CommentaryThe challenge of changing drug and sex risk behaviors of runaway and homeless adolescents☆
Introduction
THROUGH DECEMBER 1998, 3,423 AIDS cases among adolescents aged 13–19 had been reported by state and territorial health departments to the Centers for Disease Control and Prevention (1998). In addition, 117,717 cases were reported among young adults 20–29, many of whom were likely infected with the human immunodeficiency virus (HIV), the etiological agent for AIDS (Barre-Sinoussi et al., 1983), while adolescents (Gayle & D’Angelo, 1991). Currently, one-quarter of all new HIV infections in the United States are estimated to occur in individuals aged 13–21 and one-half in persons less than 25 (Office of National AIDS Policy, 1996).
Runaway and homeless adolescents are at even greater risk for HIV infection than adolescents in other settings Athey 1991, Rotheram-Borus et al 1991a due to both drug (Windle, 1989) and sex risk behaviors (Anderson, Freese, & Pennbridge, 1994). A study of homeless youth in Hollywood, for example, reported that 39% met the criteria for a diagnosis of substance abuse, a rate five times higher than that of non-homeless adolescents (Robertson, 1989). Studies have reported that initial sexual intercourse among runaways occurs at about 12.5 years, or 2 years earlier than that of non-runaways Rotheram-Borus et al 1991b, Yates et al 1988, Zelnik and Shah 1983. Runaways are also more likely to have multiple sex partners Rotheram-Borus et al 1992a, Sondheimer 1992, Wells et al 1992; exchange sex for food, drugs, money, or shelter Pires and Silbert 1991, Price 1989, Yates et al 1988; and to not use condoms Rotheram-Borus et al 1992, Shalwitz and Bermundez 1992 than other adolescents.
These risk patterns point to the increased probability of HIV infection among runaways relative to other adolescent populations. Surveys of youth seen in facilities serving runaway and homeless adolescents have found infection rates ranging from 2.1% and 2.2% in Houston and New Orleans (Stricof, Novick, & Kennedy, 1990), respectively, to 5.3% in New York City (Stricof, Kennedy, Nattell, Weisfuse, & Novick, 1991) and 6.5% in San Francisco (Shalwitz, Bermundez, & Baxter, 1993). These infection rates are up to 15 times that of other adolescent samples D’Angelo et al 1991, Quinn et al 1988.
For more than a decade, public health experts have recognized the need to prevent the spread of HIV infection among adolescents (Hingston & Strunin, 1992). A number of cognitive-behavioral models suggest ways in which to reduce the risk behaviors known to be associated with HIV. Two of these models, the health-belief model and the peer influence model, are the subject of this investigation. According to the health-belief model, HIV risk behaviors are less likely if the individual has: (1) knowledge about HIV transmission, the consequences of infection and ways in which to avoid infection; (2) perceived susceptibility to infection; (3) concern about infection; and (4) beliefs that the benefits of avoiding infection outweigh the costs (Becker & Joseph, 1988). Among adults, the model has been shown to predict safer sex (Steers, Elliott, Nemiro, Ditman, & Oskamp, 1996) and safer injection practices (Falck, Siegal, Wang, & Carlson, 1995). Among adolescents, the model is supported by studies showing that HIV preventive behaviors are associated with knowledge about HIV, high perceived susceptibility, and concern that HIV is a serious threat Koopman et al 1990, Rotheram-Borus and Koopman 1991, Rotheram-Borus et al 1995.
The peer influence model is based on the premise that peers substantially influence one another’s behaviors (Catania, Kegeles, & Coates, 1990; Jessor, Van Den Bos, Vanderryn, Costa, & Turbin, 1995) and thus, with training, peers can intervene to change other’s behavior. The model has been successfully used to prevent smoking, reduce alcohol use, increase knowledge about HIV infection, and reduce high-risk sex behaviors Perry and Grant 1988, Slap et al 1991, Telch et al 1990. In the current study, the model was also based on the peer helper principle, emphasizing the use of individuals with a current or past problem to help others with the same problem Brager 1967, Pearl 1964. The underlying assumption was that not only can peers help other peers, but when peer helpers are given a stake or role in addressing a problem, they become committed to the task in a way that brings about meaningful development of their own abilities (Pearl, 1964).
The present investigation was designed to further our understanding of both drug and sex risk behaviors of runaway adolescents and to assess factors associated with change in risk behaviors. In particular, we were interested in assessing the effect of three components of the health belief model, including knowledge about HIV and AIDS, perceived likelihood for infection, and concern about HIV infection, as well as the effect of a peer intervention model, on change in drug and sex risk behaviors.
Section snippets
Study design
It was not possible to randomly assign individuals to experimental and control groups since runaways in the peer helper condition were encouraged to speak to other runaways about AIDS and AIDS prevention and thus could contaminate those concurrently recruited into a control group. Instead, a modified crossover design (Fleiss, 1986) was utilized, with recruitment into a control condition (11/92 through 2/93), followed by an experimental condition (5/93 through 8/93), followed by another control
Study sample
Study participants (N = 147) averaged 17.4 (SD = 1.5) years of age and 9.8 (SD = 1.6) years of education, 51% were male, 73% White, 12% Hispanic, 8% African American, 5% Native American, and 3% of other ethnic groups. Ninety percent had been placed in living situations other than with their birth parents (M = 2.6, SD = 1.1), including adoptive parents (15%), foster parents (25%), grandparents (37%), other relatives (35%), group homes (50%), and other social service agencies (15%). More than
Discussion
Three major findings emerged from this study. First, the relationship between greater AIDS knowledge and lower risk behaviors was not supported. In fact, knowledge was significant in only one multivariate test and the results showed that runaways with greater knowledge were more likely to have engaged in high-risk sex. Since one of the objectives of the project was to increase knowledge about AIDS, and thereby reduce risk behaviors, this finding is troubling. Other studies have reported that
Acknowledgements
The authors acknowledge Larry D’Angelo, MD, Francesca Pinto, MPH, and Barry Brown, PhD, for their thoughtful and helpful suggestions regarding earlier versions of this manuscript. We also acknowledge the enormous contribution of the late John Watters, PhD, the Principal Investigator for the Project. John’s compassion for the plight of the unfortunate was without equal, and his dedication to improving the lives of those who were threatened, genuinely heroic.
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2017, Journal of Substance Abuse TreatmentCitation Excerpt :Another evaluation of a four-session one-on-one motivational intervention, with average total treatment exposure of 73 min, similarly found no effect on AOD use at 3 month follow-up (Baer, Garrett, Beadnell, Wells, & Peterson, 2007). Other brief interventions include a street outreach HIV prevention intervention that offered service listings/referrals and supplies (e.g., condoms and bleach) which did not find a statistically significant effect on condom use (Gleghorn et al., 1997), and a peer-delivered HIV prevention intervention which increased HIV knowledge, but did not significantly reduce AOD use or sexual risk behavior at 3 month follow-up (Booth, Zhang, & Kwiatkowski, 1999). An exception was a 2-session HIV intervention that was integrated into ongoing substance use treatment at a drop-in center, which was found to have statistically significant positive effects on condom use at 6 month follow-up and number of sex partners at 12 month follow-up (Carmona, Slesnick, Guo, & Letcher, 2014).
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2014, Children and Youth Services ReviewCitation Excerpt :While Booth et al. (1999) found a reduction in the number of sex partners at 3 months post-intervention, the reduction was not statistically significant. Booth et al. (1999) concluded that peer prevention educators may not be effective. Possibly, the use of professional substance use counselors, as in the current study, may have the greatest potential impact with this particular population.
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This study was supported by the National Institute on Drug Abuse, contract 271–90–8402.