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Be Proud! Be Responsible!

Blueprints Program Rating: Promising

A six-session group intervention to reduce risky sexual behavior (unprotected sex) leading to potential HIV/STD contraction among adolescents. It teaches self-efficacy and skills that help to avoid risky sexual behavior.

  • Sexual Risk Behaviors
  • STIs

    Program Type

    • After School
    • Cognitive-Behavioral Training
    • Peer Counseling and Mediation
    • School - Individual Strategies
    • Skills Training

    Program Setting

    • Community (e.g., religious, recreation)
    • Hospital/Medical Center
    • School

    Continuum of Intervention

    • Universal Prevention (Entire Population)
    • Selective Prevention (Elevated Risk)

    A six-session group intervention to reduce risky sexual behavior (unprotected sex) leading to potential HIV/STD contraction among adolescents. It teaches self-efficacy and skills that help to avoid risky sexual behavior.

      Population Demographics

      Be Proud! Be Responsible! was designed as an intervention program for minority (African Americans [Jemmott, Jemmott & Fong 1992; Jemmott, Jemmott & Fong 1998; Jemmott et al. 1999], Latinos [Jemmott et al. 2005]) at risk adolescents of urban (inner-city) residency. The program has been also evaluated in suburban areas with a socio-economic and racially mixed sample (Borawski et al. 2009).

      Age

      • Early Adolescence (12-14) - Middle School
      • Late Adolescence (15-18) - High School

      Gender

      • Male and Female

      Gender Specific Findings

      • Male
      • Female

      Race/Ethnicity

      • All Race/Ethnicity

      Race/Ethnicity Specific Findings

      • African American
      • Hispanic or Latino

      Race/Ethnicity/Gender Details

      Most of the studies have targeted African-Americans (Jemmott, Jemmott & Fong 1998, Jemmott et al. 1999) and Latinos (Jemmott et al. 2005) of both genders. It has been studied with a male only (Jemmott, Jemmott & Fong 1992) and a female only sample (Jemmott et al. 2005). Be Proud! Be Responsible! was also evaluated in a racially mixed sample (including whites, Asians, blacks, Latinos) for which the program was not effective (Borawski et al. 2009).

      Poor contraceptive knowledge

      • Individual
      Protective Factors
      • Individual: Clear standards for behavior*

      *Risk/Protective Factor was significantly impacted by the program.

      Be Proud! Be Responsible! is designed to decrease the frequency of risky sexual behavior and related HIV/STD infection among minority (African American, Latino) adolescents. Based on cognitive-behavior theory, the program uses group discussions, videos, games, brain-storming, experiential exercises, and skill-building activities to improve teens knowledge about HIV and STDs, and to increase self-efficacy and skills that might help to avoid risky sexual behavior (e.g., abstinence, condom use). The intervention includes six sessions, of 60-minute length, led by trained facilitators, but can also be implemented within a school setting as part of the curriculum of a required health education class. The program can be implemented in a six-day, two-day, or one-day format.

      Be Proud! Be Responsible! (BPBR) is designed to decrease the frequency of risky sexual behavior and potential HIV/Aids infection by improving adolescent’s knowledge, skills, and attitudes towards safer-sex practices. The program has been implemented as a one-day (Jemmott, Jemmott & Fong 1992, Jemmott et al. 1999; Jemmott et al. 2005) or two-day (Jemmott, Jemmott, Fong 1998) Saturday program. The program has been designed to be culturally appropriate for teens living in low SES, inner-city environments. The program targets minority (mostly African American and Latinos) adolescents (age 11-19) of both genders. Facilitated by trained educators, the interventions involve group discussions, videos, games, brain-storming, experiential exercises, and skill-building activities. BPBR has been implemented with different emphases, focusing on abstinence (reduction of intercourse) vs. safer sex (condom use) (Jemmott, Jemmott, Fong 1998) or skill-based vs. information-based (Jemmott et al. 2005).

      Borawski et al. (2009), extended the target group for BPBR to adolescents from diverse socio-economic and racial/ethnic backgrounds, who attend high schools in urban and sub-urban areas. In this study, the BPBR curriculum was modified to be incorporated into a regular health education class, taught by teachers and school nurses. Students received the intervention in six 50-minute classroom sessions.

      Be Proud! Be Responsible! is informed by the social cognitive theory, the theory of reasoned action, and its extension, the theory of planned behavior.

      Social cognitive theory is the core framework used to explain HIV risk-associated behavior. The theory has two key components: 1) perceived self-efficacy and 2) outcome expectancies. Perceived self-efficacy is defined as the conviction that one can successfully execute the behavior required to produce desired outcomes. Perceived self-efficacy has been shown to affect whether people consider changing their behavior, the degree of effort they invest in changing, and long-term maintenance of behavioral change. Outcome expectancy is defined as a person’s estimate that a given behavior will lead to specific consequences. Only if a person is convinced that for example, condoms are able to effectively prevent HIV/STD infection, will they consider using them. Outcome expectancies are important regarding the effectiveness of safer-sex practices, partner’s approval of safer-sex practices, and hedonistic expectancies (Jemmott and Jemmott 1992).

      The theory of reasoned action suggests that intentions closely correspond to subsequent behavior (Jemmott et al. 1992).

      • Behavioral
      • Cognitive Behavioral

      Out of the five studies evaluating Be Proud! Be Responsible!, four used the same design. Using a randomized controlled trial setup, these studies examined inner-city minority (African-American and Latino) adolescents (age 12 to 19) of both genders (Jemmott, Jemmott, & Fong 1998; Jemmott et al. 1999) or with single sex groups (Jemmott, Jemmott, & Fong 1992; Jemmott et al. 2005). The intervention activities changed only slightly across studies with varying foci (e.g., skill-based vs. information-based; abstinence vs. safer-sex), and varying length (5 to 8 hours) conducted as a Saturday program. Ideally, the program’s effectiveness in reducing risky sexual behavior was evaluated 12-months after intervention (Jemmott, Jemmott, & Fong 1998; Jemmott et al. 2005), but earlier studies only investigated long-term effects at 6-month (Jemmott et al. 1999) or 3-month (Jemmott, Jemmott, and Fong 1992) follow-ups.

      One study did not follow this general approach. Borawski et al. (2009) extended the program to suburban and urban high schools. The authors used a school-based, group-randomized replication approach with students in grades 9 and 10 (N=1,576) of diverse racial background enrolled in 10 large urban and suburban high schools in the Midwest. Schools were paired by location (urban vs. suburban) socioeconomic status and racial composition. This study evaluated program effectiveness 12-months after the intervention.

      Two other studies failed to use a control group or did not study behavioral outcomes but only mediators (Jemmott & Jemmott 1992; Jemmott et al. 1992).

      Out of the five studies that evaluated Be Proud! Be Responsible! four demonstrated that cognitive-behavioral interventions significantly reduced risky sexual behavior compared to a general health control intervention. For example, the HIV/STD intervention reduced unprotected sexual intercourse (Jemmott, Jemmott, & Fong 1992; Jemmott, Jemmott, & Fong 1998; Jemmott et al. 1999; Jemmott et al. 2005), anal intercourse (Jemmott et al. 1999), increased condom use (Jemmott, Jemmott, & Fong 1998), and reduced STD rates (Jemmott et al. 2005). These positive results were reported 3-months (Jemmott, Jemmott, and Fong 1992), 6-months (Jemmott et al. 1999), and 12-months after intervention (Jemmott, Jemmott, & Fong 1998; Jemmott et al. 2005). As for the study design, it has been found that a safer-sex (condom use) intervention is more effective than an abstinence intervention (Jemmott, Jemmott, & Fong 1998), and that a skill-based intervention works better than an information-based intervention (Jemmott et al. 2005).

      However, these encouraging findings were largely obtained under specific study conditions (e.g., small intervention groups, large participation incentive, low-SES inner-city minority adolescents, voluntary Saturday programs, well trained facilitators). Under less favorable conditions, the program did not lead to the desired outcomes. For example, when Be Proud! Be Responsible! was implemented as part of the curriculum for a mandatory health education class, facilitated by teachers in a heterogeneous school setting (students of varying SES and racial background), the program did not reduce risky sexual behavior (Borawski et al. 2009).

      The strongest evidence for the program, compared to a general health control intervention, showed in the following long term (12 – month) effects:

      • The HIV/STD intervention (safer sex) resulted in significantly higher levels of condom use (Jemmott, Jemmott, & Fong 1998).
      • The HIV/STD interventions (skill-based, safer sex) reduced the frequency of unprotected intercourse (Jemmott, Jemmott, & Fong 1998; Jemmott et al. 2005).
      • The HIV/STD intervention (skill-based) reduced multiple sexual partners, and STD rates (Jemmott et al. 2005).

      Weaker evidence for the program, compared to a general health control intervention, showed in the following medium (6-month) and short-term (3-month) effects:

      • The HIV/STD intervention significantly reduced unprotected intercourse, the frequency of anal intercourse and the number of anal sex partners, measured 6 months after the intervention (Jemmott et al. 1999).
      • Adolescents in the HIV intervention reported engaging in less risky sexual behavior (Jemmott, Jemmott, and Fong 1992).

      Significant Program Effects on Risk and Protective Factors (as Mediating Variables):

      • Significant increases in HIV/STD and condom knowledge and safer sex-related skills (impulse control, condom negotiation, condom use).
      • Significant program effects on intentions to have less sexual intercourse (abstinence) and to use condoms more frequently.

      All studies (Jemmott, Jemmott & Fong 1992, Jemmott, Jemmott & Fong 1998, Jemmott et al. 1999, Jemmott et al. 2005, Borawski et al. 2009) report that the Be Proud! Be Responsible! impacted cognitive factors that operate as mediators for safer sex practices important for HIV/STDs prevention. For example, the intervention has been found to increase HIV/STD and condom knowledge, safer sex related skills (impulse control, condom negotiation, condom use), and favorable beliefs regarding condoms (effectiveness, prevention, hedonism) as well as intentions to have less sexual intercourse (abstinence) and to use condoms more frequently.

      Jemmott, Jemmott & Fong (1998):
      This study reported strong program effects on risky sexual behavior of minority adolescents. For example, 3 months after posttest, the safer sex intervention reduced unprotected sexual intercourse by 65% (OR .35) and resulted in a 238% increase (OR 3.38) in consistent condom use.

      Jemmott et al. (2005):
      This study generally found weak effects of the program. For example, after 12 months, the skill-based intervention reduced the number of days of sex without condom by 2.93 days (2.80 vs. 5.73; d=.28; p=.002); reduced the number of days of having unprotected sex while high on drugs or alcohol by 0.40 days (0.10 vs. 0.50; d=.20; p=.02); and reduced the percentage of reported multiple partners in the past 3 months by 10.1% (7.4 vs. 17.5; d=.25; p=.002).

      Borawski et al. (2009):
      No important program effect was observed.

      A number of studies do not report effect sizes (Jemmott, Jemmott & Fong 1992, Jemmott et al. 1999).

      The results from Be Proud! Be responsible! may be generalized to African American (Jemmott, Jemmott & Fong 1998, Jemmott et al. 1999) and Latino (Jemmott et al. 2005) adolescents (age 11-19). The program has shown to be effective for both genders and was implemented as a male-only (Jemmott, Jemmott & Fong 1992) and female-only (Jemmott et al. 2005) intervention.

      For the main study (Jemmott, Jemmott & Fong 1998):

      • Selection bias is possible since parental consent was required (biased towards children of caring parents) and a relatively large monetary incentive was offered (may attract especially poor individuals).
      • The actual intervention program is not described in detail.
      • No effort to validate self-reports with actual behavior patterns.

      Across the other studies:

      • A problem for all studies is that self-reporting of risky sexual behavior might not correctly represent actual behavior.
      • Selection bias might be a problem for the generalizability. Either only a limited fraction of individuals eligible participated (Jemmott et al. 2005) or relatively large monetary incentives were offered for participation (Jemmott, Jemmott, & Fong 1998, Jemmott et al. 2005).
      • The four studies that showed a significant effect for Be Proud! Be Responsible! (Jemmott, Jemmott, & Fong 1998, Jemmott et al. 2005, Jemmott et al. 1999, Jemmott, Jemmott & Fong 1992) were all led by a single individual (John B. Jemmott). The only study led by another researcher (Borawski et al. 2009), did not find significant long-term program effects.
      • Delayed effects of the intervention were observed for two studies. Results become significant only at 6-months (Jemmott et al. 1999) and 12-months (Jemmott et al. 2005) after treatment.
      • Two studies failed to test for baseline equivalence (Jemmott, Jemmott & Fong 1992, Jemmott et al. 1999).
      • Two studies assessed long-term effects only 3-months (Jemmott, Jemmott & Fong 1992), or 6-months (Jemmott et al. (1999) after the intervention.

      • Blueprints: Promising

      Borawski, E.A., Traple, E.S., Adams-Tufts, K., Hayman, L.L., Goodwin, M.A. & Lovegreen, L.D. (2009). Taking Be Proud! Be Responsible! to the suburbs: A replication study. Perspectives on Sexual and Reproductive Health, 41(1),12-22.

      Jemmott, L. S., & Jemmott, J. B. III (1992). Increasing condom-use intentions among sexually active inner-city adolescent women: Effects of an AIDS prevention program. Nursing Research, 41, 273-278.

      Jemmott, J.B. III, Jemmott, L.S., Braverman, P.K., & Fong G.T. (2005). HIV/STD risk reduction interventions for African American and Latino adolescent girls at an adolescent medicine clinic: A randomized controlled trial. Archives of Pediatric Adolescent Medicine, 159, 440-449.

      Jemmott, J.B., Jemmott, L.S., & Fong, G.T. (1998). Abstinence and safer sex HIV risk-reduction interventions for African American adolescents. Journal of the American Medical Association, 279(19), 1529-1536.

      Jemmott, J. B., Jemmott, L. S., & Fong, G. T. (1992).Reductions in HIV risk-associated behaviors among black male adolescents: Effects of an AIDS prevention initiative. American Journal of Public Health, 82(3), 372-377.

      Jemmott J.B., Jemmott, L.S., Fong, G.T., & McCaffree, K. (1999). Reducing HIV risk-associated sexual behavior among African American adolescents: Testing the generality of intervention effects. American Journal of Community Psychology, 27(2), 161-187.

      Jemmott, L.S., Jemmott, J.B. III, & McCaffree, K.A. (1996). Be Proud! Be Responsible! Strategies to empower youth to reduce their risk for AIDS, Curriculum Manual. New York: Select Media.

      Jemmott, J. B., Jemmott, L. S., Spears, H., Hewitt, N., & Cruz-Collins, M. (1992). AIDS information, self-efficacy, hedonistic expectancies, and condom-use intentions: Testing the information alone hypothesis. Journal of Adolescent Health, 13, 512-519.

      ETR
      100 Enterprise Way. Suite G300
      Scotts Valley, CA 95066
      Tel: (800) 620-8884
      Fax: (831) 438-4284
      Main Website: etr.org
      Program Website: www.etr.org/ebi/programs/be-proud-be-responsible/

      Study 1

      Jemmott, J.B., Jemmott, L.S., & Fong, G.T. (1998). Abstinence and safer sex HIV risk-reduction interventions for African American adolescents. Journal of the American Medical Association, 279(19), 1529-1536.

      Study 2

      Jemmott, J.B. III, Jemmott, L.S., Braverman, P.K., & Fong G.T. (2005). HIV/STD risk reduction interventions for African American and Latino adolescent girls at an adolescent medicine clinic: A randomized controlled trial. Archives of Pediatric Adolescent Medicine, 159, 440-449.

      Jemmott, J.B., Jemmott, L.S., & Fong, G.T. (1998). Abstinence and safer sex HIV risk-reduction interventions for African American adolescents. Journal of the American Medical Association, 279 (19), 1529-1536.

      Evaluation Methodology

      Design:
      Recruitment:
      African American adolescents from the 3 middle schools who had signed parent or guardian consent forms were eligible to participate (N=827). Recruitment relied on announcements in assemblies, classrooms, cafeterias, and letters to parents. The adolescents volunteered for the “Spruce Adolescent Health Promotion Project.” The teens were offered $100 for participating: $40 at the end of the 2-session intervention and an additional $20 for each of the 3 follow-ups (3, 6, 12 months after intervention). Of those invited, 659 adolescents (80%) of eligible adolescents consented to participate in the study.

      Study type/Randomization/Intervention:
      These adolescents were stratified by gender and age, and based on computer-generated random number sequences, were assigned to 1 of 3 interventions (RCT): an abstinence HIV intervention, a safer-sex HIV intervention, or a health promotion intervention that served as the control group. They were also randomized into groups of 6 to 8 adolescents led by (1) 1 male or female adult facilitator or (2) 2 male, 2 female, or 1 male and 1 female peer co-facilitators. Each intervention consisted of 8 1-hour modules divided equally over 2 consecutive Saturdays. Designed to be educational, but entertaining and culture sensitive, each intervention involved group discussions, videos, games, brainstorming, experiential exercises, and skill-building activities. The abstinence intervention emphasized the reduction of intercourse frequency while the safer-sex intervention emphasized the importance of using condoms. The control group received a health promotion intervention that focused on behaviors associated with risk of cardiovascular disease, stroke, and certain cancers.

      Assessment/Attrition:
      Participants in all 3 groups completed confidential questionnaires before intervention, immediately after intervention, and at 3-, 6-, and 12-month follow-ups. Attrition was low: About 96.5% of the original participants attended the 3-month follow-up, 94.4% attended the 6-month follow-up, and 92.6% attended the 12-month follow-up.

      Sample characteristics:
      The participants were African American adolescents (mean age 11.8 years) recruited from sixth and seventh grade classes of 3 middle schools serving low-income African American communities in Philadelphia, PA. About 53.0% were female and 26.8% lived with both of their parents. On the pre-intervention questionnaire, 25.2% of respondents reported ever having sexual intercourse and 15.4% of respondents reported having sexual intercourse in the previous 3 months.

      Measures:
      Validity of measurement:
      A number of steps were taken to increase the measurement validity. To reduce potential memory problems, the period of self reported behavior was short (3 months). The data were collected by proctors who were blind to the participant’s intervention group. Proctors stressed the importance of responding honestly (tried to tap into “social responsibility motives”). Participants signed an agreement pledging to answer the questions honestly. Participants were ensured that data was treated confidentially.

      Primary outcome measures:
      The primary outcomes were self-reported sexual behaviors in the previous 3 months, including sexual intercourse, condom use, and unprotected sexual intercourse. Frequency of sexual intercourse was the number of days on which the participants had sexual intercourse. Frequency of condom use was rated on a scale from 1 (indicating never) to 5 (indicating always). Frequency of unprotected sexual intercourse was the number of days on which the participants had sexual intercourse without using a condom.

      Secondary outcome measures (mediators):
      Based on the theory of reasoned action, the theory of planned behavior, and social cognitive theory, a number of variables measured potential mediators of the effects of the interventions.

      Safe-sex intervention:

      • Condom-use prevention beliefs (5 items, Cronbach’s alpha=.76)
      • Condom-use hedonistic beliefs (7 items, alpha=.74)
      • Condom availability beliefs (5 items, alpha=.75)
      • Condom-use technical skills beliefs (3 items, alpha=.76)
      • Condom-use impulse control beliefs (3 items, alpha=.73)
      • Condom-use negotiation beliefs (3 items, alpha=.77)
      • Condom-use self-efficacy (1 item)
      • Intention to use condoms (3 items, alpha=.75)
      • Knowledge specific to condom use (6 items, alpha=.53)

      Abstinence intervention:

      • Abstinence prevention beliefs (2 items, alpha=.57)
      • Goal attainment beliefs (2 items, alpha=.80)
      • Attitude towards having sexual intercourse (1 item)
      • Intention to have sexual intercourse in next 3 months (1 item)

      All participants:

      • HIV risk reduction knowledge (34 items, alpha=.87)
      • Participants' evaluation of the intervention (10 items, alpha=.84)
      • Evaluation of facilitator (1 item)
      • Evaluation of educational value of the intervention (3 items, alpha=.80)
      • Extent to which participants would recommend the program (1 item)
      • Marlowe-Crowne Social Desirability Scale

      Analysis:
      To compare the difference between self-reported sexual behavior between intervention and control groups, a two-tailed test (alpha=.05) was used. Analysis of covariance as well as logistic regression models were used for hypothesis testing, controlling for baseline scores. Baseline scores were not used as controls for hypotheses regarding condom use because of the small number of participants who reported sexual intercourse at both baseline and follow-up.

      Linear regression models were used to predict frequency of unprotected sexual intercourse after the outcome variable was log-transformed (x+1) to account for the skewed distribution.

      A series of analyses of variance and chi-square tests on baseline measures were conducted to determine whether the randomization procedures were successful. Chi-square tests and t tests were used to analyze attrition.

      Intention-to-treat: The study used an intention-to-treat approach in which participants are analyzed in their original randomized group regardless of the number of intervention sessions they attended.

      Outcomes

      Implementation fidelity : Each intervention was pilot tested, highly structured, and was implemented by facilitators who used intervention manuals.

      Facilitator training: The 25 adult facilitators (10 men and 15 women) were African Americans (mean age, 39.5 years). The facilitators had, on average, a master’s degree and 8 years of experience working with African American adolescents. The adult facilitators were stratified by age and gender and randomly assigned to receive 2.5 days of training to implement one of the three interventions. The peer facilitators were 45 Philadelphia high school students (mean age, 15.6 years). The peer facilitators were selected based on letters of recommendation and interviews (about 56% were female). They participated in a 3-day intensive leadership training retreat on the basic skills of small-group facilitation. They were then stratified by age and gender and randomly assigned to receive 4 days of training to implement 1 of the 3 interventions.

      Implementation: Several procedures were used to monitor the interventions. The facilitator trainers continually, and unobtrusively, monitored how each facilitator delivered the intervention. Facilitators reported their reactions and participants’ reactions to the intervention and recorded any intervention activities they did not cover. In addition, participants’ confidential evaluative ratings of the interventions were collected.

      Baseline Equivalence : The analyses of variance revealed a significant difference among groups in pre-intervention condom use knowledge (P=.05). Contrasts indicated that pre-intervention condom-use knowledge was greater in the safer-sex group than in the control group (P=.02). No other differences among groups on pre-intervention measures of conceptual variables, sexual behavior, or demographic variables were significant. The authors included the variable for pre-intervention condom-use knowledge as covariate in the regression models.

      Differential attrition : The intervention groups did not differ significantly in the percentage of participants remaining in the follow-ups. Completers differed significantly on few preintervention variables. Completers scored higher in condom prevention beliefs, scored higher in abstinence prevention beliefs, and scored lower on condom use knowledge compared to attritors. However, no significant interaction of these variables with the intervention measure was observed in predicting self-reported sexual behaviors in the previous 3 months. Thus, attrition did not appear to bias the results.

      Posttest : The post-test revealed that the intervention was successful for a number of conceptual variables (mediators).

      Abstinence intervention: Out of 4 tests for abstinence-related conceptual variables, all were significant. The adolescents in the abstinence group believed more strongly (p<.05) that practicing abstinence would prevent pregnancy and AIDS, expressed less favorable (p<.05) attitudes toward sexual intercourse, and reported weaker (p<.05) intentions of having sexual intercourse in the next 3 months than did those in the control group or the safer-sex group. Adolescents in the abstinence group also believed more strongly (p<.05) that practicing abstinence would help them achieve their career goals than did those in the control group, but did not differ (p=.24) from those in the safer-sex group.

      Safer-sex intervention: Out of 9 tests for condom use-related conceptual variables, 6 were significant. Immediately after the intervention, the adolescents in the safer-sex group scored significantly (p<.05) higher in condom use knowledge; believed more strongly (p<.05) that condoms can prevent pregnancy, STDs, and HIV; believed more strongly (p<.05) that using condoms would not interfere with sexual enjoyment; and expressed greater (p<.05) confidence that they could have condoms available when they needed them than did those in the control group or the abstinence group. Adolescents in the safer-sex group reported greater confidence (p<.05) that they could exercise sufficient impulse control to use condoms and greater (p<.05) self-efficacy for using condoms than did those in the control group, but not more than those in the abstinence group. Adolescents in the safer-sex group did not differ from those in the other 2 groups in technical skills belief, negotiation skills belief, or condom-use intentions.

      Adolescents in both HIV-prevention groups scored significantly (p<.05) higher in HIV risk-reduction knowledge than did those in the control group. However, adolescents in the safer-sex group scored even higher (p<.05) than did those in the abstinence group.

      Long-term effects : The main outcome of interest was a change in risky sexual behavior. Since behavior changes take time to manifest, the behavioral variables were not measured at post-test but rather were evaluated using three follow up questionnaires (3, 6, 12 months after the posttest).

      Abstinence intervention: Adolescents in the abstinence group were significantly less likely to report having sexual intercourse in the 3 months after the intervention than were those in the control group (odds ratio [OR], 0.45). This effect was stronger for adolescents who were sexually inexperienced at pre-intervention (interaction: sexual experience x group). However, at the 6 and 12 month follow up, the reductive effect of the abstinence intervention was lost.

      Safer-sex intervention: Adolescents in the safer-sex intervention were significantly more likely to report consistent condom use at the 3-month follow-up than were those in the control group (OR, 3.38). Self-reported frequency of condom use was also significantly higher in the safer-sex group than in the control group. Adolescents in the safer-sex group were less likely to report having unprotected sexual intercourse in the previous 3 months than were those in the control group (OR, 0.35). Adolescents in the safer-sex group also reported fewer days on which they had unprotected sexual intercourse than did those in the control group. The latter two effects were significantly stronger for adolescents who were sexually experienced at pre-intervention (interaction: sexual experience x group). At the 6-month follow-up the impact of the intervention was still strong and individuals in the safer-sex group reported significantly more frequent condom use compared to the control group. Among participants who reported pre-intervention sexual experience, the safer-sex intervention caused significantly less self-reported sexual intercourse than did the control or abstinence intervention and less self-reported unprotected sexual intercourse than did the control group. These three effects remained significant at the 12 month follow-up.

      Jemmott, J.B. III, Jemmott, L.S., Braverman, P.K., & Fong G.T. (2005). HIV/STD risk reduction interventions for African American and Latino adolescent girls at an adolescent medicine clinic: A randomized controlled trial. Archives of Pediatric Adolescent Medicine, 159, 440-449.

      This study differs from Jemmott, Jemmott & Fong (1998) in that the subjects were recruited from an adolescent health clinic and not from a school. In this study, subjects were both of African American and Latino ethnicity, while Jemmott, Jemmott & Fong (1998) focused only on African Americans. Also, the study population was slightly older - 12-19 years of age (mean 16 years), compared to the 6th and 7th graders (mean 12 years) studied by Jemmott, Jemmott & Fong (1998). Further, the focus was on comparing a skill-based vs. pure information-based intervention while Jemmott, Jemmott & Fong (1998) investigated differences between an abstinence and a safer sex (condom use) intervention. While Jemmott, Jemmott & Fong (1998) focused on differential effects between sexually experienced and sexually inexperienced adolescents, Jemmott et al. (2005) focused only on sexually experienced youth.

      Evaluation Methodology

      Design:
      Sample selection: African American and Latino adolescent girls were eligible to participate if they (1) were patients at the adolescent medicine clinic, (2) were sexually experienced, (3) were not pregnant, (4) were 12 to 19 years of age, (5) could read and speak English, and (6) did not plan to move from the area of the clinic. During the adolescents’ biannual STD screening visit, clinicians referred eligible adolescents to the site coordinator who informed them about the study and scheduled interested adolescents to participate. Research subjects were reimbursed up to $120 for participating.

      Attrition: Of the 1150 adolescents assessed for eligibility, only 682 (59%) adolescents participated in the study. However, for randomized study subjects, little attrition was reported. About 97.6% of the adolescents attended at least 1 follow-up; 94.3% attended the 3-month follow-up; 92.8% attended the 6-month follow-up, and 88.6% attended the 12-month follow-up.

      Study type/Randomization/Intervention: The study was a randomized controlled trial (RCT) conducted at the hospital where the adolescents were recruited. Participants were stratified by age, and based on computer-generated random number sequences, they were assigned to 1 of the following 3 interventions: skill-based HIV/STD intervention, information-based intervention, or health-promotion control intervention. Each intervention involved 250 minutes of group discussions, videotapes, games, and experiential exercises implemented in a single session with 2 to 10 participants (mean = 5.3 participants).

      Assessment: The adolescents completed confidential self-administered questionnaires pre-intervention, immediately after the intervention, and at the 3-, 6-, and 12-month follow-ups.

      Sample characteristics: The participants were sexually experienced African American (n=463) and Latino (n=219) adolescent girls, 12 to 19 years of age (mean age, 15.5 years) who were family planning patients at the adolescent medicine clinic in a children’s hospital serving a low-income, inner-city community in Philadelphia, PA. Thus, study subjects showed some concern for the consequences of sexual behavior prior to the intervention. Of the Latinos, 92.7% were Puerto Rican. The participants had volunteered for the “Women’s Health Project” designed to reduce the chances that African American and Latino adolescent girls would develop devastating health problems, including cardiovascular diseases, cancer, and AIDS.

      Measures:
      Validity: The proctors emphasized to participants the importance of responding honestly and assured them that their responses were confidential. Participants signed an agreement pledging to answer the questions honestly, a procedure that has been shown to yield more valid self-reports on sensitive issues. To reduce the likelihood of demand from giving their responses to the intervention facilitators, proctors blind to the participants’ intervention assignment collected the questionnaire data.

      Primary outcome measures:
      The primary outcome measure was the number of days on which the adolescent reported having unprotected sexual intercourse in the previous 3 months.

      Secondary outcome measures (mediators):
      Other sexual risk behaviors
      : Participants reported the number of sexual partners, the number of days on which they had sexual intercourse while high on drugs or alcohol in the previous 3 months, and the number of days on which they had unprotected sexual intercourse while high on drugs or alcohol in the previous 3 months.

      STD prevalence: As patients in the clinic, all the participants underwent biannual STD screening by clinicians who were blind to their intervention assignment. This allowed for obtaining sexually transmitted disease data from medical records which were used as the measure of STD presence.

      Mediator measures: Several variables from the theory of reasoned action, the theory of planned behavior, and social cognitive theory that might mediate the efficacy of the interventions were measured with 5-point Likert scales:

      • Intention to use condoms (3 items, alpha=.86)
      • Condom use hedonistic beliefs (7 items; alpha=.84)
      • Beliefs regarding partner’s approval of using condoms (1 item)
      • Condom use technical skills beliefs (3 items, alpha=.65)
      • Condom use impulse control beliefs (2 items; alpha=.61)
      • Condom use negotiation beliefs (3 items; alpha=.82)
      • HIV/STD risk-reduction knowledge (48 true-false items)
      • Knowledge specific to condom use (6 true-false items)

      Intervention evaluation:

      • Evaluation of the intervention overall (5 items; alpha=.87)
      • Evaluation of learning success (3 items; alpha=.83)
      • Extent to which participants would recommend the intervention to others (1 item)
      • Marlowe-Crowne Social Desirability Scale

      Analysis: Hypotheses regarding primary and secondary outcomes were tested in analyses that used planned contrasts of pre-specified hypotheses and 2-tailed tests, controlling for baseline scores. Analyses of counts of sexual behaviors were performed using Poisson regression. Analyses of conceptual mediator variables used analyses of covariance. Hypotheses regarding STDs and sexual behaviors measured with dichotomous variables were tested using logistic regression analyses.

      Validity tests: Chi-square tests, analyses of variance, and Poisson regression analyses were performed to identify significant differences among conditions on pre-intervention measures. Chi-square and t-tests were performed to analyze attrition.

      Intention-to-treat: The study gathered and used data on all subjects who were randomized.

      Outcomes

      Implementation fidelity: The facilitators were 14 African American women (mean age = 38.2 years) who had at least a baccalaureate degree and experience working with inner-city adolescents. They received an 8-hour facilitator training. Implementation fidelity was emphasized during the training sessions and before each intervention session when the facilitators met with the project coordinator.

      Baseline Equivalence: The authors conducted a statistical comparison of all demographic characteristics, sexual behavior measurements, conceptual mediator variables, and STD test results at baseline. No statistically significant differences were observed.

      Differential attrition: The intervention conditions did not differ significantly in the percentage of adolescent participants who attended at least 1 follow-up, 2 follow-ups, or all 3 follow-ups. Across all measured characteristics, 4 significant differences between returnees and nonreturnees were observed. Nonreturnees reported more frequent intercourse while intoxicated (mean = 3.44 vs. 0.40, P<.001) and more unprotected sexual intercourse while intoxicated than did returnees (mean = 0.94 vs. 0.24, P<.001). Latinos compared with African Americans were less likely to return (95.9% vs. 98.5%, P=.04). Adolescents who did not live with their mother were less likely to return than were those who lived with their mother (93.9% vs. 98.7%, P=.001). No measures were taken to account for differential attrition.

      Posttest (mediators): Both HIV/STD risk-reduction interventions had significant effects on the conceptual mediator variables, measured directly after the intervention.

      Skill-based intervention: Female adolescents who received the skill based intervention scored higher in post-intervention HIV/STD knowledge (d=0.62; P<.001), condom use knowledge (d=0.59; P<.001), intentions (d=0.21; P=.008), hedonistic beliefs (d=0.28; P<.001), sexual partner approval (d=0.20; P=.009), technical skills beliefs (d=0.20; P=.01), and impulse control beliefs (d=0.19; P=.02) than did those who received the health-promotion control intervention. Out of 8 tests, 7 were significant.

      Skill vs. information: In addition, the skill-based intervention caused significantly greater increases in condom use knowledge than did the information-based intervention (d=0.30; P<.001). No other differences on conceptual mediator variables between the skill- and information-based interventions were statistically significant. Thus, out of 8 tests, only 1 was significant.

      Information-based intervention: Information-based intervention participants scored higher in HIV/STD knowledge (d=0.72; P<.001), condom use knowledge (d = 0.30; P<.001), intentions (d=0.29; P<.001), hedonistic beliefs (d=0.31; P<.001), technical skills beliefs (d=0.15; P=.049), and impulse control (d=0.19; P=.02) than did health-promotion control intervention participants. Out of 8 tests, 6 were significant.

      Long-term effects: Overall, the skill-based intervention had significant effects on risky sexual behaviors while the information-based intervention did not significantly reduce risky behaviors compared to the control group. However, it is important to note that the significant difference between skill intervention and control emerged for most outcome variables only at the 12-month follow-up. The numbers indicated that although the general health treatment (control) decreased sexual behavior, the effect was lost over time while the positive effect of the skill intervention remained. To illustrate, the number of days of sex without condom use in the past 3-months increased for the control group across time (3mo=2.71; 6mo=3.47; 12mo=5.73) while it stayed constant for the skill based intervention (3mo=2.58; 6mo=2.99; 12mo=2.80). A significant positive effect at the 12-months follow-up, comparing the skill based intervention to the control intervention, was observed for the following outcome measures:

      • No. of days of sex without condom use in the past 3 months (2.80 vs. 5.73; d=.28; p=.002)
      • No. of partners in the past 3 months (0.93 vs. 1.06; d=.17; p=.04)
      • Percentage reporting multiple partners in the past 3 months (7.4 vs. 17.5; d=.25; p=.002)
      • No. of days of having unprotected sex while high on drugs or alcohol in the past 3 months (0.10 vs. 0.50; d=.20; p=.02)
      • Percentage testing positive for an STD (10.8 vs. 17.4; d=.18; p=.05)
      • No differences were observed at the 12-month follow-up for self-reported frequency of sexual intercourse while intoxicated. However, for this outcome (as the only outcome) a significant positive short term effect was observed after 3 months (0.11 vs. 0.29; d=0.18; P=.03) and after 6 months (0.10 vs. 0.36; d=0.23; P=.005).

      Other outcomes:
      Participant evaluation
      : Participants liked the information-based intervention better than the health-promotion control intervention or the skill-based intervention.
      African Americans vs. Latinos: Analyses testing whether the efficacy of the interventions was different with African Americans and Latinos revealed no significant differences on sexual risk behavior or the STD rates as the main outcomes of interest. However, few significant differences were reported for mediator variables.
      Social desirability: Social desirability scores did not interact with intervention condition to influence sexual behavior at any of the follow-ups.

      Limitations:

      • Selection bias might be a problem for the generalizability of the findings. Only 59.3% of the eligible adolescents (682 of 1150) participated in the study and differed on a few characteristics (age, ethnicity) from eligible nonparticipants.
      • Delayed effect of the intervention (results become significant only 12 months after treatment).
      • Self-reporting of risky sexual behavior might not correctly represent actual behavior.
      • Differential attrition existed, but the models failed to adjust for the potential bias.

      Borawski, E.A., Traple, E.S., Adams-Tufts, K., Hayman, L.L., Goodwin, M.A. & Lovegreen, L.D. (2009). Taking Be Proud! Be Responsible! to the suburbs: A replication study. Perspectives on Sexual and Reproductive Health, 41 (1),12-22.

      This replication study implemented the program at urban and suburban high schools as part of the school activities. Thus, compared to the original study (Jemmott, Jemmott & Fong 1998), this study shifts the focus away from inner-city minority youth. The original intervention was executed in a nonschool environment (Saturday program) and in small groups (6-8 individuals), while Borawski et al. (2009) tested the program in a school setting, taught by teachers and other school personnel. The school setting differs in that it provides a less controllable environment in which program fidelity is not guaranteed and where participants include young people who may be unlikely to volunteer for a weekend program. The intervention in this study was delivered in six small (50-minute) modules while the original intervention was delivered in two consecutive Saturday programs.

      The intervention curriculum in this study was slightly changed and adjusted compared to the original curriculum (Jemmott, Jemmott, & McCaffree 1996) in that a condom use skill activity was dropped, the term “inner-city” was changed to “community,” and a message-specific booster session was implemented between the 4 and 12 month follow ups. Finally, the adolescents in the study were significantly older than those in the original studies.

      Evaluation Methodology

      Design:
      Sample selection: Five pairs of high schools were recruited; pairs were selected on the basis of the schools’ location (inner city, suburb) and similarity regarding community socioeconomic status and racial composition of the student body. Two pairs were from an urban school district in an area of low socioeconomic status; one pair had predominantly black student bodies, and the other had mixed student bodies. Two pairs of schools were from inner-ring suburbs; one pair was in an area of low socioeconomic status and had predominantly white students, and the other was in an area of moderate socioeconomic status and had racially mixed populations. The last pair of schools was from outer-ring suburbs; both schools were in areas of high socioeconomic status and had predominantly white populations. Of each pair, one school implemented the Be Proud! Be Responsible! intervention while the other school implemented the general health control intervention. Thus, the study population comprised ninth- (46%) and tenth-grade (54%) students enrolled between the years 2000 and 2002 in mandatory health education classes in 10 high schools in a midsize, metropolitan area in the Midwest.

      Attrition: Due to a number of reasons (expelled, transferred, or no longer attended school), the sample was reduced from 1,576 eligible individuals to 1,357 adolescents (86%). Of these, 99% completed the immediate posttest, 97% completed the 4-month follow-up and 92% completed the 12-month follow-up.

      Study type/Randomization/Intervention/Follow-up: Schools agreed to be randomly assigned to intervention or control curriculum and to recruit all teachers responsible for teaching health to be trained in their respective curriculum. A two-stage, double blinded randomization procedure was used to randomize each pair.

      The intervention was delivered by trained teacher and nurse facilitators (majority was female and white), using six 50-minute modules that include a variety of developmentally appropriate teaching methods, such as group discussions, role model stories depicted in videos, interactive exercises and role playing. The three core themes of the intervention curriculum were the role of sexual responsibility and accountability, the importance of having a sense of community, and the role of pride in making safer sexual choices. The intervention was focused on abstinence as the best way to avoid HIV/STD contraction and unwanted pregnancies, and recommended safer-sex practices in case the adolescents decided to be sexually active.

      Three adjustments to the original curriculum were made:

      • Because of objections from several urban as well as suburban schools, one 10-minute activity (How to make condoms fun and pleasurable) in the condom-use skills session was dropped.
      • The ethnocentric and urban focus of the curriculum was retained across all schools, except that the term “inner-city” was replaced with “community.”
      • Both intervention and control groups received a message-specific booster session between 4 and 12 months after the initial programs. Students in the intervention arm attended an assembly featuring a young HIV-positive woman, while students in the control arm attended an assembly in which a speaker discussed healthy eating and exercise.

      Data were collected from students via confidential, self-administered questionnaires at four time points: prior to the intervention (baseline), immediately following the intervention (post-test), and 4 and 12 months later.

      Sample characteristics:
      The research subjects were 52% female, 61% lived with two parents, and in 60% of the cases, at least one parent had some postsecondary education. Students lived in neighborhoods with an average poverty rate of 15%. Of the study population, 50% were white, 36% black, 12% Hispanic, and 3% identified with another racial/ethnic group. 38% of all participants had had sexual intercourse by baseline. 67% of sexually experienced students had had sex in the three months preceding the study, and 60% of this group had always used a condom in this period.

      Measures:
      Primary outcome measures:
      The primary outcome measures were a number of questions regarding sexual behavior patterns. The questions asked:

      • Whether students had ever had sexual intercourse
      • Whether they had talked to a nurse or doctor about a sex-related issue
      • Whether they carried condoms or had quick access to them
      • Whether students had had intercourse within the past three months
      • Whether students had avoided sex in the last three months because they did not have a condom
      • How often they had drunk alcohol or used drugs before having sex
      • How often they had used condoms when they had had sex in the past three months

      Secondary outcome measures (mediators):
      The intervention was positioned to influence sex-related behaviors both directly and indirectly through cognitive processes that are assumed to mediate behavioral change. Five categories of sex-related cognitive mediators were included in the study: knowledge, efficacy, participant’s beliefs, perceived peer beliefs, and behavioral intention.

      Knowledge (additive scale of yes/no items):

      • Knowledge of condoms (5 items)
      • Knowledge of HIV/STDs (7 items)
      • Health promotion knowledge (9 items)

      Efficacy:

      • Impulse control (2 items, alphas .81-.87 across time points)
      • Condom negotiation skills (3 items, alphas .60-.64)
      • Condom technical skills (3 items, alphas .67-.72)

      Beliefs:

      • Condom use belief (3 items, alphas .86-.89)
      • Condom use hedonistic beliefs (3 items, alphas .55-.61)
      • Condom use prevention belief (2 items, alphas .42-.64)
      • Abstinence belief (4 items, alphas .78-.80

      Perceived peer beliefs:

      • Acceptability of sexual activity (3 items, .64-.72)
      • Condom use (3 items, .85-.87)

      Intentions:

      • Intention to have sexual intercourse (3 items, .90-.94)
      • Intention to use condom should they have sex (1 item)

      Demographics:

      • Age, gender, ethnicity, living arrangement, parents’ education were assessed at baseline.
      • A SES measure for the neighborhood of residency was generated by using proportion of households in the neighborhood that lived below the federal poverty line based on the 2000 census.
      • In addition the proportion of curriculum sessions attended was measured.

      Facilitator performance and student assessment:
      Students rated:

      • How well their facilitator presented the material and how comfortable the facilitator was in doing so
      • How much the curriculum challenged how students thought about their health
      • How comfortable students were with the activities
      • How the classroom was organized
      • How seriously their peers regarded the curriculum

      Analysis:
      To test the impact of the curriculum on the change in sexual behavior, the authors used general linear models with group membership as the main predictor, controlling for baseline characteristics. In order to account for intragroup (school) correlation, they used STATA’s cluster option, which adjusts the standard errors of estimates but does not affect the estimates themselves. Using stratified analyses, the authors explored the intervention effects by gender, location, and race.

      Intention-to-treat: The study gathered and used data on all subjects who were randomized and completed the surveys.

      Outcomes

      Implementation fidelity : Each intervention facilitator received a 2-day training session on how to implement the intervention curriculum. Facilitators were instructed on how to complete a detailed checklist for each session, including rating their command of the materials, their rapport with the students, and the extent to which the material was covered. In addition, each facilitator was observed at least once during the six curriculum sessions to assess his/her fidelity to the curriculum. However, curriculum fidelity was limited since on average only 70% of the original intervention activities were implemented.

      Baseline Equivalence : The two groups had similar scores for the cognitive mediators. However, a few small but significant differences between the intervention and control groups at baseline were observed. Differences were observed in gender, ethnicity, neighborhood SES, and session attendance. To control for possible confounding, these variables were included as covariates in all models.

      Differential attrition : The rates of follow-up did not differ between the intervention and control groups. However, compared with students who completed every questionnaire, students lost to follow-up were older, more likely to be male, non-white, less likely to live with two parents, attended fewer sessions, and lived in lower SES neighborhoods.

      Posttest :
      Mediators
      : For the mediator variables, significant effects were found for 7 out of 11 predictors. The intervention group scored higher on condom and STD knowledge, reported better impulse control, condom negotiation skills, condom technical skills, and believed more strongly that condom use effectively prevents pregnancies and HIV/STD contraction. Further, the intervention group reported higher intentions to use a condom.

      Long-term effects :
      Main outcome
      : None of the sexual risk behavior variables differed significantly between the intervention and control group. The intervention had a significant effect on only one out of twenty behavioral outcomes. At the four-month follow-up, among students who had been sexually inexperienced at baseline, a higher proportion of intervention students reported having talked to a health professional about sex-related matter.

      Mediators: For the mediator variables only condoms and STDs knowledge was significantly higher for the intervention vs. control group after 12 months. Condom negotiations skills and condom technical skills were higher for the intervention compared to the control group after 4 months but lost significance at the 12 month follow up.

      The stratified analysis revealed some gender, ethnicity, and location effects on mediators:
      Gender effects: The largest gender differences were found in the area of self-efficacy, for which males in the intervention group scored higher than the control group. Regarding behavioral intentions, female intervention students reported significantly lower intentions to have sex than their control peers.

      Effects by geographic location: The effects for both condoms and STD knowledge as well as for condom technical skills and condom negotiation skills were stronger and lasted longer for suburban than for urban schools when comparing the intervention group to the control group.

      Ethnicity effects: The intervention had a stronger and sustained impact on condom knowledge among white students, while a stronger and longer lasting impact was observed for STD knowledge among black students. Also, only significant for whites, the intervention group showed higher scores on condom negotiation and condom technical skills at four months compared with the control.

      Other outcomes: Many differences emerged in student’s evaluation of the intervention. On average, students receiving the BPBR curriculum gave higher ratings to their facilitators than did their control peers; they also gave a higher score to the extent to which the curriculum made them think about their health. Finally, when compared with the control group, BPBR students reported that their fellow classmates took the material more seriously and that the classroom was more orderly.

      Limitations:

      • Curriculum fidelity was limited since on average only 70% of the original intervention activities were implemented.
      • Randomization was done at the school level but the analysis (statistical models) is done at the individual level. The study controlled for clustering at the school level but the use of a two-level model structure would have been more appropriate.
      • Limited comparability due to variations in program delivery (e.g., number of sessions, group size).
      • Few behavioral benefits at 12-months.

      Jemmott J.B., Jemmott, L.S., Fong, G.T., & McCaffree, K. (1999). Reducing HIV risk-associated sexual behavior among African American adolescents: Testing the generality of intervention effects. American Journal of Community Psychology, 27 (2), 161-187.

      This study is a close replication of Jemmott, Jemmott, and Fong (1998). For example, both studies recruited African American adolescents of similar age range and both genders. However, a few differences deserve mentioning: this study was fielded in a different geographical setting (New Jersey vs. Philadelphia), and the intervention was delivered in a single session (5 hours) as compared to a two-Saturdays program. While Jemmott, Jemmott, and Fong (1998) compared abstinence and risky sex reduction interventions, this study tested the matching hypothesis, that is, whether effects of the intervention were enhanced when the characteristics of the participants and facilitators (gender, race) were matched.

      Methodology

      Design:
      Recruitment: The study was conducted in New Jersey, which ranks high among states in reported AIDS cases and new infections. The participants were 496 African American adolescents from Trenton, an urban, low SES, high STD risk area of New Jersey. The adolescents volunteered in response to public school announcements by project staff during 7th- and 8th-grade assemblies or lunch periods.

      Attrition: Of the original 496 participants, 480 (96.8%) attended the 3-month follow-up assessment and 460 (92.7%) attended the 6-month follow-up assessment.

      Study type/randomization: The authors used a randomized control trial with a four-way factorial design, crossing intervention (HIV, health education control) with facilitator gender (male, female), facilitator race (African American, White), and gender composition of the small group (single gender, mixed gender). The main focus, however, was on comparing the HIV intervention and health education control group.

      On one of three Saturdays, the adolescents participated in the intervention (duration of 5 hours) to which they were assigned. Each intervention involved group discussions, videos, games, experimental exercises, and skill-building activities. On the morning of the intervention session, the adolescents completed pre-intervention questionnaires and were stratified by gender and age and, based on computer-generated random number sequences, were randomly assigned to a small group (6-8 people) that was either homogeneous or heterogeneous in gender and that was led by a male or female facilitator who was African American or White.

      Assessment: Immediately after the intervention, the participants completed a post-intervention questionnaire. They also completed follow-up questionnaires 3 and 6 months after the intervention.

      Sample characteristics: Participants were African-American adolescents (mean age =13.2 years). About 53.8% were female and 46.2% were male. All were currently enrolled in school, and their average grade was 7.51 (SD = 0.53). Pre-intervention measures indicated that 55.3% of respondents reported having experienced coitus at least once, and 30.2% of respondents reported having coitus in the previous 3 months.

      Measures:
      Validity of measurements:
      All questions had been carefully pilot-tested to ensure that the questions were clear and that the phrasing was appropriate for the specific population in this study. To reduce potential memory problems, adolescents were asked to report their behaviors over a relatively brief period (i.e., 3 months). To reduce the likelihood of demand from giving their responses to the same individuals from whom they received an intervention, the data were collected by specially trained proctors who were blind to the participants' intervention condition. Proctors emphasized the importance of the data collection, and assured confidentiality. In addition, participants signed an "agreement" pledging to answer the questions honestly.

      Primary outcomes:
      The participants answered questions about their sexual behaviors, including coitus, unprotected coitus, sex with multiple partners, and anal intercourse. They were asked whether they had ever engaged in the behaviors and the frequency of the behaviors in the previous 3 months. An additive risk behavior index was created based on the standardized logged frequency of unprotected sexual intercourse, sexual partners, anal intercourse, anal intercourse partners (alpha=.72-.77).

      Secondary outcomes (mediators):
      Several potential mediators of the effects of the intervention on HIV risk-associated sexual behavior were measured at pre- and post-intervention.

      • HIV risk-reduction knowledge (56 items, alpha=.83-.90)
      • Prevention beliefs (3 items, alpha=.78-.85)
      • Hedonistic beliefs (5 items, alpha=.61-.63)
      • Perceived self-efficacy (2 items, alpha=.65-.69)
      • Condom-use intention (1 item)
      • Norms regarding condoms (3 items, alpha=.91-.94)

      Participants' assessment of intervention:

      • How much they liked the intervention (13 items, alpha=.93)
      • How much they thought they have learned from intervention (5 items, alpha=.74)
      • How much they talked and actively participated (3 items, alpha=.74)

      Facilitator’s perception:

      • How much participants liked the intervention (3 items, alpha=.79)
      • How much participants talked and actively participated (3 items, alpha=.81)
      • How much participants learned from the intervention (3 items, alpha=.81)

      Social desirability measure:

      • Marlowe-Crowne Social Desirability Scale

      Analysis: Analysis of covariance was performed to test for the effectiveness of the HIV intervention on important mediator variables, controlling for baseline outcomes. No effect sizes were reported. A set of interactions was used to test the matching hypothesis, whether effects of the intervention were enhanced when the characteristics of the participants and facilitators (gender, race) were matched. Chi-square tests were used to investigate attrition.

      Intention-to-treat: The study gathered and used data on all subjects who were randomized and completed the surveys.

      Outcomes

      Implementation fidelity : The 41 adult facilitators were generally well educated and were experienced in working with adolescents. One week before the first intervention day, the facilitators received 8 hours of training. The training stressed strict adherence to the intervention procedure.

      Baseline Equivalence : No statistical evaluation of the baseline equivalence between intervention and controls was reported.

      Differential attrition : The HIV risk-reduction intervention group and the health intervention group did not differ significantly in the percentage of adolescents who completed the 3-month follow-up (97.8 and 95.6%, respectively) or the 6-month follow-up (94.0 and 91.2%, respectively).

      Attrition at the 3-month follow-up was not related to any of the 17 behavior and belief variables. Attrition at the 6-month follow-up was related to 3 of the 17 measurements: Completers had more positive pre-intervention hedonistic beliefs about condoms, were less likely to having had coitus in the previous 3 months, and were younger compared to attritors.

      The authors tested the impact of attrition on the intervention condition (interaction terms) and found that one interaction was significant (treatment x pre-intervention self-reported coitus in predicting HIV knowledge). However, no additional steps were taken to adjust for differential attrition.

      Posttest : The HIV risk-reduction intervention had significant effects in the predicted direction on most (5 out of 6) of the conceptual variables. At post-intervention, the adolescents who had received the HIV risk-reduction intervention scored higher in HIV risk-reduction knowledge (p =.0001); believed more strongly that condoms can prevent pregnancy and STD, including HIV (p =.003); believed more strongly that condoms would not interfere with sexual enjoyment, (p =.014), had greater self-efficacy to use condoms (p =.044) and expressed firmer condom use intentions than did those who had received the general health promotion intervention (p =.02). These effects were sustained through the 3- and 6-month follow-ups, with the exception of the prevention belief which lost its significance after 6-months.

      Long-term effects : Behavior reported at the 3-month follow-up revealed no significant difference between the HIV risk-reduction condition and the general health promotion condition on the risky sexual behavior index or any of the contributing variables separately. In contrast, at the 6-month follow-up, responses revealed that adolescents in the HIV risk-reduction condition reported significantly (p =.007) less HIV risk-associated sexual behavior, as measured by the risky sexual behavior index, than did those in the general health promotion condition.

      The following factors contributed to this result: After 6 months, adolescents in the HIV risk-reduction condition were less likely to report unprotected coitus (p =.031). The HIV intervention also reduced the percentage of adolescents who reported engaging in anal intercourse in the previous 3 months (p =.0007) and the frequency of this sexual practice (p=.001) as well as the number of anal sex partners (p=.004).

      Other outcomes: Analyses performed on conceptual mediator variables as well as on the self-reported sexual behavior revealed little support for the matching hypothesis. Out of 144 tests on the conceptual mediator variables (various forms of matching [gender and ethnicity of subjects and participants] for each of the 6 variables and each of the 3 time points), only 3 were significant. Out of the 112 tests on the sexual behavior variables, only 1 one was significant and in the expected direction. For example, a significant Condition x Gender composition interaction indicated that the effects of the HIV risk-reduction intervention on self-reported coitus were enhanced in single-gender as compared with mixed-gender groups (p =.04).

      Limitations:

      • Although, some large differences between groups were apparent, no baseline equivalence test was conducted.
      • Delayed effects: The effect of the intervention was not statistically significant 3-months after intervention and only received significance 6-months later.
      • Long term effects of the intervention were not investigated a year after the intervention but only at 6-months.
      • Self-reported sexual behavior might not adequately represent actual behavior patterns.

      Jemmott, J. B., Jemmott, L. S., & Fong, G. T. (1992).Reductions in HIV risk-associated behaviors among black male adolescents: Effects of an AIDS prevention initiative. American Journal of Public Health, 82 (3), 372-377.

      This study was chronologically the first implementation of Be Proud! Be Responsible! Compared to Jemmott, Jemmott, & Fong (1998), the study population comprised only male African-American inner-city adolescents and the adolescents were considerably older (mean age=15 years vs. 12 years). Instead of a general health intervention, this study used a career opportunities intervention as control. Although a randomized control trial, this study only evaluated the effect of the intervention after 3-months and thus is limited in assessing long-term effects.

      Evaluation Methodology

      Design:
      Recruitment:
      Study subjects were recruited from among outpatients at a medical clinic in West Philadelphia (44%); students attending the 10th, 11th, and 12th grade assemblies at a local high school (32%); and adolescents at a local YMCA (24%).

      Sample size/Attrition:
      Of the 157 participants, 150 (96%) completed the 3-month follow-up questionnaire. The return rate did not differ between experimental conditions.

      Study type/Randomization/Intervention/Assessment:
      With parental consent, adolescents were stratified by age and randomly assigned to a HIV intervention or a career opportunity control intervention, and to one of 27 small groups. The intervention sessions (5-hours) were led by trained male or female facilitators and were held at a local school on Saturday, October 15, 1988. Participants completed questionnaires pre-intervention, post-intervention, and 3-months after the intervention had taken place.

      Sample characteristics: Only African-American males were eligible for participation in the study. About 97% of the participants were currently enrolled in school. The mean number of years of education of their mothers was 13.82. Few participants (4.5%) reported ever sharing needles or ever having same sex relationships (1.6%). About 33.9% reported having more than one coital partner in the previous 3 months. About 20.9% who had sexual intercourse in the previous 3 months reported that they never used condoms during those experiences and only 30.2% reported always using condoms.

      Measures:
      Validity of measurements:
      Four measures were taken to ensure the reliability of responses:

      • Code numbers rather than names were used on the questionnaires
      • Facilitators were not involved in any way in the administration of questionnaires (research assistants administered the questionnaires)
      • The importance of responding honestly was emphasized (participants signed an agreement)
      • Participants were assured that their responses would be kept confidential

      Primary outcomes:
      On the pre-intervention and follow-up questionnaires, the participants answered a series of questions about their sexual practices in the previous 3 months, including coitus, multiple sexual partners, condom use, and heterosexual and anal intercourse. The resulting variables were z-standardized and an additive risky sexual behavior scale was created (alpha=.67-.72).

      Secondary outcomes (mediators):
      The participants’ attitudes and intentions regarding engaging in risky sexual behavior were measured at pre-intervention, immediately post-intervention, and at the 3-month follow-up.

      • Intention to engage in risky sexual behavior (5 items, alpha=.68-.72)
      • Attitude towards risky sexual behavior (5 items, alpha=.63-.68)
      • HIV/STD knowledge (57 items, alpha=.73-.89)
      • Participants rating of intervention activity (multiple items – number not specified)
      • Marlow-Crowne Social Desirability Scale

      Analysis: Although not formally described, ANCOVA was used to compare mean differences (adjusted for the baseline outcome) between the intervention and control group. No effect sizes were reported.

      Intention-to-treat: The study gathered and used data on all subjects who were randomized and willing to complete the assessments.

      Outcomes

      Implementation fidelity: All 27 facilitators were of the same race (African-American) as the study subjects. One week before the intervention, the facilitators received 6 hours of training. The training sessions emphasized that all facilitators of the same intervention must implement it in the same way so as to reduce facilitator effects.

      Baseline Equivalence & Differential Attrition: No statistical analysis for baseline equivalence or differential attrition was performed.

      Posttest: Immediately after the intervention, participants in the HIV intervention group had greater knowledge about HIV/STDs (p<.0001), expressed less favorable attitudes toward risky sexual behaviors (p<.004), and reported weaker intentions to engage in such behavior (p<.0001) than did their counterparts in the control group. Thus, 3 out of 3 tests were significant.

      Long-term effects :
      Main outcome
      : Participants in the HIV condition reported engaging in less (p<.01) risky sexual behavior in the 3 months following the intervention compared to the control group. The effects of the intervention were fairly consistent across different sexual behaviors. Although adolescents in the HIV condition were not significantly (p=.10) more likely than those in the career-opportunities condition to practice complete abstinence in the 3 months after intervention, they did report having coitus on fewer days, with fewer women, and with fewer women who were involved in sexual relationships with other men. Subjects in the HIV condition also reported fewer occasions of coitus without a condom and were less likely to report having anal intercourse.

      Mediators: Three-months after the intervention, participants in the HIV intervention still scored higher on HIV/STD knowledge (p<.003), and reported weaker intentions to engage in risky sexual behavior in the next 3 months (p<.007), than did those in the career opportunity control group. However, no significant difference was observed in the intention to engage in risky sexual behavior, comparing HIV intervention to the control group (p=.10). Thus, 2 out of 3 tests were significant.

      Limitations:

      • No description of the statistical methods was provided
      • No statistical analysis of baseline equivalence and attrition
      • Long-term effects of the intervention were only assessed 3-months after the intervention

      Jemmott, L. S., & Jemmott, J. B. III (1992). Increasing condom-use intentions among sexually active inner-city adolescent women: Effects of an AIDS prevention program. Nursing Research, 41, 273-278.

      This study was performed at the very beginning of the development of the Be Proud! Be Responsible! program. It investigated whether culturally sensitive information- and skill-based HIV interventions impact important mediator variables that are associated with risky-sexual behavior. Compared to Jemmott, Jemmott, & Fong (1998), this study did not use a control group or randomization procedure and merely compared pre- and post-test changes in self-efficacy, knowledge, and condom use intention. Due to its severe methodological shortcomings, the results deserve little attention.

      Evaluation Methodology

      Design:
      Recruitment:
      The women were participants in an Urban League AIDS prevention program. Some of them (66.0%) had been recruited to the AIDS prevention program from a local high school, some (22.1%) had been recruited from weekend programs for high school students, and some (11.9%) had been recruited from community-based organizations that serve adolescent women. The intervention was fielded in New Jersey. The sample was a highly selective one that consisted of women already concerned about AIDS prevention.

      Sample size/Attrition:
      A total of 214 adolescents participated in the program. Of these adolescents, 172 (80%) completed the post-intervention questionnaire. However, the article discussed only outcomes for the 109 sexually experienced adolescents who completed the postintervention questionnaire.

      Study type/Randomization/Intervention:
      The subjects received the intervention in small groups (6-10) led by a trained black female health educator. The intervention involved 5-hours of videotapes, games, and educational exercises. The intervention was implemented in three sessions. The first session focused on factual information about the cause, transmission, and prevention of AIDS; the second session focused on outcome expectancies regarding partner reactions and effects of condom use on sexual pleasure; the third session focused on skill building and self-efficacy to use condoms. The study did not use a control group or randomization procedure and thus constitutes neither a randomized control trial nor a quasi-experimental design.

      Assessment:
      Questionnaires were used to evaluate intervention related changes in HIV/STD related knowledge and self-efficacy prior to and after the intervention.

      Sample characteristics: The subjects were sexually active, unmarried black adolescent women (mean age of 17 years). On average respondents had completed 10 years of schooling. As for socio-economic status, respondent’s mothers and fathers had about 12 years of schooling. The mean age for first coitus was 14 years. About 72% of the respondents indicated that they had had coitus in the past 3 months. About 19% of those who were sexually active in the past 3 months never used condoms and only 29% always used condoms.

      Measures:
      Validity of measurements:
      All measures were pilot tested to ensure that questions were clear and that phrasing was appropriate. Most measures have been used in prior studies.

      Primary outcomes:
      This study focused only on intervention related changes in cognitive variables (mediators) and did not evaluate long-term effects or behavior changes. The cognitive characteristics evaluated included the following measures:

      • Intentions to use condoms in the next three months (1 item)
      • Perceived self-efficacy to use condoms (6 items, alpha=.56-.71)
      • Outcome expectancies regarding condom use
      • Prevention expectancies (3 items; alpha=.70-.73)
      • Hedonistic expectations (5 items; alpha=.50-.68)
      • Partner’s approval of condom use (2 items; alpha=.77-.82)
      • Knowledge about HIV/STDs (56 items; alpha=.82-.85)

      Analysis: The study used repeated measures analyses of variance (ANOVA) to compare intervention related changes in pre- and postintervention means.

      Intention-to-treat: Study procedures were consistent with the intent-to-treat principle.

      Outcomes

      Implementation fidelity : The intervention facilitator received a specialized training.

      Baseline Equivalence and Differential attrition : The study did not analyze differential attrition and baseline equivalence (since no control group was used).

      Posttest : Self-efficacy to use condoms was significantly higher after the intervention than before the intervention (p<.0001). Differences in outcome expectancies were also significant. After the intervention, the women believed more strongly that condoms do not interfere with sexual pleasure (p<.0001), that their sexual partners would be supportive of condom use (p<.01), and that condoms prevent pregnancy, STDs, and AIDS (p<.002). There were also increases in general HIV/STD knowledge (p<.0001) associated with the intervention. Finally, after the intervention, adolescents reported significantly (p<.04) stronger intentions to use condoms.

      Limitations:

      • The study used a highly selective sample
      • The study did not use a control group and thus did not randomly assign any subject to an intervention vs. control group
      • The study did not evaluate long-term effects on behavior

      Jemmott, J. B., Jemmott, L. S., Spears, H., Hewitt, N., & Cruz-Collins, M. (1992). AIDS information, self-efficacy, hedonistic expectancies, and condom-use intentions: Testing the information alone hypothesis. Journal of Adolescent Health, 13, 512-519.

      This study differed in its general set-up from Jemmott, Jemmott, and Fong (1998) in that the interventions were shorter (105 min), and the study population was smaller (19 participants). In addition, this study was conducted with a female-only sample (mean age 18), recruited from an inner-city family planning clinic, while Jemmott, Jemmott, and Fong (1998) recruited younger (mean age 12) study subjects of both genders from three schools. Since the study did not assess the long term effects on behavioral changes, which constitutes the main program effect of interest, the study results do little to support the program.

      Evaluation Methodology

      Design:
      Recruitment
      : Participants were black female adolescents recruited from a family planning clinic serving a low-income inner-city area of New Jersey. Participants were recruited in the waiting room of the family planning clinic by an assistant who described the project and informed them of the possibility that they might be assigned to one of the AIDS risk-reduction conditions or to the control condition on general health promotion.

      Sample size/Attrition: Participants were 19 sexually active black female adolescents. No attrition was reported.

      Study type/Randomization/Intervention: The study defined three conditions, a skill-based intervention, an information-based intervention, and a general health intervention. Those who came to the program for the first two days were randomly assigned to the skill-based or information-based intervention. Those showed up on the third and fourth day were all assigned to the general health control intervention. There was no apparent random assignment for the third group, which may differ in unknown ways from the first two groups. The intervention sessions were held during evening hours over a 3-week period at the family planning clinic during the summer of 1990. A total of six women participated in the skill-based condition, six participated in the information-based condition, and seven participated in the general health condition. Four female facilitators implemented the interventions. All interventions lasted 105 minutes.

      Assessment: The impact of the intervention on cognitive mediator variables, which are associated with risky sexual behavior, was evaluated through pre- and post-test questionnaires.

      Sample characteristics: Participants were African-American female adolescents (mean age 18). Study subjects came from a low SES background which is reflected in the average formal schooling of their mothers of around 11 years. Study subjects mean age of first coitus was 15.78 years, and all experienced coitus in the past 6 months. About half reported having been pregnant at least once. Only 22% of the sample reported using a condom the last time they had coitus.

      Measures:
      Validity of measurements: Participants were assured that their answers would be confidential, and their name would not be put on their questionnaire.

      Primary outcomes: A number of questions were used to assess attitudes, beliefs, knowledge, and intentions regarding sexual risky behavior.

      • Intention to use condoms (1 item)
      • Perceived self-efficacy to use condoms (6 items, alpha=.42-.65)
      • Hedonistic expectancies regarding condom use (5 items, alpha=.82-.79)
      • Prevention expectancies regarding condom use (3 items, alpha=.56-.94)
      • Knowledge about AIDS/STDs (56 items, alpha=.78-.82)
      • Participants answered factual true-false questions on general health
      • Participants rated their attitudes and intentions toward specific health behaviors in the next 3 months
      • Participants evaluated the intervention
      • Participants answered questions about their sexual practices in the past 6 months, including intercourse, multiple sexual partners, condom use, and anal intercourse

      Analysis: The study used analysis of covariance and planned contrasts to compare the social cognitive (skill-based) intervention with the combined information-alone and general health-promotion intervention, controlling for pre-intervention scores on the outcome of interest.

      Intention-to-treat: The study gathered and used data on all subjects who were randomized.

      Outcomes

      Baseline Equivalence and Differential attrition : No test for baseline equivalence was performed. Attrition did not occur.

      Posttest : Adolescents in the social cognitive condition reported significantly (p<.04) stronger intentions to use condoms than did those in the other conditions considered together. The information-alone and general health-promotion conditions did not differ in intentions (p=.18). Women who received the social cognitive intervention expressed significantly (p<.05) greater confidence regarding their ability to implement condom use (p<.05) and scored higher on hedonistic expectancies (p<.02) than did women in the other two conditions. Adolescents in the information-alone and social cognitive conditions scored substantially (p<.002) higher on AIDS knowledge than did those in the general health-promotion condition.

      Limitations:

      • Two of three groups were randomized but not the third
      • Small sample – only 19 African-American females participated in the study and were assigned to three interventions
      • No long-term follow up assessment to evaluate behavior change
      • Some measures show a relatively low alpha reliability
      • No test for baseline equivalence was performed
      • Limited generalizability since study subjects were recruited from a reproductive health clinic and thus already show a concern for risky sexual practices

      Video

      http://www.selectmedia.org/programs