manajemen rumah sakit 6
0 likes202 views
This document discusses optimizing HIV prevention interventions for adolescents. While past interventions have shown some effectiveness in modifying risk behaviors and increasing protective skills, their effects have been modest. The authors argue for expanding interventions beyond the individual level to address broader social and contextual influences. Specifically, they propose developing contextual interventions that target families, relationships, and communities in order to create supportive environments encouraging sustained behavior change. The authors also call for new theoretical models to guide the design of these expanded intervention approaches.
manajemen rumah sakit 6
- 1. EDITORIAL Human Immunodeficiency Virus Prevention for Adolescents Windows of Opportunity for Optimizing Intervention Effectiveness I N RESPONSE to the human immunodeficiency vi- scope and complexity of the HIV epidemic among ado- rus (HIV) epidemic among adolescents, there is lescents, new and innovative intervention research is criti- an overriding urgency to develop and imple- cal to optimize prevention efficacy. In this article, we ment prevention interventions designed to mo- briefly describe some discrete but cognate areas that hold tivate adolescents adoption and maintenance of considerable promise for enhancing the effectiveness of HIV-preventive practices. In the past decade, numerous HIV prevention interventions. HIV prevention programs have been designed, imple- mented, and evaluated. Modifying adolescents HIV risk RECONCEPTUALIZING ADOLESCENTS behavior has been a formidable challenge, but accumu- HIV RISK BEHAVIOR lating empirical evidence suggests that in general these programs are effective.1 However, estimating the mag- Historically, research conducted by scientists in the field nitude of intervention efficacy across these studies has of HIV prevention was useful in characterizing factors been difficult given the diversity of research designs and associated with adolescents sexual risk behavior. Many the heterogeneity of adolescent populations. of these studies implicitly conceptualized HIV- associated sexual behavior as an individual-level phe- See also page 381 nomenon. However, emerging evidence indicates that a spectrum of contextual factors and exposures are promi- In this issue of the ARCHIVES, Johnson et al2 present nent and interact with each other in promoting or pre- their findings from a meta-analysis of HIV prevention in- venting adolescents HIV-associated sexual behavior, in- terventions for adolescents conducted between 1985 and cluding psychological, social, relational, familial, 2001. Johnson and colleagues synthesized the data from developmental, structural, environmental, and cultural 56 HIV interventions. The authors calculated mean effect factors.6 Given the scope and complexity of influences sizes as a measure of the magnitude of HIV intervention that can affect adolescents sexual behavior, it is not likely efficacy for relevant psychosocial and behavioral out- to be understood in unidimensional or simplistic terms. comes. Their findings are encouraging: HIV prevention This individual-level perspective has also domi- interventions were found to enhance theoretically im- nated the field of HIV intervention research. The theo- portant psychosocial mediators of HIV-preventive be- ries guiding the design of these interventions and behavior- havior (ie, condom use negotiation skills, condom use change techniques have focused to a large extent on the skills, and communication with sexual partners). More adolescent. In general, interventions at this level were de- important, HIV interventions were also effective for modi- signed to enhance adolescents HIV prevention knowl- fying adolescents behavior; specifically, increasing ado- edge, attitudes, and beliefs, foster the development of per- lescents condom use and reducing the frequency of sexual ceived peer norms as supportive of HIV-preventive intercourse. However, marked differences were ob- practices, promote mastery of risk reduction skills, and served in mean effect sizes for psychosocial mediators and finally, motivate adolescents to adopt these preventive preventive behaviors. Psychosocial mediators demon- practices.3,4 Although they are effective at reducing HIV- strated larger mean effect sizes (range, 0.27-0.50), whereas associated sexual behavior, individual-level interven- statistically significant but modest mean effect sizes were tions may not be sufficient to promote the adoption and identified for HIV-preventive behaviors (range, 0.05-0.07). maintenance of HIV-preventive behaviors for pro- The findings of Johnson et al2 substantiate a grow- longed periods. Adhering to HIV-preventive sexual prac- ing body of evidence indicating that HIV prevention in- tices may be particularly challenging in the face of per- terventions can effectively enhance the acquisition of pre- vasive countervailing pressures, such as peer pressure or ventive skills and behaviors.3,4 It is unclear, however, media exposure, that encourage risky behavior. Further- whether the changes observed, particularly for HIV- more, addressing behavioral change at the individual level, preventive behaviors, are of sufficient magnitude to sub- whether targeting adolescents through individualized stantially affect the HIV epidemic among adolescents from counseling or group-based interventions, may lack suf- a public health perspective. A critical question is whether ficient breadth to reach large segments of the at-risk ado- we can enhance the efficacy of HIV prevention interven- lescent population. To amplify prevention efficacy, there tions. As the lessons of history have shown, there are un- is a clear, cogent, and compelling need to expand and fortunately no magic bullets or easy answers.5 Given the diversify the portfolio of HIV prevention interventions (REPRINTED) ARCH PEDIATR ADOLESC MED/ VOL 157, APR 2003 WWW.ARCHPEDIATRICS.COM 319 息2003 American Medical Association. All rights reserved.
- 2. to include programs that transcend individual-level in- been achieved, much remains to be accomplished. Op- terventions and effectively target the broader range of timizing HIV prevention efforts for adolescents will re- influences that promote and reinforce adolescents risk quire a sustainable and coordinated infrastructure to and protective behavior.6 stimulate and support contextual intervention research. Contextual HIV intervention research can marshal new THE SEARCH FOR kinds of data, ask new and broader questions regarding CONTEXTUAL INTERVENTIONS adolescents and their risk of HIV, and most important, create fresh options for prevention. Ultimately, to be op- Contextual interventions offer a promising approach for timally effective, the primary prevention of HIV infec- optimizing the efficacy of HIV prevention interventions tion among adolescents must become a public health for adolescents.7 Contextual interventions are designed priority. to affect important socializing networks at the family, re- lational, and community levels. These interventions pro- Ralph J. DiClemente, PhD mote behavioral change by providing adolescents with Gina M. Wingood, ScD, MPH the information and skills to motivate change through Atlanta, Ga naturally occurring channels of influence (ie, their com- munity, family, or relationships). Simultaneously, these Corresponding author and reprints: Ralph J. DiClemente, interventions provide a supportive environment that en- PhD, Rollins School of Public Health, Emory University, 1518 courages maintenance of these behaviors. Furthermore, Clifton Rd NE, Suite 554, Atlanta, GA 30322 (e-mail: contextual interventions recognize the power and po- rdiclem@sph.emory.edu). tential of supportive relationships. They take advantage of the diverse social networks within which adolescents REFERENCES are embedded by enhancing network linkages, creating health-promoting norms, and building supportive rela- tionships designed to encourage the adoption of HIV- 1. DiClemente RJ, Crosby R. Sexually transmitted diseases among adolescents: risk factors, antecedents, and prevention strategies. In: Adams G, Berzonsky M, eds. preventive behaviors. The Blackwell Handbook of Adolescence. Oxford, England: Blackwell Publish- ers. In press. DEVELOPMENT OF A NEW GENERATION 2. Johnson BT, Carey MP, Marsh KL, Levin KD, Scott-Sheldon LAJ. Interventions OF THEORETICAL MODELS to reduce sexual risk for the human immunodeficiency virus in adolescents, 1985- 2000: a research synthesis. Arch Pediatr Adolesc Med. 2003;157:381-388. 3. Kirby D. School-based interventions to prevent unprotected sex and HIV among As the focus of intervention research shifts from indi- adolescents. In: Peterson JL, DiClemente RJ, eds. Handbook of HIV Prevention. vidual-level to contextual interventions, a cognate area New York, NY: Kluwer/Plenum Press; 2000:83-101. of research that holds promise for optimizing interven- 4. Jemmott JB III, Jemmott LS. HIV behavioral interventions for adolescents in com- tion efficacy is the development of a new generation of munity settings. In: Peterson JL, DiClemente RJ, eds. Handbook of HIV Preven- tion. New York, NY: Kluwer/Plenum Press; 2000:103-128. theoretical models. In HIV prevention, as in any field of 5. Brandt AM. No Magic Bullet. New York, NY: Oxford University Press; 1987. health promotion, theory is integral for guiding the de- 6. DiClemente RJ, Wingood GM. Expanding the scope of HIV prevention for ado- velopment, implementation, and evaluation of behav- lescents: beyond individual-level interventions. J Adolesc Health. 2000;26:377- ioral change interventions. Contextual frameworks in- 378. cluding the behavioral ecological model,8 the theory of 7. DiClemente RJ, Wingood GM, Crosby RA. Contextual perspective for under- standing and preventing STD/HIV among adolescents. In: Romer D, ed. Reduc- gender and power,9 and prevention marketing10 posit risk ing Adolescent Risk: Toward an Integrated Approach. Thousand Oaks, Calif: Sage behavior as the result of diverse social and environmen- Publications. In press. tal influences. Accordingly, these models provide a theo- 8. Hovell MF, Wahlgren DR, Gehrman CA. The behavioral ecological model: inte- retical blueprint for constructing and implementing in- grating public health and behavioral science. In: DiClemente RJ, Crosby R, Keg- ler M, eds. Emerging Theories in Health Promotion Research and Practice: Strat- terventions tailored toward an array of social and egies for Enhancing Public Health. San Francisco, Calif: Jossey-Bass Inc; 2002: environmental influences. 347-385. 9. Wingood GM, DiClemente RJ. Application of the theory of gender and power to CONCLUSIONS examine HIV-related exposures, risk factors, and effective interventions for women. Health Educ Behav. 2000;27:539-565. 10. Kennedy MG, Crosby RA. Prevention marketing: an emerging integrated frame- As Johnson et al2 demonstrate, the scales of evidence weigh work. In: DiClemente RJ, Crosby R, Kegler M, eds. Emerging Theories in Health in favor of interventions designed to reduce adoles- Promotion Research and Practice: Strategies for Enhancing Public Health. San cents HIV-associated sexual behavior. Although a lot has Francisco, Calif: Jossey-Bass Inc; 2002:255-284. (REPRINTED) ARCH PEDIATR ADOLESC MED/ VOL 157, APR 2003 WWW.ARCHPEDIATRICS.COM 320 息2003 American Medical Association. All rights reserved.