(Holistic Nursing Practice)
A 2-year pilot program implemented by public health nurses (PHNs) in
partnership with the leaders of parent associations of 10 urban high
schools encouraged communication about health-promoting sexual
behavior between adults and adolescents. The purpose was to assess
the feasibility of involving parents in health promotion efforts in
schools. During the first year, PHNs prepared a cohort of 17 parent
trainers to make presentations to parent groups about the reality of
teens' risk for human immunodeficiency virus (HIV) exposure, facts to
counter myths about outcomes of sex education, and the skills teens
need to implement healthy choices, including abstinence, correct
condom use, and talking about sex with a potential sexual partner.
Each parent trainer was then scheduled to make two presentations at
parent association meetings. Criteria for assessing the impact of
extending the program, including broader diffusion in the community,
are proposed. This approach may be effective for community-based
education about other health issues. Key words: adolescent
development, adolescent health, community health nursing, community
trials, HIV education, parenting education, sexual health
BARELY 15 YEARS after the first outbreaks of acquired
immunodeficiency syndrome (AIDS) were first recognized,[sup1] the
pathogen that causes it has become endemic in diverse populations
around the globe. In much of the industrialized world, it is a
"mature" epidemic.[sup2,3] That is, incidence has more or less
plateaued and mortality may offset the number of new cases each year,
yielding a fairly steady or declining overall prevalence that can
mask emerging epidemics in subpopulations. Because progression to
AIDS is likely to trail 10 years or so behind infection--even longer
as earlier, more effective antiviral therapy is used--the epidemic's
advance is more evident in statistics of viral seroprevalence.
Increasingly, minority populations, particularly women, are
disproportionately affected.[sup3-5] Adolescents' risk may remain the
least visible, however.
Although the rate of new AIDS cases reported in people over age 35
appears to be reaching a plateau, it is rising in those under age
30,[sup3,6] which reflects disease transmission that likely occurred
during the teen years. Indeed, HIV "must be considered an endemic
infection affecting successive cohorts of young adults."[sup3(p1375)]
Thus, a growing challenge as prevalence rises in many urban
centers is to devise ways to enhance the HIV-prevention lessons
provided in school and to make sure that teens perceive these lessons
as personally relevant. Teens--and the significant adults in their
lives--need to recognize that age does not separate them from risk of
AIDS and other sexually transmitted infections and that preventive
precautions are always essential, regardless of a sexual partner's
age.
TEENAGERS' RISK: THE CURRENT PICTURE
It is estimated that half of the human immunodeficiency virus
(HIV)-positive population acquired the infection between the ages of
15 and 24 years.[sup7] We can easily be fooled by the relatively
small number of teenage AIDS cases. But when we focus on the
increasing number of cases in young adults younger than 30 years,
particularly those under age 25, the picture of the incidence of HIV
transmission during teen years is clearer. This number rises each
year, as does HIV seroprevalence in teens between 16 and 19 years old
applying to Job Corps and seen in sexually-transmitted disease (STD)
clinics.[sup5]
In the 1980s, approximately 4% of non-perinatally transmitted AIDS
cases in the United States were diagnosed in people under age 25. In
1997, 15% of men and 25% of women diagnosed with HIV infection were
between 13 and 24 years old.[sup8(pp4,15)] It is particularly
sobering to recognize that the current cumulative AIDS
incidence[sup8] in people between 20 and 30 years old (114,627)
exceeds the total number of adult and pediatric cases reported in the
United States during the 1980s, and that the number of 13- to 24-year
olds (19,395 men and 7,636 women) diagnosed exceeds the total number
of U.S.
AIDS reported by 1985 when the U.S. Secretary of Health and Human
Services declared AIDS to be the nation's "number one health
priority."[sup9] Clearly, without attention to prevention in the
adolescent population now, we can project an explosion of HIV disease
in young adults in coming decades.
Notably, adolescent girls are at greater risk than males in their
respective age cohorts,[sup6,10] and this risk differential is
greater in the early teen years.[sup10] The disproportion reflects
not only the growing incidence among women, but also the tendency for
girls to have their first sexual experiences with boys that are
somewhat older than they are, whereas boys' first experiences tend to
be with girls their own age or younger. Hence, a girl's first sexual
partner is more likely to have had more sexual partners and thus more
opportunity to have been exposed to a sexually transmitted pathogen
than a boy's first partner. The prevention lesson must therefore
underscore how vital it is for adolescent and young adult women to
use a condom the first and every time they have sex--which means
parents and health educators (health care providers, teachers, and
counselors) must convey this lesson early enough so that it is not
too late for the young person to benefit from it.
CONSTRAINTS ON PREVENTIVE EFFORTS THAT TARGET ADOLESCENTS
There are many hurdles to making HIV prevention for adolescents a
priority. Although every one involved in public health, adolescent
health care, or HIV prevention would acknowledge the need for
school-based sex education for both adolescents and preadolescents,
"powerful social and political obstacles block the implementation of
effective AIDS education."[sup11] There are many effective advocacy
groups representing virtually every possible point of view concerning
HIV prevention and sex education, whose diverse perspectives must be
considered in planning any school-based preventions activity. So too,
constituencies with concerns and priorities not related to HIV,
including some that run counter to the achievement of prevention and
harm reduction goals, also exercise a role in shaping school and
youth programs that address family life and/or sexuality. The most
vocal of these groups may be the most influential in shaping parents'
awareness of health issues and risks as well as their opinions about
what interventions for prevention are beneficial. The result is that
program design often reflects what is most popular, or at least what
is achievable through political compromise, rather than what may be
necessary.
There can also be more pressing school health priorities, even in
areas where HIV prevalence is relatively high. The number of actual
and potential health problems of an urban student body can be
enormous. For example, in a single year, physical examinations of new
students in New York's schools found over 26,062 problems requiring
intervention, including 2,500 cases of asthma, 2,520 vision problems,
1,997 hearing disorders, and 2,079 cases of obesity.[sup12] One in
five students were referred for mental health services during the
school year.[sup12]
Educators, no matter how well-intentioned and conscientious, have
only so much space and time in the curriculum for any single topic.
Hence, the most extensive HIV program imaginable will, inevitably,
have a relatively minor place in the overall curriculum (compared
with the space thinking and talking about sex--and perhaps also
acting sexually--may occupy in teenage life). Indeed, health-related
topics altogether make up a small portion of the curriculum.
Moreover, although there is a statewide mandated curriculum[sup13]
for HIV education in all grades--kindergarten through high
school--there is substantial diversity in its implementation across
and within schools (eg, at least six hours per year in New York City
high schools). There may be systematic, institutional limitations to
delivering selected specific information. For example, some
jurisdictions require that the proportion of time allocated to
explaining abstinence be equal to the total time spent addressing
other methods of protective intercourse, effectively limiting
discussion about contraception and safer-sex (infection control)
precautions.
Even community-wide programs to prevent adolescent HIV infection do
not necessarily emphasize efforts in high schools, particularly in
high-prevalence areas. Triage demands emphasis on those at greatest
risk. Because specific patterns of behavior leading to HIV
transmission are not identified for the general high school
population, it is expected that prevention can be addressed
generically through health, social, and mental health (education and
service) programs.[sup14] So prevention outreach efforts and dollars
deliberately target higher-risk subpopulations, such as the
following: - challenged youth, such as those in residential treatment
facilities - those receiving family planning, prenatal, or abortion
services - gay, lesbian, and transgendered youth - those being
treated for other STDs - those who drop out of school, particularly
street youth and runaways - sex workers - those involved with
drugs - those who get involved in the criminal justice system
THE PARENT-TO-PARENT PROGRAM
Teenagers' risk of contracting HIV, like adults', varies with the
seroprevalence in the larger surrounding population and will be
greater in areas with higher incidence of infection. New York has
been an epicenter of the HIV epidemic since it began, and currently
has approximately 17% of the nation's reported cases.[sup15] From
1981 through 1995, AIDS cases had been diagnosed in 2354 adolescents
in the United States, with 10% in New York City.[sup15,16] By
mid-1998, these numbers were 45% higher and the cumulative incidence
in 20- to 24-year-old persons had risen by 10%.[sup8,15]
The Bronx is an epicenter within the epicenter, with the highest
incidence of non-homosexually transmitted cases of the city's five
boroughs.[sup15] With 16% of the city's total population, it reports
21% of the cumulative reported AIDS cases.[sup16] Its demographics
mirror those of populations targeted as having high priority for HIV
prevention.[sup16,17] Vital statistics, along with STD rates,
provide an indirect (under)estimate of unprotected sexual activity.
The gonorrhea case rate in adolescents is five times higher than for
the general population, and is rising for females between 15 and 19
years old; the rate for girls is 1.6 times higher than for
boys.[sup14] The Bronx accounts for 19% of live births among the
city's adolescents, which represent about half of teenage
pregnancies.[sup14]
With over a quarter of a million students, the city's high school
population includes many individuals who fit in one or more of the
higher priority categories listed above. For example, approximately
1350 adolescents are in custody in the city's jails for some period
each year (that is, 7% or more of inmates at any given time) and
return to the general school population or attend an alternative
school.[sup12] In addition, students may enter the general high
school population up to the age of 20 and remain in school until they
complete the course. This variable risk for HIV exposure within the
student body, in turn, heightens the risk overall. That is, those
with higher risk put their sexual partners at risk.
Within this context, public health nurses (PHNs) from the Bureau of
School Health of the New York City Department of Health working among
10 high schools in the Bronx planned and implemented a program to
raise community awareness about local adolescents' HIV risk and to
empower parents to be more actively involved in teaching adolescents
and preadolescents about healthy sexuality and STD prevention. The
Bureau of School Health shares responsibilities for health education
and related services with the Department of Education. In-classroom
health education is predominantly the responsibility of the
Department of Education whereas PHNs assigned to schools address the
Bureau's essential public health mission--screening, case finding,
referral, and follow-up.
Program goals
The Parent-to-Parent Pilot Program was one of 10 one-year
demonstration projects funded by the CDC Division of Adolescent and
School Health (DASH) through the American Nurses Foundation (ANF)
School Health Initiative's Campaign to Reduce Adolescent High Risk
Behaviors. The ANA campaign encourages two primary principles: (1)
that HIV prevention should be part of comprehensive school health
services and (2) that education for HIV prevention must broadly
address healthy choices about sexual behavior.[sup18]
The program used the train-the-trainer approach[sup19] (see Fig 1) to
establish a cohort of informed parents prepared to initiate
discussion of AIDS in formal and informal community groups,
particularly parent association meetings. This model reflects Rogers'
theory[sup20] of diffusion of innovation. According to Rogers,
change agents are more successful when they have a group of
champions--that is, opinion leaders and influential persons in
targeted audiences who assist in delivering their message. Hence, we
hypothesized that parents active in school-based activities,
especially parent associations, are in a prime position to be
champions of the HIV-prevention message and can be effective in
promoting both awareness and interest. We therefore sought to build a
network of parents prepared to engage concerned others in the local
community, particularly other parents of high school students, in
discussions about adolescent sexual health and HIV risks.
Ultimately, we wanted this peer education process to empower parents
to communicate knowledgeably with adolescents and preadolescents
about HIV-related issues. Although the program targeted high school
students' parents, we recognized other children in the targeted
families, particularly preadolescents, as secondary targets. Indeed,
we also recognized that parents themselves are in a demographic group
with escalating transmission rates, including the highest infection
rate for women.
We also anticipated that the consciousness-raising would give voice
and peer support to those parents, perhaps the majority, whose
concerns about risk might have previously been silenced or thwarted
by a more vocal minority arguing against enhancing school-based sex
education, and that, in turn, this raised voice would enhance the
capacity for HIV-prevention activities in schools. Our goal was thus
two-fold: on the individual/family level, to promote parent-teen "sex
talk," and on the community level, to stimulate greater parental
interest in and demand and support for more comprehensive STD/HIV
teaching in high schools.
Rationale for targeting parents
This approach of involving parents is grounded in the public health
nursing principle that school-based health promotion should be
family- and community- centered.[sup21] The notion that teens
perceive themselves to invulnerable or invincible is widely
acknowledged, but less attention is given to parents' misperceptions
of their own children's risks. And contrary to popular wisdom,
adolescents report[sup22-25] that although perception of peers'
behavior plays a major role in their choice to begin or to delay
intercourse, parents are a primary source of information about sex
and they are influenced by their parents' attitudes and behavior.
Even sexually active teens say that they need more information about
sex and that they want to have more discussion with their
parents.[sup22,25]
Indeed, researchers have found that parent-teen discussions about sex
are associated with less conformity to peer norms.[sup25] Teens who
talk with their parents about sexual issues are less likely to have
sexual intercourse and if they do, are more likely to use
contraception.[sup24-26] Parent-teen communication about sex is also
a factor promoting open discussion of sexual risks and subsequent
condom use with sexual partners.[sup26] Whether parent-teen talk
takes place, however, depends on parents' confidence in their ability
to discuss sex with their children and their expectations about the
results of those discussions.[sup27] Indeed, parents often report
difficulty raising the topic or knowing what to say. Many
acknowledge, "Since my parents didn't talk to me, I never really know
how to talk to my kids." They report they are afraid they will be
unable to answer questions. Thus, parents need to be assured both
about the positive impact of effective sex education and also that
they themselves can make an important, life-enhancing, potentially
life-saving, difference in their children's sexual development.
Program description
The program had four components: (1) a six-hour training for parent
trainers, (2) a community diffusion effort through a "curious
symbol," (3) presentations by parent trainers at parent association
meetings and to other community groups, and (4) ongoing telephone
backup. During our first year, the parent trainer training was
offered twice within a single school semester: with two 3-hour
mid-day sessions and three two-hour evening sessions (a schedule
format proposed by the participating parents themselves). The goal
was for each parent trainer to make at least two 30-to-40-minute
presentations within three months of completing the training. Parent
trainers were reimbursed for round-trip public transportation to
attend the training sessions and for making two subsequent
presentations to parent groups. They also received a $15 stipend for
each of these presentations.
Promoting the message: the curious symbol
At the end of their training, we gave the parent trainers
symbol-bearing buttons, which they could wear themselves and also
distribute to those attending their presentations. (The symbol,
designed by the PHNs in collaboration with a high school art class,
depicted a pink gift box wrapped in blue ribbon.) We envisioned that
these buttons would serve as conversation starters, providing a segue
for introducing the topic of teen's HIV risk into conversations when
a person was asked what the button was for or where it was from. Such
buttons (not necessarily the one designed for this pilot) might be
more valuable in a more extensive, community-wide program that could
also feature posters bearing the designated symbol mounted around a
neighborhood as well as in the school. This would heighten curiosity
and invite more inquiry, perhaps even requests for presentations.
Alternatively, we might include a message on some or all of the
posters, such as "I'm talking to teens about AIDS," "Talk to a teen
about AIDS," and "Have you talked to your teenager about AIDS?"
Logistics
The PHNs designing this program had previously completed both the DOH
certification training for HIV pre- and posttest counseling and ANA's
AIDS Train the Trainer Program[sup28] for health care providers. The
two supervising nurses collaborated with the Director of Continuing
Education in Nursing to organize a one-day workshop to address
additional content specific to adolescent sexuality, STD prevention,
and an overview of the state-of-the-art in community-based programs
for HIV prevention among adolescents and pre-adolescents. Then the
group prepared the six-hour parent trainer curriculum.
Logistic planning involved collaborative meetings with school
representatives and the presidents of the parent associations. The
presidents' forum was key to determining the optimum schedule for
training, determining how to invite and select candidates for the
parent trainer training, and arranging the subsequent presentations
at parent association meetings at the targeted schools. Guidance
counselors, health educators, and faculty-counselors who worked with
gay and lesbian students from the respective schools were invited to
participate in preliminary planning sessions. The school district's
faculty liaison to the Federation of Parent Associations handled
correspondence with the selected parents and facilitated the
logistics of arranging space for the training sessions.
Although the work of presenting the training was divided among seven
PHNs and a colleague from the Bureau of STD, for the purpose of the
pilot all the nurses attended all the training sessions. This
approach was quite labor-intensive, but it provided peer support and
review. It also allowed all the nurses to get to know all the parent
trainers (and vice versa). We also videotaped the training sessions
for subsequent review so we could plan revisions and critique our own
presentations. Handouts included brochures (in English and Spanish)
available from the Bureau of STD, the Bureau of HIV Preventions
Services, and several community-based organizations that addressed
(1) risk factors for exposure and ways that HIV is not transmissible,
(2) symptoms and sequelae of various STDs, (3) safer sex practices
and ways to enjoy intimacy without having sex, (4) correct use and
storage of condoms, including cautions about misuse and precautions
about their storage, and (5) personal HIV risk appraisal checklists.
We also included lists of self-referral resources (clinics,
counseling centers, anonymous testing sites, hotlines, and teen and
family support programs) and contact information for obtaining
additional flyers free of charge.
Parent presentations
The PHN assigned to the respective school, together with the school's
faculty liaison to the parent association, coordinated the logistics
for the parent trainers' first two presentations. The PHN would also
attend these two meetings to provide support to the parent trainer.
The parent trainer could thus feel confident that he or she would not
be faced with an unanswerable question from the audience. It was also
a means for initial monitoring to ensure that the presentations
addressed the intended content. Debriefing afterwards allowed the
parent trainer to express how he or she felt during the presentation
and to review audience response. The nurse had an opportunity to
offer suggestions about the presentation, answers to questions, and
group dynamics. In this context, the nurse could also correct any
factual errors.
By thus monitoring each parent trainer's first two presentations, we
could feel confident about their ability to schedule other
presentations without nurse backup. Just as important, we would be
able to make a firsthand assessment not only of the parent trainers'
grasp of the relevant issues and audience receptiveness, but also of
the larger groups' general knowledge and attitudes about the topics.
To provide continued nurse support, we had originally planned to
institute a "warmline" whereby all parent trainers could have a
single phone number to call with questions and one of the project
nurses would return the call within 24 hours. Instead, each parent
was given the number of the nurse assigned to the school with which
he or she was associated. Although this deviation from the original
plan was necessitated by agency logistics external to the project, it
seemed to turn out to be more appropriate than the warmline approach:
It facilitated the PHN partnership with parent trainers at their
assigned schools. The warmline approach might be used with an
expanded program, involving more schools and a larger group of parent
trainers. It might even be appropriate (depending on needs assessment
and coordination with the Department of Health AIDS hotline) to offer
the number to all parents and students to call with questions, not
just parent trainers.
TRAINING FOCI: BEYOND "AIDS 101"
Selection of training content (see boxes entitled "Outline of Parent
Trainer Training and Parent Trainers' Presentations to Others" and
"Key Components of All Parent Presentations") was guided by the
planned behavior[sup29] and self-efficacy[sup30,31] models (see Fig
2). Because the primary behavioral objective was open parent-teen
talk about sexual health and safer sexual behavior (and for the
parent trainers, to address this objective, as well as the reasons
for it and ways to achieve it, with other parents informally and in
group settings), program content had to (1) target parents'
knowledge, beliefs, values, attitudes, and perceived norms related to
teen sexual activity, sex education, and parent-teen communication
about sex, and (2) promote parents' self-efficacy in discussing
sexual values and concerns openly. In other words, our goal was not
to address knowledge deficits about the immunodeficiency underlying
AIDS symptoms or its epidemiology and etiology. (Nor did we want
parent trainers to feel they had to learn scientific terms and
medical jargon.) And unlike train-the-trainer programs for health
care professionals,[sup19,28] our program did not aim to prepare the
parent to be a resource with answers about a broad array of
AIDS-related issues.
Rather, we wanted to activate parents to be more involved in talking
about sexual health with their children, particularly teens and
pre-teens. Hence, the most essential tasks were to provide the
opportunity for audiences to examine the attitudes and beliefs on
which they based their concerns and opinions concerning what their
children should learn about sex and when, and to address parents'
personal discomfort about talking to teens about intimacy and
sexuality. Thus, we needed to shift from a focus on what is
popularly called "AIDS 101" to emphasize the epidemiology of
adolescent sexual activity and the knowledge and skills parents need
to feel comfortable initiating discussions with their children about
sexual behavior--values, facts, and safer-sex skills.
Debunking myths with facts
A frequent argument against providing young teenagers information
about sex is that such knowledge encourages sexual activity. In
fact, sex education is associated with delayed initiation of sexual
activity--even when frank, specific "how-to" information about
contraception and infection precautions (such as condom and
spermicide use) is included.[sup32,33] Similarly, despite the
contention that access to condoms promotes more and riskier sexual
behavior, including having sex with more partners, condom
distribution programs in schools have demonstrated the opposite.
Condom availability does not hasten or increase sexual activity, but
by improving access and reducing embarrassment and cost makes it more
likely that teens, especially boys, will use condoms when they have
vaginal intercourse, including the first time they do so.[sup34-36]
Conversely, fear-based, "just-say-no," abstinence-only approaches to
sex education are not so effective. These programs' strategy often
relies on scare tactics, emphasizing negative consequences without
providing the opportunity to explore values.[sup37] They often omit
or distort health and medical information (related to sexual
response, contraception, STDs, the efficacy of prophylaxes) and
promote sexual stereotypes, which suggest gender-biased expectations
and depict nontraditional family structures as troubled. For example,
single parents are assumed to be mothers; men are depicted as sexual
predators, women as vulnerable.[sup37] Such content is not credible
when it is incongruent with students' own experience of reality or
messages conveyed by other media. And rather than deterring sexual
activity, strategies that suggest that condom use is not so effective
in preventing STDs are more likely to encourage risk-taking. The
sexually active person of any age needs to understand why not all
contraceptive methods are effective for STD prevention (for example,
the pill, diaphragm, intrauterine device) and that condom "failures"
often reflect inconsistent use (that is, occasions when it was not
used) rather than lack of efficacy per se.
Skills-building
Research has repeatedly demonstrated that only behaviorally focused
sex education achieves behavioral outcomes.[sup32,33,37] Neither
facts nor rules are sufficient guide for learning complex, intimate
behavior. The necessary "how-to" includes not only deciding what one
wants to do (and when), but also how not to do what one doesn't want
to do in a given moment or situation. Carrying out one's decision may
involve negotiating about alternative (intimate as well as
not-so-intimate) activities, or determinedly resisting peer pressure
and assertively refusing to do something one doesn't want to do.
Like any other skill, communicating about intimate feelings takes
practice and one must learn to talk about sex-related issues outside
of the immediate situation. Teens, like adults, must learn to deal
with feeling uncomfortable and to be assertive even when
uncomfortable. Comfort evolves with self-esteem. Being able to talk
with parents can provide a nonthreatening situation in which an
adolescent can admit insecurity or ask questions without worrying
about appearing ignorant in front of peers.
These skills are just as important for the person who has already had
intercourse. Having had sex does not preclude subsequent
abstinence--with the same or different partner. Similarly, the
context of negotiating for condom use may change in a long-term and
"steady" relationship. Proper condom use requires being prepared to
introduce its use and, if necessary, to insist on using it if a
partner disagrees--whether it's the first time a couple is together
and whether or not they have used one on previous occasions.
The askable parent
Just as adolescence can bring awkwardness in many ways to the teen,
so is it a time of transition for parents. Despite considerable
rhetoric that sex education belongs in the home, many parents feel
unprepared for, or overwhelmed by, this aspect of parenting.[sup39]
Often, little guidance is available and the only frame of reference
for some may be their own teenage insecurity. Parents need not expect
themselves to have all the answers. Listening is more important.
A central lesson is to put sex in the context of adolescent growth
and development. The parenting goal is to prepare the child for the
independence of adulthood and to help them develop the self-care
skills necessary for all aspects of healthy living, including sexual
health. As children grow up, parental promotion of healthy behavior
depends less on surveillance and more on fostering children's
ownership of their own self-protective behaviors.[sup40]
In this context, parent-teen sex talk cannot be anticipated as a
single conversation--The Big Talk--but rather, an ongoing
conversation in which ideas are shared and values explored. Parents
can provide valuable teaching and feedback, but they need to be alert
to teachable moments and to beware of conversation-stopping
responses, such as responding to complex questions with prohibitions,
warnings, or messages of caution.[sup41] They must be able to convey
respect for the teen's perspective and, at the same time, help the
teen to see alternatives and consider consequences. Otherwise the
typical teen response is to reassure the parent that one understands
the dangers and doesn't engage in the risky or taboo activity.[sup41]
But making the child agree is not the goal! The goal is to break down
teens' isolation from the most significant adults in their lives so
that they can feel that support and guidance are available for
exploring and affirming their own values, including learning to deal
with sexual situations and setting their own limits.
The parent trainers
To prepare the parent trainers to bring this message to other
parents, a substantial part of the parent trainer training was spent
in values clarification discussions. We showed video clips of
effective and ineffective parental responses to teens' comments about
sexual behavior as well as clips of teenagers discussing attitudes
about sex. To address the content for teen-parent conversations and
to facilitate their becoming comfortable talking with other parents
about these topics, we used a number of exercises:
- "Where do you stand?"[sup42(p7)] is an exercise that places
intercourse on a continuum of many behaviors and allows discussion of
definitions and boundary-setting in diverse circumstances--for
example, hugging, kissing, petting, dating, going steady,
contraception, masturbation, use of male and female condoms--at what
age? with same-sex partner? for boys? for girls? for single, married,
or divorced adults? Then we ask parents to reconsider each behavior
in terms of what they think most other parents believe. Finally, we
ask whether they think their children would know their opinions and
if so, how they had conveyed them.
Discussion in this exercise provides an opportunity for each parent
to explore one's own values, the sources of those values, and
inconsistencies. It may also counter assumptions about community
standards and others' views. Open, broad conversation with a teenager
will not be possible unless a parent has had the opportunity to
consider a set of standards and the values and beliefs on which it
rests.
- Another exercise is to have parents write on index cards what they
find most difficult about discussing sex or HIV/AIDS with their
children, then sort and redistribute the cards so that each parent
can suggest ways (from their own experience or not) to handle someone
else's difficulty. Parents may choose to "pass" or, rather than
suggesting how to handle a topic, to discuss whether they too find a
particular issue difficult. This exercise provides a "safe space" for
sharing solutions as well as problems. Participants can choose the
extent to which they will "own" any particular concern and, while
learning from each other, they can also recognize in others their own
hesitations and misgivings. They can thus be reassured about their
own competence.
- A flip chart or blackboard can be used to list things about
individuals and relationships that characterize readiness for mature
sexual relationships. This discussion allows parents to recognize the
range and diversity of topics for parent-teen talk and helps shift
the focus from sexual behavior itself to relationship concerns.
- In the "carousel,"[sup43] participants role play in "parent-child"
pairs. The assigned pairings keep rotating and at each turn, the
"child" selects a card on which is written the sex and age (preteen
through 19) for the role along with a question to ask the "parent."
We used a list of 15 questions[sup43] (including questions about
sexual orientation) that can be expanded or purged as needed (eg,
according to whether or not a group needs more or less practice
reviewing facts). Initially, those in the parent roles may simply
answer with the requested information. Then the exercise can be
continued to allow practice in seizing a teachable moment either to
get at a question behind a question or simply to expand on related
issues.
Together the exercises not only covered a wide range of issues, but
they also got the parent trainers talking about topics and in a way
they did not typically talk with other parents. In this way, they do
not merely acquire information, but they experience the discussions.
The experience conveys what is possible. The experience is thus the
first step in changing the norm of parent-parent conversations.
In the fourt hour (which was either the end of the second of three
sessions or the beginning of the second of two sessions), we provided
an outline for a 20-30-minute presentation to address (1)
epidemiologic facts of adolescent sexual activity and HIV infection,
(2) HIV risk reduction, and (3) effective approaches for
adult-adolescent discussions about healthy sexual behavior and sexual
decision-making. The brevity of the proposed content for their
presentations was so that they would emphasize the core message and
have plenty of opportunity for interaction.
The remainder of the training addressed their trainer role. Because
they would have to be able to facilitate discussion and accommodate
diverse perspectives about sexual behavior (including views that
differed from their own or opposed the principles that guided their
presentations), we discussed group dynamics and suggested tips for
recognizing and handling resistance. To move a debate about
abstinence forward, for example, we proposed shifting the focus to
considering what differences should be anticipated in children's
behavior at ages 14 and 18 years (when beginning and finishing high
school) and how the course "from here to there" should be planned. In
whatever context the "first time" is viewed as appropriate, the
question can still be raised--what does a couple need to be prepared
and how can parents prepare them?
LESSONS LEARNED FOR CONTINUING THE PROGRAM
Though self-selected, we expected that the participating parents
would reflect the socioeconomic and ethnocultural diversity of the
student population (43% Hispanic, 31% Black, 23% White, and 5%
diverse others)--and they did. The groups included mothers, fathers,
and a grandmother. They ranged in age from their early thirties to
mid-sixties. Some were juggling two jobs; others were full-time
parent-homemakers. Some were single, never-married parents, others
were divorced; some headed blended families and others lived with
more than one generation in the same household; some were in a
stereotypical two-parent family. Although some had already raised
several children to adulthood, some now had their first child in high
school; others had only one child. Their children included freshmen,
sophomore, junior, and senior students, from 13 to 18 years old.
Preparing parents of children at all grade levels to be trainers
might be key to institutionalizing the program within the parent
association's annual agenda. In any case, year-to-year planning for a
continuing program must anticipate the number who will "graduate"
with their children (although one parent of a graduate returned the
following fall even though she no longer had a child in high school).
Of course, there can be many reasons why a parent trainer would not
return after summer break. Another foreseeable impact of summer break
is that parent trainers may want--and need--refresher rehearsal
sessions before resuming presentations in the new school year.
Recruitment strategy should seek an explicit commitment regarding
making group presentations or at least clarify that doing so is
integral to the parent's motivation for participating. By design,
participants were essentially self-selected activitsts, so their
enthusiasm was not surprising. But they all had full calendars, in
some instances over-extended with both parent association and other
community activities. Hence, although they fit the training into
their schedules, they could not always offer the flexibility to
accommodate presentations afterwards. In the future, we would include
discussing reasons for wanting to be trainers in the ice-breaker
discussion at the beginning of the first session. It might even be
reasonable to ask parent trainer candidates to commit to two specific
presentation dates at the time they sign up for the training.
Given the intensity of presentation-skill training, including the
need for rehearsals (discussed below), a group should probably be no
larger than five or six people. On the other hand, role plays and
experiential exercises may not be so effective if group size falls
below this number. We had a high completion rate (only one person who
started did not complete the training), but both times it was
offered, only 60% of those who originally agreed to the scheduled
dates actually joined the group. Therefore, to allow for drop-outs
and absentees, "enrollment" may have to be greater than desired.
Thus, it may be most feasible to schedule a larger than desired group
and plan to divide it if necessary. Of course, this approach
requires the simultaneous availability of several nurse-trainers.
Training content
Six hours is a very brief time allocation. Time must be allocated to
discussing the logistics of planning presentations. When divided into
two or three sessions, a certain portion of each session must be used
for review at the beginning and then summation and confirming
subsequent arrangements at the end. All-day sessions were considered
to reduce unnecessary repetition. But just as evenings are more
feasible for some parents and daytime for others, few can devote an
entire day at any one time. Having more than one occasion to meet
allows more of a partnership to evolve between nurse and parent
trainer.
Although the parent trainers were experienced and fairly comfortable
talking to larger parent groups and although the proposed AIDS
presentations were intended to be no more formal, perhaps less so,
than their typical association agendas, the parents regarded them as
inherently special and somewhat formal. Nearly all initially
anticipated preparing "a speech" that they would read verbatim,
perhaps reflecting that they did not feel the same ownership of the
content being presented as they did for other issues on their
association agendas. In any case, we needed to provide more time than
originally planned to rehearsing the use of informal
discussion-points. Multiple, short role plays did not appear to be
adequate substitutes for "full" rehearsals of an entire presentation,
even one intended to be highly interactive. To provide additional
rehearsal time in future parent trainer trainings, we would eliminate
the limited review of factual content about AIDS and STDs. Indeed,
the knowledge pretest (which we would retain) suggested it was
unnecessary.
ASSESSING OUTCOMES
One-time only presentations, inevitably, have limited efficacy.
Hence, an essential ingredient of this program is the PHNs'
partnership with the federation of parent associations to maintain
the ongoing schedule of repeated presentations--that is, to keep the
conversation among parents going. And presentations must be regularly
monitored to ensure that content focus is maintained.
Criteria for outcome evaluation must reflect beliefs and norms
related to parent interactions with teens about sexual behavior.
Initial assessment of program implementation measured only parent
trainers' beliefs and self-efficacy before and after the training
sessions and again, after 6 months (see box entitled
"Pretest/Posttest for Parent Training"). In self-efficacy a
continuing program, we would attempt to survey parents about
attitudes and behavior related to talking with teen and preteen
children about sexuality. Parents' reported behavior could be
cross-validated by surveying students' perceptions of parents'
communications, their comfort talking with parents about sex, and
their feelings about family rules and parents' values and counsel.
With program expansion to other school districts, the curious symbol
(discussed above) could be integral to assessing diffusion of the
intended message: Random, brief street interviews of people wearing
the button, asking how they got the button, what the symbol meant,
and key questions about teens and AIDS (such as the questions about
beliefs in the "Pretest/Posttest for Parent Training" box). The same
questions could also be asked of people not wearing the button.
Those (button wearers and nonwearers) who indicated they had
adolescent or preadolescent children could be asked additional
questions about their conversations with the children about HIV.
Conducting these interviews over a designated time period and linking
the findings with the schedule of presentations would provide a
measure of the diffusion impact of the program--as well as the level
of need for continuing or more extensive prevention campaigns in
specific communities. The ultimate measure of program impact, of
course, is students' knowledge, attitudes, and behavior.
The importance and urgency for raising community awareness about
teens' HIV risk cannot be overstated. Nevertheless, it is often
understimated. The rising incidence of symptomatic HIV disease among
people in their twenties evidences disease that started a decade or
so earlier. In other words, people who experience symptomatic HIV
disease in their twenties were infected during their mid-teens--while
they were in high school or shortly thereafter. Without attention to
(primary and secondary) prevention in the adolescent population now,
we can project an explosion of HIV disease in young adults in the
coming decade, particularly in urban communities where the virus is
endemic. Without heightened risk awareness, the urgency of universal
safer-sex precautions may not seem personally relevant to many
adolescents who are indeed at risk and those who do experience
exposures are not likely to recognize the need to seek testing, thus
delaying diagnosis until symptoms emerge--a delay that can sharply
limit the potential benefit currently available treatments offer.
The approach described herein is a brief intervention that seeks to
enlist existing grassroots communication networks for the
dissemination of AIDS prevention information to high school students'
parents. It embodies the notions of self-empowerment and promotes sex
education for teens that is necessary as opposed to what is popular.
By engaging representatives of the target group in both program
planning and implementation, it attempts not only to circumvent
institutional barriers restricting the sexual content of school-based
HIV education, but also to involve the broader community in
AIDS-awareness conversation (ie, adults with children). The goal is
for these conversations to extend throughout participating parents'
social network (including nonparents) and then beyond. This outreach
is not intended to replace, but to enhance and complement,
school-based programs that target students. A rigorously designed
study is needed to determine the ultimate impact on family
communication behavior and, in turn, teens' sexual decision-making.
The pilot program's success demonstrates the feasibility of involving
parents in health promotion efforts in schools. Additionally, this
approach may be effective for community-based education about other
health issues, even those concerning populations other than school
children and adolescents.
Outline of Parent Trainer Training and Parent Trainers' Presentations
to Others
Parent Trainer Training
- AIDS facts & local statistics
- video clips:
parent-child talking about AIDS
teens talking about sexual activity
- STD slide presentation
- adolescent growth and development,
including sexuality
- exercises and role play
- the message for all parents
- presentation skills--practice
Parent Presentations
- local epidemiology & facts about teen
HIV/AIDS
- the biggest risk factor is sexual activity
- the askable parent's skills
- when to start talking about sex
- the focus is health
Key Components of All Parent
Presentations
- the reality of risk to "our" kids
- good kids get AIDS
- smart kids get AIDS
- adolescent sexuality
- sexual health
- fear-based education doesn't work
- get beyond the abstinence debate
- focus on planning for the 'first time'
- "AIDS 101" is not key to prevention
- the focus is not the science of AIDS
Pre-test/Post-test for Parent Training
Knowledge
- Giving teens information about sex makes
it more likely that they will have sex Definitely Definitely not Not sure
- How do most teenagers get HIV infection? Drug Use When a condom Sex without
breaks during sex a condom
Efficacy
How confident are you that you could
- explain how HIV is spread Somewhat Not at all Very confident
- talk to other parents about teens' HIV risk Somewhat Not at all Very confident
- talk to other parents about teen sexuality Somewhat Not at all Very confident
- discuss sex with your teenage children Somewhat Not at all Very confident
Figure 1
[Figure not reproduced]
The Train-The-Trainer Concept. Source: Adapted with permission from
H. Schietinger et al. A strategy for educating health care providers
about AIDS, Nursing Clinics of North America, Vol. 23, pp. 779-787 ©
1988, W. B. Saunders Co.
Figure 2
[Figure not reproduced]
According to the teory of planned behavior, one's intention to carry
out an activity (behavioral goal) depends on one's attitudes about it
(such as whether one thinks it is useful or needed), one's
perceptions of whether significant others think it is desirable and
appropriate (norms), and whether one feels able to achieve it
(control). Behavioral control (which reflects, in part, self-efficacy
or confidence in one's knowledge and skills as well as control over
external barriers and facilitate) influences not only intention, but
actual performance of the behavior. Source: Data from I. Ajzen,
Attitudes, Personality and Behavior, © 1998, Dorsey Press.
Jo Anne Bennett, RN, CS, ACRN, PhD Consultant Public Health Nurse
Sylvia T. Contessa, RN, MA Associate Commissioner Nursing and Quality
Improvement
Levonne C. Turner, RN, MA Director of Nursing Bureau of School Health
New York City Department of Health New York, New York
The program team includes District Supervising Nurses Mary Johnson,
Biodun Adeyemi, and Mercedes Price; Public Health Nurses Brenda
Austin and Judith Maldonado; Jr. Public Health Nurses Wanda
Armstrong, Laurel Mitchell, and Denise Ximines; Public Health
Assistants Marie Brown and Pamela Perkins; and Health Educator
Clerenice Petersen-Flores. We thank Beatrice Krauss, PhD, and Edna
Bula of National Development Research Institute for their assistance
in preparing the parent trainer curriculum and sharing teaching
exercises; Carole Lippold, MEd, for advice and assistance with
logistics at all stages of the project; and Joseph N. DeJesus,
Superintendent of Bronx High Schools for his support.
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