HIV/AIDS and Substance Abuse Primary Prevention in at Risk Adolescents: A Program Analysis
Sarah V. Curtis,
John S. Wodarski*
College of Social Work, Center for Behavioral Health Research,
The University of Tennessee, Knoxville, TN, USA
*Corresponding
author: John S. Wodarski, College of Social Work, Center
for Behavioral Health Research, The University of Tennessee, 214 Henson Hall,
Knoxville, TN 37996-3333, USA. Tel: +18659743988; Fax: +1865 9741662; Email: jwodarsk@utk.edu
Received Date: 01 May, 2018; Accepted Date: 21 May, 2018; Published Date: 28 May, 2018
1. Introduction
Knoxville is the county seat of Knox County and is the third
largest city in the state. Knoxville is home to approximately 448,644 people,
and of this population, 48,005 (10.7%) are minorities [1]. Currently, 26,136
people, 10,004 of whom are minorities, live in the inner city of Knoxville,
which consists of a collection of urban housing that was primarily a black
community from the beginning. Many housing opportunities were developed, but
due to lack of economic development, the urban neighborhoods began to decline.
In general, housing project communities have the lowest per capita income in
the nation and report some of the highest nationwide numbers of drug and child
abuse [2].
According to the National Household Survey on Drug Use and
Health, an estimated 9.6 million people have tried methamphetamine at some
point in their lives [3]. In recent years, Tennessee in particular has seen a
dramatic increase in methamphetamine abusers. In 2010, Tennessee led the
country in meth lab seizures [4]. The Tennessee Bureau of Investigation reports
that East Tennessee is part of the Appalachia High Intensity Drug Trafficking
area. With rural geography and proximity to I-40, East Tennessee is a prime
location for the production and distribution of illegal drugs [5].
In 2013, the Knox County Health Department released the results
of the 2013 Youth Risk Behavior Survey (YRBS). In Knoxville, 23% of Knox County
high school students admitted to using marijuana one or more times during their
life. Of that 23%, 7% disclosed that they had tried marijuana for the first
time before the age of 13. Other popular drugs used by Tennessee adolescents
were cocaine (5%), inhalants (8.4%), ecstasy (7.1%), and prescription drugs
(16%).
Underage drinking is also significantly prevalent in Knoxville
adolescents. According to the Knox County Youth Risk Behavior Survey (2013),
60% of high school students had ever had at least one drink of alcohol during
their life. Of that percentage, nearly 28% drank alcohol for the first time
before the age of 13. A third of participants responded as having at least one
drink of alcohol during the 30 days prior to the survey [6].
In 2011, Tennessee ranked 15th in the number of
new HIV diagnoses. There were a total of 921 individuals diagnosed that year
across the state [7]. In East Tennessee, there are currently 93 cases of
individuals living with HIV. Of those 93 individuals, 17 are under the age of
25 [8]. In East Tennessee, risky sexual behaviors are prevalent. Nearly 40% of
Knox County high school student reported ever having sexual intercourse. Of
that percentage, only half of the students reported that they used a condom the
last time that they had sexual intercourse [6].
The ultimate goal of the program was to provide a coordinated
continuum of culturally competent HIV/AIDS preventive services for adolescents
and those linked to them, in order to reduce their use of substances and help
prevent transmission of HIV/AIDS and ultimately improve their lives and ability
to function. In order to achieve the primary goal of the project, eleven
process goals were identified:
1. Intervene
effectively to provide culturally competent HIV/AIDS-related substance abuse
prevention services for adolescents and to others linked to the client in both traditional and non-traditional settings;
2. Help adolescents
abstain from or reduce their use of alcohol and/or drugs;
3. Reduce adolescents’
involvement in illegal activities and thereby reduce criminal justice
expenditures;
4. Increase
adolescents’ academic involvement and productivity;
5. Improve adolescents’
family and community lives;
6. Enhance adolescents’
relationships with others;
7. Facilitate
adolescents living in a stable environment;
8. Improve adolescents’
mental and physical health;
9. Expand adolescents’
life management skills to improve their quality of life;
10. Decrease substance abuse-related
costs to society; and
11. Reduce the health and social costs of
substance abuse and dependence to the public and increase the safety of
America’s citizens by reducing substance abuse related crime and violence.
2. Method
This project targeted male and female adolescents 12-17 years
old. The program implemented small group educational techniques based on the
Teams-Games-Tournaments (TGT) Alcohol Prevention curriculum, cited as a Model
Program in SAMHSA’s National Registry of Effective Programs and Practices
(NREP) and as a Model Program by the Office of Juvenile Justice and Delinquency
Prevention, and the Reducing the Risk (RTR) curriculum, both of which have been
empirically evaluated as effective methods of teaching adolescent skills
development in the areas of substance abuse and high-risk sexuality prevention.
This program was originally conducted in conjunction with The
Boys and Girls Clubs of the Tennessee Valley. While working with The Boys and
Girls Clubs, the participants would attend a total of twenty sessions over the
course of school year. With the twenty-session format it was difficult to
recruit adolescents who were willing to commit to the twenty sessions and it
was also difficult to retain the participants who were recruited. We decided to
shorten the program to five sessions. This method proved to be much more efficient
and we were able to reach more adolescents. Eventually we had to discontinue
our partnership with The Boys and Girls Clubs because of an abstinence-only
initiative they began implementing in the Clubs. We began outreach in other
venues and found that advertising in the local newspaper was very effective for
recruitment. We used our community connections and found several churches in
East Tennessee that allowed us to use their space to hold our classes. We
changed the format for these classes to an all-day seminar. The all-day
seminars allowed us to reach a large number of adolescents while still
maintaining the integrity of the program. Our program gained strong notoriety
and we had an extensive waitlist for the final two years of the project.
Participants completed a baseline survey before the session
began and an exit survey at the end of the session. This exit (follow-up)
survey was completed between three and six months after the intervention. The
survey tool used was the National Minority SA/HIV Prevention Initiative Youth
Questionnaire (OMB No.: 0930-0298). Participants were given a $20.00 gift card
to WalMart for each survey completed for a possible total of $60.00 in gift
cards. The individuals who led the sessions were graduate students in the MSSW
program at the University of Tennessee College of Social Work. Sarah Curtis,
L.M.S.W., developed a curriculum guide that each facilitator used during the
sessions.
2.1. Sessions
2.1.1. 20-Session Format
Session 1: Introduction and Initial Survey
Session 2: Ice Breakers/Ground Rules
Session 3: Introduction to Major Classifications of Substances
Session 4: Tournament
Session 5: Physical Effects of Psychoactive Substances
Session 6: Tournament
Session 7: Exploring Attitudes about Drugs and Sex in the Media
Session 8: Tournament
Session 9: Peer Pressure, Psychoactive Substance Use and Sexual
Activity
Session 10: Tournament
Session 11: Values
Session 12: Tournament
Session 13: Sexually Transmitted Infections
Session 14: Tournament
Session 15: Facts and Myths about HIV/AIDS
Session 16: Tournament
Session 17: How HIV/AIDS is transmitted
Session 18: Final Tournament
Session 19: Final Tournament
Session 20: Final Survey
2.1.2. 5-Session Format
Prior to Class: Introductions and Initial Survey
Session 1: Icebreakers, Values/Ethics, Peer Pressure, and the
Media; Tournament
Session 2: Introduction to Major Classifications of Substances;
Physical Effects of Psychoactive Substances; Tournament
Session 3: Sexually Transmitted Infections; Facts/Myths about
HIV/AIDS; How HIV/AIDS is transmitted
Session 4: STI/HIV/AIDS Tournament
Session 5: Final Tournament; Final Survey
2.1.3. All-Day Format
9:45am-10:00am: Registration
10:00am-10:45am: Baseline Survey
10:45am-11:40am: Introduction to Major Classifications of
Substances; Physical Effects of Psychoactive Substances; Tournament
11:40am-12:00pm: Sex and Drugs in the Media
12:00pm-12:45pm: Lunch
12:45pm-1:30pm: Sexually Transmitted Infections
1:30pm-2:30pm: Facts/Myths about HIV/AIDS; How HIV/AIDS is
transmitted; Tournament
2:30pm-3:15pm: Peer Pressure, Values/Ethics
3:15pm-4:00pm: Final Tournament/Activity; Exit Survey
3. Results
3.1. Participant Demographics
3.2. Survey Results
4. Discussion
The program was adapted several times in order to meet the needs
of the population. The program was originally designed as a twenty-session
format but was reduced to a five-session format and then reduced again to an
all-day workshop. We found that this not only aided in the retention of our
participants but also allowed us to reach more adolescents.
Capacity building was vital during the course of the program. We
fostered relationships with many community agencies including The Boys and
Girls Clubs, various mental health agencies, local churches, local news
outlets, and the Knox County School System. These relationships aided in
building a sustainability plan. Helen Ross McNabb, a local mental health
services agency, has assumed responsibility in continuing to offer these
services to East Tennessee adolescents.
Our program served a total of 580 participants in East
Tennessee; 45.5% identified as male and 53.6% identified as female (Figure 1).
Participants’ knowledge of risky behaviors increased as evidenced by the
initial data analysis. The number of participants who believed there was great
risk in drinking five or more drinks of alcohol once or twice a week increased
from 60.7% at baseline to 66.6% at follow-up. (Figure 2) When asked how likely
are you to be sexually active in the next three months, 71.7% of participants
responded “not at all likely” at baseline, which increased to 79.6% at the
three-month follow-up (Figure 2.1). Participants’ knowledge of HIV/AIDS greatly
improved over the course of the program. After the educational intervention
provided, a greater number of participants correctly answered the true/false
questions regarding HIV/AIDS such as “only people who look sick can spread the
HIV/AIDS virus,” (Figure 2.3) and “birth control pills protect women from
getting the HIV/AIDS virus” (Figure 2.4). The number of participants who
reported being tested for HIV increased from 7.8% at baseline to 9.1% at the
follow-up (Figure 2.9). After the intervention, 45% of participants stated that
they would be willing to be tested for HIV if given the opportunity (Figure 3).
The participants who expressed interest in being tested for HIV were referred
to the Knox County Health Department.
5. Limitations
It was difficult to recruit the number of adolescents needed
while also trying to solely focus on targeting minority adolescents. Because of
the predominantly white demographic in East Tennessee, it was difficult to
obtain a large number of participants who identified in a minority group. We
did end up with a sizeable sample size over the course of the project. Some of
the data may have been skewed due to adolescents not completely understanding
the survey instrument that was used. Also, because this program was an optional
program for adolescents to participate in, it is difficult to monitor how our
selection process may have biased the data.
Throughout the study, we also found that many of the
participants were confused with several of the survey questions leading to them
either not respond, or incorrectly answer the questions. For example, questions
47 and 48 ask participants “I can get my boyfriend or girlfriend to use a
condom, even if he or she does not want to,” and “I would be able to say to my
boyfriend or girlfriend that we should use a condom.” These questions are
hypothetical when a respondent does not have a boyfriend or girlfriend. Many
participants selected “strongly disagree” to these two items which might seem
to indicate that they would be inclined to practice unsafe sex. In reality,
those participant’s responses were due to sexual abstinence. Another question
that was confusing for participants was “describe where you live.” If they
lived in a home with their parents, they should have selected “in my own home
or apartment.” However, many of the participants interpreted that as meaning
they owned or rented the home themselves and thus the participants indicated
they lived “in a relative’s home.” Several participants also brought it to our
attention that questions 36 through 40, which addressed the approval of risky
behaviors, should have included answers indicating approval. For example, one
question stated, “How do you feel about someone your age trying marijuana or
hashish once or twice?” The answer options include: neither approve nor disapprove,
somewhat disapprove, strongly disapprove, don’t know or can’t say.
6. Recommendations
Future sustainability of the program presented here is hopeful
with the cooperation of the Helen Ross McNabb Center guided by the Principal
Investigator of this project. Helen Ross McNabb has repeatedly shown great
enthusiasm for incorporating new ideas and programs to better serve at-risk
populations in East Tennessee. They have a wonderful track record of developing
new ideas stemming from research projects into real world programs. They will
hopefully continue the work presented in this study by constantly updating
their procedures and refining the survey presented here to be more concise and
easy to understand while maintaining the validity of the items as they relate
to this at-risk group of adolescents.
7. Funding
The research work for the Substance Abuse and Mental Health
Services Administration has got Grant # SP14989 support.
Results
Participant Demographics
Figure 1 |
|
Gender |
|
Male |
45.5% |
Female |
53.6% |
Figure 1: Participant Demographics.
Figure 1.1 |
|
Race/Ethnicity (Participants were allowed to select multiple categories) |
|
Hispanic |
5% |
White |
55.3% |
Black or African American |
42.9% |
American Indian |
2.1% |
Native Hawaiian or Other Pacific Islander |
0.2% |
Asian |
1.2% |
Alaskan Native |
0.3% |
Other |
5% |
Figure 1.1: Race/Ethnicity.
Survey Results
Figure 2: RSKALC |
||
How much do people risk harming themselves when they have 5 or more drinks of alcohol once or twice a week? |
||
|
Baseline |
Follow-up |
No risk |
7.0% |
4.5% |
Slight risk |
8.3% |
5.5% |
Moderate risk |
24.0% |
23.4% |
Great risk |
60.7% |
66.6% |
Figure 2: RSKALC.
Figure 2.1: SEX_ACTIVE_3MOS |
||
How likely are you to be sexually active in the next 3 months? |
||
|
Baseline |
Follow-up |
Not at all likely |
71.7% |
79.6% |
A little likely |
14.5% |
7.3% |
Somewhat likely |
6.5% |
6.8% |
Very likely |
7.3% |
6.4% |
Figure 2.1: SEX-Active-3Mos.
Figure 2.2: HIV_SICK |
||
Only people who look sick can spread the HIV/AIDS virus |
||
|
Baseline |
Follow-up |
False |
73% |
89% |
Figure 2.3: HIV_GAYSEX |
||
Only people who have sex with gay people get HIV/AIDS |
||
|
Baseline |
Follow-up |
False |
73% |
89% |
Figure 2.3: HIV-Gay Sex.
Figure 2.4: HIV_BCPILL |
||
Birth Control pills protect women from getting the HIV/AIDS virus |
||
|
Baseline |
Follow-up |
False |
63% |
81% |
Figure 2.4: HIV-BC Pill.
Figure 2.5: HIV_CURE |
||
There is no cure for AIDS |
||
|
Baseline |
Follow-up |
True |
50% |
66% |
Figure 2.5: HIV-Cure.
Figure 2.6: HIV_18TEST |
||
Young people under the age of 18 need their parents’ permission to get an HIV test |
||
|
Baseline |
Follow-up |
False |
29% |
49% |
Figure 2.6: HIV-18 Test.
Figure 2.7: HIV_STD |
||
Having another STD increases a person’s risk of becoming infected with HIV |
||
|
Baseline |
Follow-up |
True |
35% |
48% |
Figure 2.7: HIV-STD.
Figure 2.8: HIV_DRGS |
||
There are drugs available to treat HIV that can lengthen the life of a person infected with the virus |
||
|
Baseline |
Follow-up |
True |
37% |
55% |
Figure 2.8: HIV-DRGS.
Figure 2.9: HIV_IVDRG |
||
Sharing intravenous needles increases a person’s risk of becoming infected with HIV |
||
|
Baseline |
Follow-up |
True |
58% |
80% |
Figure 2.9: HIV-IV-DRG.
Figure 3.0: HIV_ORAL |
||
You can become infected with HIV by having unprotected oral sex |
||
|
Baseline |
Follow-up |
True |
59% |
82% |
Figure 3.0: HIV-Oral.
Figure 3.1: HIV_TESTED |
||
Have you ever been tested for HIV? |
||
|
Baseline |
Follow-up |
Yes |
8% |
9% |
Figure 3.1: HIV-Tested.
Figure 3.2: HIV_OP2TEST |
||
If you had the opportunity to be tested for HIV, would you? |
||
|
Baseline |
Follow-up |
Yes |
36% |
45% |
Figure 3.2: HIV-OP2 Test.
Statistical Significance: ANOVA |
|
Variable Name |
Significance (* denotes significance) |
RSKALC |
.027* |
SEX_ACTIVE_3MOS |
.175 |
HIV_SICK |
.252 |
HIV_GAYSEX |
.376 |
HIV_BCPILL |
.587 |
HIV_CURE |
.048* |
HIV_18TEST |
.000* |
HIV_STD |
.006* |
HIV_DRGS |
.002* |
HIV_IVDRG |
.345 |
HIV_ORAL |
.002* |
HIV_TESTED |
.761 |
HIV_OP2TEST |
.000* |
Statistical Significance: ANOVA.
- Metropolitan Planning
Commission (2014) Population Data: Demographic profile 2011-2013.
- Marcum E (2002) East Knox: Diversity, friendliness makes East
attractive.
- Substance Abuse and Mental Health Services Administration (2003)
National Household survey on Drug Abuse, 2002.Washington, DC: DHHS.
- Tennessee Methamphetamine Task Force (2010) Seizure trends.
- Centers for Disease Control
and Prevention (CDC) (2013) Tennessee-2013 state health profile.
- Tennessee Department of Health (2013) 2013 HIV disease epi
profile for East Consortium Region.
- Epidemiology Program (2013) 2013 Knox County Schools Risk
Behavior Survey. Knoxville, TN: Knox County Health Department.
- Tennessee Bureau of Investigation, Drug Investigation Division. Appalachia High Intensity Drug Trafficking Area (HIDTA).