parents. The main disclosers were the children’s current caregivers. Some children knew about their parent’s HIV infection based on their own observations or through overheard conversation, or their interactions with villagers. Both positive and negative psychological outcomes related to parental HIV disclosure were reported. Psychological counseling is needed for both parents and children to dealing with the parental HIV infection.
doi:10.1080/21507686.2013.826261
PMCID: PMC3992264  PMID: 24761258
Parental HIV disclosure; Psychosocial impact; Orphan; China
11.  INTENTION TO USE CONDOM, CUSP MODELING, AND EVALUATION OF AN HIV PREVENTION INTERVNETION TRIAL 
Adolescents are at particularly high risk to acquire HIV infection; increasing the likelihood of condom use is an effective measure to reduce the risk of such infections. Challenges in assessing actual condom use behavior among early adolescents render the precursor measure, intention to use condoms, an appealing alternative. While analyzing data from a randomized controlled trial to evaluate a theory-based intervention program to promote condom use among early adolescents, we observed a modest effect with regard to condom use intention when the linear analytical approach was used. If intention, as a measure of the readiness to perform a behavior, also contains a nonlinear discrete component, it would be more appropriately modeled using a non-linear approach. In this study, data from a randomized controlled trial (N=1360) were analyzed using the cusp catastrophe method with HIV knowledge and condom skills as the asymmetry variables and condom use self-efficacy as the bifurcation variables. Findings from concurrent and longitudinal modeling analyses indicated a much better fit of the cusp model (R2 = 0.85 and 4+ times smaller AIC and BIC) than the linear (R2 <=0.10 and 4+ times larger AIC and BIC) or the logistic model (R2<0.15, also 4+ times larger AIC and BIC). Receipt of the intervention as an asymmetry variable was significantly predicted condom use intention but did not as a bifurcation variable. In conclusion, adolescent intentions to use a condom contain both a continuous process and a discrete process and can better be modeled with cusp methods. A much greater program effect is likely from the same prevention intervention if additional measures are taken to foster sudden changes in condom intention.
PMCID: PMC4106698  PMID: 23735493
Behavioral Intention; Cusp modeling; HIV/AIDS; Bahamian Youth; Condom use
12.  Preparing for National Implementation of an Evidence-based, Effective HIV Prevention Program among Bahamian Sixth-Grade Students 
World health & population  2012;13(4):28-42.
Using data from the preparatory phase prior to national implementation of an effective HIV prevention program [Focus on Youth in the Caribbean (FOYC)] in all Bahamian government sixth-grade classes, we describe: 1) actual FOYC implementation; 2) factors which influenced implementation; and 3) the relationship of implementation with intervention outcome. Six elementary schools (with 17 grade six classrooms) were selected to participate in the preparatory phase. The 17 teachers were invited to: attend a training workshop; coordinate administration of questionnaires to the students; teach the 10 sessions of FOYC; and complete self-assessment checklists. 395 students submitted baseline and 311 students submitted year-end questionnaires. Thirteen teachers initiated FOYC; five completed all 10 sessions. Implementation of FOYC was not related to teacher FOYC workshop experience but did cluster by school. There were significant positive correlations between improved student knowledge of HIV/AIDS, protective health skills, perceived parental monitoring and reduced risk behaviors with the number of FOYC sessions delivered. Implementation was impeded by logistic impediments, structural issues with the measures, and comfort-level issues, most of which can be addressed for national implementation. Degree of FOYC implementation is correlated with positive student outcomes.
PMCID: PMC4063301  PMID: 23089726
Bahamas; implementation; HIV prevention; AIDS knowledge; intention; risk behavior; preadolescents
13.  A Cluster Randomized Controlled Trial of an Adolescent HIV Prevention Program among Bahamian Youth: Effect at 12 Months Post-Intervention 
AIDS and behavior  2008;13(3):499-508.
Background
Behavioral interventions based on the Protection Motivation Theory (PMT) have been demonstrated to reduce HIV risk behavior among mid- and older adolescents in different settings across the globe but have not been evaluated among Caribbean nations and have received limited evaluation among pre-adolescents.
Objective
To determine 1) the effectiveness among pre-adolescents in The Bahamas of a PMT-based HIV prevention program “Focus on Youth in the Caribbean” (FOYC) and 2) the role of the targeted PMT constructs in intervention effect.
Methods
1,360 sixth grade youth (10-11 years of age) from 15 urban schools in New Providence, The Bahamas were randomized by school to receive either FOYC or a control condition. Data collected at baseline, six and 12 months post intervention were analyzed. A five-step scheme was used to assess sexual behavior progression, ranging from “1” = “a virgin without intention to have sex” to” 5″ = “having sex without a condom”. Group-based trajectory analysis was utilized in assessing the program effect.
Results
Two sexual behavior progression patterns were detected: slow progressors and quick progressors. Receiving FOYC reduced the likelihood for adolescents to become quick progressors (adjusted OR = 0.77, 95% CI: 0.64-1.00). The observed effectiveness was especially impacted by a subset of the targeted PMT constructs.
Conclusion
FOYC effectively delays sexual risk among Bahamian pre-adolescents. The group-based trajectory analysis provides an analytical approach for assessing interventions among adolescents with low rates and diverse progression patterns of sexual activity.
doi:10.1007/s10461-008-9511-0
PMCID: PMC4026176  PMID: 19116781
Behavioral Intervention; FOK; HIV/AIDS; Adolescent risk behavior; The Bahamas
14.  Domestic chores workload and depressive symptoms among children affected by HIV/AIDS in China 
AIDS care  2012;25(5):632-639.
Limited data are available regarding the effects of domestic chores workload on psychological problems among children affected by HIV/AIDS in China. The current study aims to examine association between children’s depressive symptoms and the domestic chores workload (i.e., the frequency and the amount of time doing domestic chores). Data were derived from the baseline survey of a longitudinal study which investigated the impact of parental HIV/AIDS on psychological problems of children. A total of 1,449 children in family-based care were included in the analysis: 579 orphaned children who lost one or both parents due to AIDS, 466 vulnerable children living with one or both parents being infected with HIV, and 404 comparison children who did not have HIV/AIDS infected family members in their families. Results showed differences on domestic chores workload between children affected by HIV/AIDS (orphans and vulnerable children) and the comparison children. Children affected by HIV/AIDS worked more frequently and worked longer time on domestic chores than the comparison children. Multivariate linear regression analysis showed that domestic chores workload was positively associated with depressive symptoms. The data suggest that children affected by HIV/AIDS may face increasing burden of domestic chores and it is necessary to reduce the excessive workload of domestic chores among children affected by HIV/AIDS through increasing community-based social support for children in the families affected by HIV/AIDS.
doi:10.1080/09540121.2012.722603
PMCID: PMC3622201  PMID: 22970996
Domestic chores workload; Depressive symptoms; Orphan; HIV/AIDS; China
15.  Alcohol use and client-perpetrated sexual violence against female sex workers in China 
Psychology, health & medicine  2012;18(3):330-342.
Background
The global literature suggests that female sex workers (FSWs) experience high rates of sexual violence perpetrated by their clients, especially when FSWs are under the influence of alcohol. However, such data are limited in China. The current study is aimed to fill in the literature gap by examining the association between alcohol use by FSWs and client-perpetrated sexual violence against FSWs in China.
Methods
A total of 1,022 FSWs were recruited through community outreach in Guangxi, China. FSWs completed a self-administered survey on their demographic information, alcohol use, and sexual violence perpetrated by clients. Multivariable regression was employed to assess the relationship between alcohol use and client-perpetrated sexual violence among FSWs while controlling for possible confounders.
Results
Alcohol use was positively associated with the experience of sexual violence in both bivariate and multivariable analyses. Women who were at a higher risk level of alcohol use were more likely to experience sexual violence perpetrated by clients even after controlling confounders (e.g., demographics and alcohol-serving practice).
Conclusion
Given the association between alcohol use and client-perpetrated sexual violence, preventing or reducing alcohol use among FSWs could be an effective strategy to protect these women from sexual violence perpetrated by their clients. Alternatively, psychological counseling and other support should be available to these women so they can reduce their alcohol use as a maladaptive coping strategy. We call for culturally appropriate alcohol use reduction components, incorporated with sexual violence reduction strategies including adaptive coping skills training as well as empowerment, and targeting both FSWs and their clients.
doi:10.1080/13548506.2012.712705
PMCID: PMC3644341  PMID: 22882121
China; Female Sex Workers; Alcohol Use; Sexual Violence; Clients; Prevention
17.  Rates of HIV, syphilis, and HCV infections among different demographic groups of female sex workers in Guangxi China: Evidence from 2010 national sentinel surveillance data 
AIDS care  2013;25(11):1433-1441.
To examine the prevalence of HIV, syphilis, and hepatitis C virus (HCV) infections by demographic characteristics and identify the subgroups of female sex workers (FSW) who are at a higher risk of the infections. Secondary analysis of the 2010 National Sentinel Surveillance (NSS) data was conducted in the current study. A total of 12,622 FSW recruited from 35 NSS sites in Guangxi, China were included in the analysis. FSW were tested for HIV, syphilis, and HCV. The overall prevalence of HIV, syphilis, and HCV infections were 1.0%, 6.1% and 1.0%, respectively. The prevalence of HIV and syphilis infections were significantly higher among women who aged 40 years or older, worked in small commercial sex venues or on street, divorced or widowed, or no formal schooling. A very high HIV infection prevalence (8.2%) was observed among a small number of cross-border foreign FSW (n=49). The prevalence of HCV infection did not differ by most of the demographic characteristics. Living in other provinces or being a Zhuang-ethnic served as protective factors for HCV. The multivariable analyses confirmed the results of bivariate results suggesting higher prevalence of HIV and syphilis infections among FSW who were older, divorced or widowed, or no formal schooling. Future HIV intervention prevention efforts among FSW need to pay particular attention to these women in order to effectively curtail the infections among this most-at-risk population as well as to prevent the further spread of HIV and syphilis to other populations.
doi:10.1080/09540121.2013.772282
PMCID: PMC3992266  PMID: 23438031
FSW; HIV; Syphilis; HCV; National Sentinel Surveillance; China
18.  Brief Sensation Seeking Scale for Chinese - Cultural Adaptation and Psychometric Assessment 
International behavioral research requires instruments that are not culturally-biased to assess sensation seeking. In this study we described a culturally adapted version of the Brief Sensation Seeking Scale for Chinese (BSSS-C) and its psychometric characteristics. The adapted scale was assessed using an adult sample (n=238) with diverse educational and residential backgrounds. The BSSS-C (Cronbach alpha=0.90) was correlated with the original Brief Sensation Seeking Scale (r = 0.85, p<0.01) and fitted the four-factor model well (CFI=0.98, SRMR=0.03). The scale scores significantly predicted intention to and actual engagement in a number of health risk behaviors, including alcohol consumption, cigarette smoking, and sexual risk behaviors. In conclusion, the BSSS-C has adequate reliability and validity, supporting its utility in China and potential in other developing countries.
doi:10.1016/j.paid.2012.11.007
PMCID: PMC3539791  PMID: 23316097
Sensation Seeking scale; Cross-cultural adaptation; Health Behavior; China
19.  Unprotected sex with their clients among low-paying female sex workers in southwest China 
AIDS care  2012;25(4):503-506.
Background
China has been experiencing a rapid increase in the HIV epidemic for decades. Commercial sex plays a critical role in heterosexual transmission of HIV. Limited studies suggested that low-paying female sex workers (FSWs) faced a higher risk of HIV infection. Low-paying FSWs are women who usually encounter their clients on the street or small establishments in rural or less-developed areas, or who charge low fees for each sexual service.
Methods
A total of 720 low-paying FSWs from 130 commercial sex venues/locations in southwest China were included in the data analysis. Multivariate regression models were employed to examine the associations of unprotected sex with a number of exploratory variables among the study sample.
Results
About 33.9% and 61.5% of low-paying FSWs reported unprotected sex with clients in the last sex act and in the last month, respectively. After controlling for confounders, women’s HIV knowledge, risk perception, experience of police arrest, and venue types were significantly associated with unprotected sex among low-paying FSWs.
Discussion
Low-paying FSWs are at an alarmingly high risk of HIV infection. HIV prevention programs are urgently needed to address risk factors posit in both individual and contextual levels among this most-at-risk population in order to curb the HIV epidemic in China.
doi:10.1080/09540121.2012.726345
PMCID: PMC3594428  PMID: 23062062
Low-paying FSWs; HIV risks; Unprotected sex; China
20.  Theoretical Models of Parental HIV Disclosure: A Critical Review 
AIDS care  2012;25(3):326-336.
This review critically examined three major theoretical models related to parental HIV disclosure (i.e., the Four-Phase Model, the Disclosure Decision Making Model, and the Disclosure Process Model), and the existing studies that could provide empirical support to these models or their components. For each model, we briefly reviewed its theoretical background, described its components and or mechanisms, and discussed its strengths and limitations. The existing empirical studies supported most theoretical components in these models. However, hypotheses related to the mechanisms proposed in the models have not yet tested due to a lack of empirical evidence. This review also synthesized alternative theoretical perspectives and new issues in disclosure research and clinical practice that may challenge the existing models. The current review underscores the importance of including components related to social and cultural contexts in theoretical frameworks, and calls for more adequately designed empirical studies in order to test and refine existing theories and to develop new ones.
doi:10.1080/09540121.2012.712658
PMCID: PMC3508317  PMID: 22866903
Parental HIV infection; HIV disclosure; Parental HIV disclosure; Literature review; Theoretical model
21.  Exploring Implementation and Fidelity of Evidence-Based Behavioral Interventions for HIV Prevention: Lessons Learned From the Focus on Kids Diffusion Case Study 
Evidence-based interventions (EBIs) are used in public health to prevent HIV infection among youth and other groups. EBIs include core elements, features that are thought to be responsible for the efficacy of interventions. The authors evaluate experiences of organizations that adopted an HIV-prevention EBI, Focus on Kids (FOK), and their fidelity to the intervention’s eight core elements. A cross-sectional telephone survey was administered to 34 staff members from organizations that had previously implemented FOK. Questions assessed how the organization adhered to, adapted, dropped, or altered the intervention. None of the organizations implemented all eight core elements. This study underscores the importance for HIV intervention researchers to clearly identify and describe core elements. More effort is needed to reflect the constraints practitioners face in nonresearch settings. To ensure intervention effectiveness, additional research and technical assistance are needed to help organizations implement HIV prevention EBIs with fidelity.
doi:10.1177/1090198108315366
PMCID: PMC3932338  PMID: 18445739
HIV/AIDS; adaptation; evidence-based interventions; fidelity
22.  Socio-demographic and Behavioral Correlates for HIV and Syphilis Infections among Migrant Men Who Have Sex With Men in Beijing, China 
AIDS care  2012;25(2):249-257.
Migrant men who have sex with men (MSM) may be particularly vulnerable to sexually transmitted infections (STIs) including HIV. This study examines the rates of HIV and syphilis infections and associated socio-demographic and behavioral factors among migrant MSM in China. Data from 307 migrant MSM were collected in Beijing, China. Blood specimens were collected to test for HIV and syphilis infections. HIV and syphilis rates were 5.9% and 20.2%, respectively. Multivariate logistic regression analyses showed that having ever been married, living a longer period in Beijing, having more sexual partners, and having a foreign MSM friend were significantly associated with HIV infection. Migrating from a rural area, experiencing one’s sexual debut at an older age, having a male as first sexual partner, having more sexual partners, and being recruited from peer outreach and social network were associated with syphilis infection. Migrant MSM in China are at high risk for HIV and syphilis infections. HIV prevention programs targeting rural migrant MSM who have been married are needed.
doi:10.1080/09540121.2012.701714
PMCID: PMC3563352  PMID: 22788859
China; men who have sex with men; HIV; syphilis; unprotected anal intercourse; sexual partners
23.  A Protection Motivation Theory-Based Scale for Tobacco Research among Chinese Youth 
Rates of tobacco use among adolescents in China and other lower and middle-income countries remain high despite notable prevention and intervention programs. One reason for this may be the lack of theory-based research in tobacco use prevention in these countries. In the current study, a culturally appropriate 21-item measurement scale for cigarette smoking was developed based on the core constructs of Protection Motivation Theory (PMT). The scale was assessed among a sample of 553 Chinese vocational high school students. Results from correlational and measurement modeling analysis indicated adequate measurement reliability for the proposed PMT scale structure. The two PMT Pathways and the seven PMT constructs were significantly correlated with adolescent intention to smoke and actual smoking behavior. This study is the first to evaluate a PMT scale for cigarette smoking among Chinese adolescents. The scale provides a potential tool for assessing social cognitive processes underlying tobacco use. This is essential for understanding smoking behavior among Chinese youth and to support more effective tobacco use prevention efforts. Additional studies are needed to assess its utility for use with Chinese youth in other settings.
doi:10.4172/2155-6105.1000154
PMCID: PMC3903136  PMID: 24478933
Protection Motivation Theory (PMT); Adolescents; Cigarette smoking
24.  Effects of Promoting Health Among Teens on Dietary, Physical Activity and Substance Use Knowledge and Behaviors for African American Adolescents 
Background
African Americans are disproportionately affected by cardiovascular disease and cancer. Health promotion interventions hold promise for reducing health disparities.
Purpose
Promoting Health Among Teens (PHAT) is a brief, culturally tailored health education intervention to decrease cardiovascular disease and cancer risk for African Americans. This study evaluated the effects of PHAT for African American adolescents ages 14 to 17 in four eastern cities in the USA.
Methods
A randomized controlled design (N = 1,654) was used to determine differences in health knowledge, diet, physical activity, and substance use behaviors between PHAT participants and a sexual health promotion control group. Data were collected at baseline, three, six, and twelve months post intervention. Growth curve modeling was used to detect differences in health knowledge, dietary behaviors, physical activity, and substance use between PHAT and control group participants.
Results
PHAT participants had significantly greater knowledge gains but modest behavior changes compared to control group participants.
Discussion
PHAT is a promising intervention to increase knowledge and address selected health behaviors in African American youth.
Translation to Health Education Practice
Future attempts to execute PHAT should continue its emphasis on knowledge building while increasing intervention dosage and modifying length of time for intervention sessions.
doi:10.1080/19325037.2013.798218
PMCID: PMC3743262  PMID: 23957017
25.  Secondary Disclosure of Parental HIV Status Among Children Affected by AIDS in Henan, China 
AIDS Patient Care and STDs  2012;26(9):546-556.
Abstract
For children affected by AIDS, one psychological challenge is whether or how to disclose their parents' HIV status to others (secondary disclosure). The current study, utilizing data from 962 rural children affected by AIDS in central China, examines children's perceptions regarding secondary disclosure (intention of disclosure, openness, and negative feelings) and their association with children's demographic and psychosocial factors. The findings indicated that a high proportion of children preferred not to disclose parental HIV status to others, would not like to tell the truth to others in the situations of having to talk about parental HIV, and also had strong negative feelings about the disclosure. The study findings confirmed that keeping secrecy of parental HIV infection was associated with higher level of negative psychological outcomes (e.g., depression, loneliness, perceived stigma, and enacted stigma), and children's age was strongly associated with both their perceptions of secondary disclosure and psychological measures.
doi:10.1089/apc.2012.0056
PMCID: PMC3426193  PMID: 22845686

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