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Development of an educational intervention to reduce the risk of HIV/AIDS for incarcerated adolescents detained in a county jail

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Development of an educational intervention to reduce the risk of HIV/AIDS for incarcerated adolescents detained in a county jail
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Sanders, Sadie B
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vii, 140 leaves : ; 29 cm.

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Adolescents ( jstor )
AIDS ( jstor )
Condoms ( jstor )
Criminal punishment ( jstor )
Disease risks ( jstor )
Educational programs ( jstor )
High school students ( jstor )
HIV ( jstor )
Jails ( jstor )
Juveniles ( jstor )
Dissertations, Academic -- Health and Human Performance -- UF ( lcsh )
Health and Human Performance thesis, Ph.D ( lcsh )
Escambia County ( local )
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theses ( marcgt )
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Thesis:
Thesis (Ph. D.)--University of Florida, 1998.
Bibliography:
Includes bibliographical references (leaves 129-139).
Additional Physical Form:
Also available online.
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Typescript.
General Note:
Vita.
Statement of Responsibility:
by Sadie B. Sanders.

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DEVELOPMENT OF AN EDUCATIONAL INTERVENTION TO REDUCE THE RISK OF HIV/AIDS FOR INCARCERATED
ADOLESCENTS DETAINED IN A COUNTY JAIL













BY
SADIE B. SANDERS














A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
DOCTOR OF PHILOSOPHY

UNIVERSITY OF FLORIDA

1998













DEDICATION

This dissertation is dedicated to my mother, Julia Sanders (December 20, 1916 March 07, 1998). Her courage, strength, love and passion for living life to the fullest have been and continue to be an inspiration to me.




































ii













ACKNOWLEDGEMENTS

I would like to thank all those who were instrumental in helping me

achieve a lifelong goal--my doctor of philosophy degree. My committee chair, Barbara A. Rienzo, provided unyielding support, encouragement, and professional guidance. My committee members, William Chen, Paul Duncan, and David Miller, graciously offered their time, professional expertise and professional guidance.

All my sisters and brothers, especially my sisters Mary S. Robbins and Sallie S. Shoemo and their families; my sister-in-law, Mary A. Sanders; and my niece, Christine Arnold, provided me unyielding support and love. My dearest friends, Lorraine Austin-McLeod, Carolyn Taylor, Edna Williams, Robert Joseph, Cynthia Ward, Evelyn Joseph, Margaret Gooden, Drucilla Washington and Alvin Lyons; and the New Macedonia Baptist Church family provided me ongoing encouragement and support. Melissa Silhan, Vice President of Lakeview Center, Inc., provided me a variety of professional opportunities. J. J. Crater and S. Kathy Zoss, Department of Forensics, eagerly offered me an opportunity to conduct my research in the Escambia Florida, jail.

Foremost, I would like to thank my brother and hero, David L. Sanders, for a lifetime of caring and support of all my educational endeavors.





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TABLE OF CONTENTS
pgqe

D E D IC A T IO N ........................................................................................ ii
ACKNOWLEDGEMENTS ........... ............................................................ iii
A B S T R A C T .......................................................................................... v i

CHAPTERS

1 IN T R O D U C T IO N .................................................... ............ 1

Statement of the Research Problem ......................... .............. 2
P urpose of the Study ............................................................ 3
Significance of the Study ...................................................... 3
D e lim ita tio n s ...................................................................... 4
L im ita tio n s ................................. ........................ ............... 5
A ssu m ptio n s ...................................................................... 6
R esearch O bjectives ............................................................ 6
D efinitions of T erm s ............................................................. 7

2 REVIEW OF THE LITERATURE ........................................... 11

In tro d u ctio n ....................................................................... 1 1
HIV and Adolescents .......................................................... 12
HIV and High-risk Adolescents .............................................. 17
HIV and Incarcerated Youth ................................................. 21
HIV Prevention Programs and Adolescents ............................. 27
Summary/Conclusion ......................................................... 39

3 MATERIALS AND METHODS .............................................. 41

In tro d u ctio n .................................................................... 4 1
Research Participants ........................................................ 42
R esearch S ettings ............................................................. 43
Instru m e ntatio n ................................................................. 44
Data Collection Procedures ................................................. 45
A na lysis of D ata ................................................................ 48


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4 RESULTS ...................................................... 50
Socio-demographics ............................................ 51
HIVIAIDS Risk Behaviors ....................................... 52
HIV/AIDS Knowledge............................................ 56
Attitudes Regarding H IV/AI DS................................... 58
UCF AIDS/HIV Risk Assessment Interview Results............. 61
Summary of Survey and Interview Results...................... 62
HIV/AIDS Educational Program for Juveniles Incarcerated in a
Count Jail Based on the AIDS Risk Reduction Model
(ARRM) .................................................. 64

5 DISCUSSION, CONCLUSIONS AND IMPLICATIONS........... 88

Socia-demographics ............................................ 89
HIV/AIDS Risk Behaviors........................................ 89
Knowledge and Attitudes about HIV/AIDS ....................... 90
HIV Prevention Programs and Incarcerated Adolescents........ 91 Implications and Conclusions ................................... 93
Recommendations for Future Research ........................ 96

APPENDICES

A UCF AIDS/HIV Questionnaire ................................. 100
B AIDS/HIV Risk Assessment Interview ......................... 108
C Institutional Review Board Approval Letter .................... 114
D Assent Form................................................... 115
E Consent Form ................................................. 116
F HIV/AIDS Educational Program Detailed Description.......... 117

REFERENCES ................................. ........................... 129

BIOGRAPHICAL SKETCH................................................... 140













Abstract of Dissertation Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy

DEVELOPMENT OF AN EDUCATIONAL INTERVENTION TO REDUCE THE
RISK OF HIV/AIDS FOR INCARCERATED ADOLESCENTS DETAINED IN A COUNTY JAIL

BY

Sadie B. Sanders

August 1998

Chairperson: Barbara A. Rienzo
Major Department: Health and Human Performance (Health Science Education)

Research reveals that youth who are detained or incarcerated in

correctional facilities constitute a subgroup of adolescents at high risk for HIV infection due to their engagement in considerably more HIV-related sexual and drug use behaviors than the general adolescent population. Although AIDS cases among adolescents appear to be low (less than 1 % of total reported AIDS cases), the majority of AIDS cases (64%) are diagnosed in persons aged 20-39, indicating that initial infection frequently occurred during the teenage years and early twenties due to the 9-15 year latency period.

Few studies have focused on HIV prevention among incarcerated

adolescents and none to date have addressed juveniles who are incarcerated in adult facilities. This study identified specific HIV/AIDS education needs of juveniles incarcerated in the Escambia County, Florida, jail and developed an Vi








appropriate educational intervention for these youth based on the AIDS Risk Reduction Model (ARRM) (Catania, Kegeles, & Coates), Survey data results revealed that, socio-demographically, these juveniles are predominantly male, they are between the ages of 13 and 17, the majority are of ethnictracial minority status (70.5% African-American), and more than a fourth have been incarcerated over three months. Regarding HIV high-risk behaviors, almost all of these juveniles are sexually experienced (98%), more than half have had over 10 lifetime partners, the majority do not use condoms consistently, and a vast majority (82.3%) had used marijuana. Research studies have found that noninjecting drug use, including alcohol, is associated with high-risk sexual behaviors. Non-injecting drug use may increase adolescents' sexual risk for HIV infection indirectly by lowering inhibitions and impairing judgement. In reference to HIV/AIDS knowledge and attitudes, overall, these juveniles possessed moderate to high levels of HIV/AIDS knowledge regarding, prevention, mode of transmission, and high-risk behaviors. However, they reported attitudes that potentially may increase their risk for becoming exposed to and infected with HIV, For example, the majority of these youth did not perceive themselves to be a high risk for contracting HIV and a large minority believed that there is a cure for AIDS. These findings were used to develop a theoretically sound prevention education program for these youths.








Vii













CHAPTER
INTRODUCTION

Acquired Immunodeficiency Syndrome (AIDS) continues to present itself as one of the most devastating epidemics of the nation and the world. HIV is beset by medical, legal, psychological, and social complexities. Although now treatable, AIDS remains a fatal disease. Infection with human immunodeficiency virus (HIV), the primary causal factor of AIDS, has the potential to severely disrupt the lives of individuals, families, and communities. It is often characterized by shame, guilt, fear, loss of dignity, financial ruin, and abandonment. Nelkin, Willis, and Paris (1990) declare, "AIDS in no'ordinary' epidemic. More than a passing tragedy, it will have long-term, broad-ranging effects on personal relationships, social institutions, and cultural configurations" (p. I).

Through December 1996, a total of 1,599,021 cases of AIDS had been reported worldwide (PAHO/WHO, 1997). The World Health Organization (WHO) estimated that 29.4 million people (worldwide) have been infected with HIV since the start of the pandemic in the late 1970s to early 1980s (PAHO/WHO, 1997). Well over 6,000 people become infected each day and an estimated average of 40 million people worldwide will become infected by the year 2000 (WHO, 1995).





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In the United States, as of December 31, 1996 over 581,000 cases of AIDS have been reported to the Centers for Disease Control and Prevention (CDC, 1996). Adults/adolescents have a 62.3 case-fatality rate, while pediatrics (children < 13 years old) have a 57.8 case-fatality rate (CDC, 1996). According to the CDC, as of January 31, 1995 AIDS is the leading cause of death in men and women aged 25-44 and the fifth leading cause of childhood deaths. To date, no AIDS cure is available and no vaccine for preventing infection with HIV exists. Currently, education appears to be the most viable weapon against the spread of HIV/AIDS.

Statement of the Research Problem

The total number of infected teenagers is unknown. Research studies reveal varying infection rates. Stein (1993) estimated that teenagers comprise approximately 20% of the HIV-infected population. In the United States, the majority of teenage AIDS cases (13-19 year olds) occur through transfusion of blood products or heterosexual transmission (HIV/AIDS surveillance report, 1995). Although AIDS cases among adolescents appear to be low (less than 1 % of total reported AIDS cases), the majority of AIDS cases (64%) are diagnosed in persons aged 20-39, indicating that initial infection occurred during the teenage years and early twenties due to the 9-15 year latency period (HIV/AIDS surveillance report, 1995).

Youths who are detained or incarcerated in correctional facilities

represent a medically underserved population that is at high risk for a host of preexisting medical and emotional disorders (Council on Scientific Affairs, 1990).





3

These youths constitute a subgroup of adolescents at high risk for HIV infection due to their engagement in considerably more HIV-related sexual and drug use behaviors than the general adolescent population (DiClemente, Lanier, Horan, and Lodico, 1991).

This study identified specific HIV/AIDS education needs of juveniles

incarcerated in the Escambia County, Florida, jail and developed an appropriate educational intervention for these youth utilizing survey data results. The educational intervention is based on the AIDS Risk Reduction Model (ARRM) (Catania, Kegeles, & Coates, 1990).

Purpose of the Study

The purpose of this study was to identify specific HIV/AIDS education

needs of juveniles incarcerated in the Escambia County, Florida jail and develop an appropriate educational intervention for these youth, to enable educators to more effectively educate incarcerated juveniles about high-risk behaviors including substance abuse and unsafe sexual practices.

Significance of the Study

Several research studies have focused on the issue of AIDS education within the correctional setting. However, few to date have targeted the jail system and even fewer have considered incarcerated youth. Jails are potentially effective vehicles for reaching drug users and individuals engaged in unsafe sex practices.

The criminal justice population, because illicit drug use and unsafe sexual practices are prevalent in their backgrounds, is at particularly high risk of HIV





4

infection (Stevens, 1993). AIDS is rapidly becoming the leading cause of death among correctional inmates (Gellert, Maxwell, Higgins, Pendergast, & Wilker, 1993). According to Pagliaro, and Pagliaro (1992), "Inmates generally engage in a greater number of these high-risk behaviors, (e.g. anal intercourse, needle sharing) more frequently than members of the general population" (p. 205). Through October 1989, a total of 5,411 cases of AIDS had been reported among inmates in state/federal correctional systems and 30 large city/county jail systems (Hammett & Moini, 1990a). Incarcerated youth are among those at risk for HIV infection due to their participation in high-risk behaviors such as illicit drug use, sexual activity with multiple partners, and/or failure to use condoms (Harper, 1992). As of 1989, approximately 94,000 10-17 year olds were detained in juvenile facilities and during 1990, an estimated 6,000 juveniles were incarcerated in local jails or in State or Federal prisons. Polonsky, Kerr, Harris, Gaiter, Fichtner, and Kennedy (1994) report that "Education and prevention counseling are at present the least controversial ways to control the spread of HIV infection" (p. 621). Education is a potentially viable prevention strategy crucial for the promotion of risk-reduction behaviors among incarcerated adolescents,

Delimitations

I Juveniles incarcerated in the juvenile section of the Escambia County

(Florida) jail and in DISC Village (Tallahassee, Florida) were invited to

participate in the study.





5

2. Data were collected from juveniles incarcerated during the months of

March-October, 1996.

3. The UCF AIDS/H IV Questionnaire (Appendix A) and the UCF AIDS/H IV

Interview Questions (Appendix B) were used to assess knowledge,

attitudes, behaviors, and socio-demographics of juveniles detained in the

Escambia County, Florida Jail and DISC Village, Tallahassee, Florida.

4. The intervention, based on the AIDS Risk Reduction Model was

developed using information obtained from the UCF AIDS/HIV

Questionnaire and the UCF AIDS/H IV Interview Questions.

5. Health risk behaviors regarding substance use and sexual practices were

determined by subject self-report.

Limitations

1 Participants incarcerated in the juvenile section of the Escambia County,

Florida jail and participants incarcerated in the DISC Village detention

facility (Tallahassee, Florida) may not represent the population of all

subjects in such settings.

2. Participants obtained were incarcerated youth available during March

through October of 1996. Participation was strictly voluntary.

3. Findings from the study were limited by the ability of the UCF AIDS/HIV

Questionnaire and the UCF Interview Questions to accurately assess

participants' knowledge, attitudes, behaviors, and socio-demographics.

4. Reliance on self-reported history of sexual and drug use behaviors.





6

Assumptions

1. Participants obtained for the study are representative of Escambia

County, Florida jail,

2. Juveniles incarcerated during the months of the study are not dissimilar to

juveniles detained in other months.

3. Data obtained by subject self-report were not dissimilar to that of inmates

detained in other months.

4. Instruments were adequate for the purpose of the study.

Research Obiectives

This study has several objectives. For all these objectives, responses

from the juveniles in the adult correctional facility will be compared with those of youth detained in a juvenile detention facility to determine if their education needs are comparable. The objectives of this study are to determine the:

1 Demographic characteristics that describe juveniles incarcerated in an

adult facility who are at high risk for HIV infection;

2. High-risk behaviors related to HIV/AIDS reported by juveniles detained in

these correctional facilities;

3. Level of HIV/AIDS knowledge of juveniles detained in these correctional

facilities;

4. Attitudes related to HIV/AIDS of juveniles detained in these facilities; 5. Components of a potentially effective HIV/AIDS prevention program

based on the AIDS Risk Reduction Model for juveniles detained in an

adult correctional facility. The UCF AIDS/HIV Questionnaire (Appendix A)





7

and the UCF Risk Assessment Interview (Appendix B) were used to plan

the educational Intervention.

Definitions of Terms

Acquired Immunodeficiency Syndrome (AIDS) the final, life-threatening stage of infection with human immunodeficiency virus (HIV) (The World Book Encyclopedia, 1995, p. 163).

Adolescence transitional phase of growth and development between childhood and adulthood. "Adolescence" is a convenient label for the period in the life span between 12 and 20 and is roughly equivalent to the term "teen" (The New Encyclopedia Britannica, 199, p. 104.

Centers for Disease Control and Prevention (CDC) the federal agency operating under the U. S. Department of Health and Human Services, Public Health Services, that is responsible for protecting the public health of the nation by instituting measures for the prevention and control of diseases, epidemics, and public health emergencies. Founded in 1946 (Huber, 1993, p. 32). High-risk Adolescents adolescents at high risk for HIV/AIDS include those who engage in unprotected sex, have multiple sexual partners, share needles and other injected drug equipment, or have sex with a "high-risk" person (Bowler, Sheon, D'Angelo, & Vermund, p. 345). Human Immunodeficiency Virus (HIV) the virus that causes Acquired Immunodeficiency Syndrome (AIDS). It is a retrovirus that infects the T4 lymphocyte cells, monocyte-macrophage cells, certain cell populations in the brain and spinal cord, and colorectal epithelial cells. HIV-infected cells weaken





8


the immune system. Individuals infected with the human immunodeficiency virus do not necessarily have AIDS. Previously called lymphadenopathy virus, human T-ceII leukemia virus III, and human T-cell lymphotrophic virus Ill (Huber, 1993, p. 76).

Jails facilities designed for detaining people awaiting trial and for people serving sentences of less than one year (Polonsky, Kerr, Gaiter, Fichtner, & Kennedy, 1994, p. 615).

Juvenile a young person who has not yet attained the age at which he or she should be treated as an adult for purposes of criminal law. In some states, this age is seventeen. Under the federal Juvenile Delinquency Act, a "juvenile" is a person who has not attained his eighteenth birthday (18 U.S. C.A. section 5031) (Black's Law Dictionary, 1993, p. 867). Juvenile Facility may include public or private detention centers, training schools, shelters, halfway houses, and the like (Polonsky et al., 1994, p. 625). Substance Abuse the Diagnostic and Statistical Manual of Mental Disorders Fourth Edition Criteria for Substance Abuse: A. A maladaptive pattern of substance use leading to clinically significant
impairment or distress, as manifested by one or more of the following,
occurring within a 12-month period:

(1) recurrent substance use resulting in a failure to fulfill major role
obligations at work, school, or home (e.g., repeated absences or
poor work performance related to substance use; substancerelated absences, suspensions, or expulsions from school; neglect
of children or household)
(2) recurrent substance use in situations in which it is physically
hazardous (e.g., driving an automobile or operating a machine
when impaired by substance use)







(3) recurrent substance-related legal problems (e.g., arrests for
substance-related disorderly conduct)
(4) continued substance use despite having persistent or recurrent
social or interpersonal problems caused or exacerbated by the
effects of the substance (e.g., arguments with spouse about
consequences of intoxication, physical fights)
B. The symptoms have never met the criteria for Substance Dependence for
this class of substance (APA DSM IV, 1994, pp. 182-183.)

Substance Dependence the Diagnostic and Statistical Manual of Mental

Disorders Fourth Edition Criteria for Substance Dependence: A maladaptive

pattern of substance use, leading to clinically significant impairment or distress,

as manifested by three (or more) of the following, occurring at any time in the

same 12-month period:

(1) tolerance, as defined by either of the following:
(a) a need for markedly increased amounts of the substance to achieve intoxication or desired effect
(b) markedly diminished effect with continued use of the same amount of the substance
(2) withdrawal, as manifested by either of the following:
(a) the characteristic withdrawal syndrome for the substance (refer to Criteria A and B of the criteria sets for withdrawal from the specific substances)
(b) the same (or closely related) substance is taken to relieve or avoid withdrawal symptoms
(3) the substance is often taken in larger amounts or over a longer
period than was intended
(4) there is a persistent desire or unsuccessful efforts to cut down or
control substance use
(5) a great deal of time is spent in activities necessary to obtain the
substance (e.g., visiting multiple doctors or driving long distances), use the substance (e.g., chain-smoking), or recover from its effects
(6) important social, occupational, or recreational activities are given
up or reduced because of substance use
(7) the substance use is continued despite knowledge of having
persistent or recurrent physical or psychological problem that is
likely to have been caused or exacerbated by the substance (e.g.,
current cocaine use despite recognition of cocaine-induced
depression, or continued drinking despite recognition that an ulcer




10


was made worse by alcohol consumption) (APA IDSM IV, 1995, p.
181)

World Health Organization (WHO) founded in 1948, this international organization is the health agency of the United Nations. Its goal is to achieve the optimum level of health care for all people. Objectives of the WHO include directing and coordinating international health work, ensuring technical cooperation, promoting research, preventing and controlling disease, and generating and disseminating information, The Organization emphasizes and supports the health needs of developing countries; establishes standards for biological, food, and pharmaceutical needs; and determines environmental health criteria (Huber, 1993, p. 162).













CHAPTER 2
REVIEW OF THE LITERATURE
Introduction

A healthy, productive generation of adolescents in the 1990s will ensure that America has the healthy generation of adults needed to support the

growing elderly population in the 21st century. The AIDS epidemic

threatens the viability, perhaps the very existence, of this next generation.

The social and economical well-being of this first "AIDS generation" may

well predict the future well-being of this nation as a whole in the next

century. (Hein, 1992, p. 3)

Medical interventions relating to HIV disease will have a significant

economic impact upon the health care industry. In 1993, $940 billion were spent on health care in the United States--1 2.1 % of the gross national product, According to Healthy People 2000, 75% of health care dollars are spent on chronic illnesses and only 1 % on preventing these same illnesses. Given the long latency period and the development of effective HIV treatments, AIDS, a chronic disease has the potential to consume a large portion of U. S. health caredollars. Jonsen and Stryker (1993) report that in the U.S., AIDS is responsible over 200,000 people receiving services from the health care system over the last 10 years, and an estimated one million are expected to receive services in this decade, many of whom are uninsured or underinsured.


11





12


The cost of AIDS is defined in terms of non-monetary and monetary costs. Non-monetary costs, according to Bloom and Carliner (1988), "include the value that AIDS patients, their families and friends, and other members of society place on the suffering and death of AIDS patients and on the need to behave differently to avoid contracting AIDS" (p. 604). Monetary costs include both direct and indirect costs. Direct costs are personal medical care costs such as diagnosis and treatment, and non-medical costs include research and prevention. Indirect costs represent the production lost to society due to the disease's morbidity and mortality (Farnham, 1994).

The literature focusing on Human Immunodeficiency Virus (HIV) disease among adolescents is presented in this chapter. This chapter will review literature on (1) HIV and adolescents, (2) HIV and high-risk adolescents, and (3) HIV prevention programs and adolescents.

HIV and Adolescents

In general, the nature of adolescence places teenagers at risk for

becoming exposed to and infected with HIV. Adolescence is characterized by the desire to seek independence from parents and other authority figures, conform to peers, take risks, and to experiment. According to Rotherman-Borus and Kooperman (1991), "The three behaviors that place persons at highest risk for HIV are typically initiated during this developmental period: unprotected sexual intercourse, IV drug use and the use of drugs and alcohol that disinhibit sexual behavior or lead to IV drug use" (p. 67).





13


Behaviors

While some research studies reveal that persons who are more

knowledgeable about AIDS engage in low risk behaviors, others show that persons who are more knowledgeable about AIDS engage in unsafe sexual practices (Morrison, Baker, & Gillmore, 1994).

A number of studies attest to youth engagement in high-risk behaviors for contracting HIV. Results from the 1993 Youth Risk Behavior Surveillance System revealed that nationally, 53% of high school students had engaged in sexual intercourse at least once; 18.5% of high school students had four or more sex partners; 58.2% of sexually active high school students had used a condom during their last sexual encounter; 32.8% ever used marijuana; and 1.4% of high school students had injected an illegal drug at least once during their lifetime (Kann, Warren, Harris, Collins, Douglas, Collins, Williams, Ross, & Kolbe, 1995). Lifetime prevalence data from the National Institute on Drug Abuse 1988 Drug Abuse Study revealed that nine million 12-17 year olds had ever used alcohol; 2.3 million had used marijuana; 3.4% had used illicit drugs; and 590,000 had used cocaine (NIDA, 1993). The 1987 National Adolescent Student Health Survey (NASHS) revealed that among a national sample of 8th- and I Oth-grade students, 77% of eight-grade students and 89% of tenth-grade students had ever used alcohol, 15% of eighth graders and 35% of tenth graders had used marijuana and 4% of eighth graders and 6% of tenth graders had used cocaine (CDC, 1989).

In a survey of 1,773 Massachusetts adolescents between the ages 16 and 19, 61 % reported that they had engaged in sexual intercourse in the past year. Among sexually active respondents, only 33% reported always using a condom, 32% reporting using a condom sometimes, and 37% reporting never using a condom. Regarding alcohol and drug use, those adolescents who





14


consumed five or more drinks per day were 2.8 times less likely to use condoms while those who used marijuana in the past month were 1.9 times less likely (Hingson, Strunin, Berlin, & Heeren, 1990).

A number of studies indicate that the use of non-injected drugs, including alcohol can increase one's risk for becoming HIV infected due to decreased inhibitions, impaired judgement, and the reduction of reluctance to participate in unprotected sexual intercourse. Hingson, et al. (1990) in a study of 1,773 Massachusetts 16-19 year-olds found that adolescents who consumed an average of five or more drinks per day were less likely to always use condoms than adolescents who were abstainers (29% versus 35%). Furthermore, those adolescents who had used other psychoactive drugs in the month prior to the survey were not as likely to always use condoms as adolescents who did not use psychoactive drugs.

Additionally, the association of drug abuse among adolescents and the exchange of sex for drugs, money, food, and shelter is well documented (CDC, 1993a).

Regarding intravenous drug use, IDUs are experiencing a greater

increase in the number of new cases of AIDS than homosexual and bisexual men (Hammett & Moini, 1990). In a national sample of 904 IDUs between the ages of 13 and 21 (92% between the ages of 18 and 21) not in drug treatment, a

6.2% seropositivity rate was found. Although, not statistically significant, females (7.2%) had a slightly higher rate than males (5.9%). Respondents who reported engaging in sexual activity With someone of the same sex or with both sexes, exchanging sex for money, or reported a previous history of syphilis, demonstrated the highest rates of HIV infection (Williams, 1993). According to the Centers for Disease Control and Prevention (CDC), youth between the ages of 13 and 19 constitute approximately 1 % of the total number of AIDS cases





15


(HIV/AIDS surveillance report, 1995). Although the actual number of HIV infected adolescents is unknown, it is believed to be much higher than the adolescent AIDS prevalence due to the 9-15 year incubation period for HIV (CDC, 1995). To date, a few national studies have focused on HIV prevalence among adolescents. Teenage applicants to the U.S. military between October 1985 and March 1989 had an overall seroprevalence rate of .34 in 1000. The rates for males and females were comparable, .35 and .32 per 1000, respectively (Burke, Brundage, Goldenbaum, Garner, Peterson, Visintine, Redfield, & the Walter Reed Retrovirus Research Group, 1990). Entrants to the Job Corp between 1987 and 1990, age 16-21, had an HIV seropositivity rate of

3.6 per 1000. The overall rate was higher in males (3.7 per 1000) than in females (3.2 per 1000). However, for entrants ages 16 and 17, the rate was higher in females (2.3 per 1000) than in males (1.5 per 1000). Geographically, the overall highest prevalence rate was found in the northeast, followed by the South, Midwest and West (St. Louis, Conway, Hayman, Miller, Petersen, & Dondero, 1991).
High teenage pregnancy rate and the increasing number of teenagers receiving treatment for STDs provide indirect indicators of sexual intercourse without the use of a condom. In the Unites States, each year, one million teenage females become pregnant and 3 million teenagers are infected with an STD (Kolbe, 1992).

Knowled-ge and Attitudes
In one of the first studies to assess adolescents' knowledge and

attitudes, Price, Desmond, and Kukulka (1985) found that, among 250 Ohio high school students only 27% of respondents were personally worried about contracting AIDS and between one half and three-fourths of these adolescents





16


did not understand how HIV is transmitted although they were knowledgeable about high-risk groups. In contrast, DiClemente, Zorn and Temoshok, (1986) in a survey of 1,326 adolescents enrolled in Family Life Education classes at 10 high schools in San Francisco, found that 92% of respondents were aware that HIV could be transmitted through sexual intercourse. However, only 60% correctly reported that using a condom during sexual intercourse could lower the risk of HIV transmission. Although 66% of the San Francisco respondents reported being worried about AIDS, over half reported that they are "less likely than most people to get AIDS."

DiClemente, et a[. (1986) attributed the apparent greater knowledge and higher awareness of the San Francisco group to the location of participants near the AIDS epicenter. However, DiClemente, Brown, Beausoleil and Lodico (1993) compared knowledge, attitude and behavior data of adolescents living in low AIDS or HIV prevalence communities with that of adolescents living in high AIDS prevalence communities and found that although both populations revealed high levels of AIDS knowledge, those adolescents in a rural area were more knowledgeable about AIDS than their inner-city counterparts.

In a study assessing AIDS knowledge and attitudes of 90 9th- and 10thgrade students from two Tennessee urban high schools before and after an AIDS education program, 75% or more of male and 75% of female respondents correctly answered 64% and 55%, respectively, of the knowledge questions (Steitz & Munn, 1993). DuRant, et al. (1992) assessed the knowledge and perceived risk of 2,483 11 th- and 12th-grade students in a southeastern community and found that 97.3% of the students knew that sharing needles with an infected person was a means of HIV transmission. However, some adolescents held several misconceptions about prevention that could increase their risk for becoming infected with HIV. For example, 17.4% of the students





17


believed that birth control pills are effective in preventing HIV transmission. Additionally, a large minority (25.7%) thought it possible to determine the HIV status of another person by looking at them.

HIV and High-risk Adolescents
Adolescents who engage in unprotected sexual intercourse, those who have multiple sexual partners, and adolescents who use illicit drugs and alcohol are at highest risk for becoming HIV seropositive (Melchert & Burnett, 1990; Morrison, et al., 1994; National Commission on AIDS, 1994; Rotherman-Borus, & Kooperman, 1991; Yarber, & Parrillo, 1992). Several subgroups of adolescents, including homeless and runaway youth, minority youth, and incarcerated youth, engage in more than one of these high risk activities, and thus are considered most vulnerable for contracting HIV (DiClemente, Lanier, Horan, & Lodico, 1991; Fullilove, Golden, Fullilove Ill, Lennon, Porterfield, Schwartz, & Bolan, 1993; National Commission on AIDS, 1994; Rotheram-Borus, Kooperman, & Ehrhardt, 1991; Stricoff, Kennedy, Nattell, Weisfuse, & Novick, 1991; Strunin, 1991). Runaway and Homeless Youth

Homeless youth, because of participation in high-risk behaviors, are

emerging as a subgroup of adolescents at high risk for HIV infection. Homeless youth, totaling about 1.5 million in the United States are defined by RotheramBorus, Kooperman, and Ehrhardt (1991) as "those who have left their homes without a parent's or guardian's consent (runaways), those who are thrown out of their homes (throwaways), those who leave problematic social service placements (system kids), and those lacking basic shelter (street youths)" (p. 1188). Homeless youth are at risk for HIV infection due to their drug abuse and sexual behaviors, as well as other problem behaviors that reduce their ability to





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demonstrate effective coping responses. According to Rotheram-Borus, Kooperman, and Ehrhardt (1991), in order to survive economically, homeless youth are subject to live in neighborhood with high HIV prevalence rates and to become involved in sexual and substance abuse behaviors that increase their risk for becoming infected with HIV. Moreover, the National Commission on AIDS (1994) reports that approximately 1 to 1.3 million teenagers, in an attempt to escape conflict, violence and abuse, run away from home every year. Many of these runaways engage in the exchange of sexual activity for money, food shelter, or drugs, thus increasing their risk for contracting HIV. Stricoff, et al., (1991) in a study of runaway and homeless youth at Covenant House, a facility serving runaway and homeless youth in New York, found an overall HIV prevalence rate of 5.3%. Research participants consisted of adolescents between the ages of 15 and 20 who were receiving health care. Over a 27month period, 2,667 specimens were analyzed. Ninety-one percent of participants were sexually active, with an average 2.8 and a range of 1 to 20 sexual partners per week, Twenty-nine percent had ever exchanged sex for food, money, shelter, or drugs. Drug use was extremely high, with 80% admitting to using alcohol, 68% marihuana, 48% cocaine, 38% crack, and 6% intravenous drug use.

In a study of 302 runaways (154 males, 148 females), aged 11 -19,

residing in four New York City area residential facilities, drug and alcohol use was prevalent and was found to be significantly related to an increased number of sexual partners and low condom use. Seventy percent of runaways in this





19


study reported ever using alcohol, while 43% admitted to ever using marijuana, 19% crack/cocaine, and 14% hallucinogens. The majority (63%) of runaways admitted to current sexual activity, With an average of two sexual partners. Only half of those participating in penile-vaginal intercourse reported using condoms. Condom use during oral sexual encounters was also very low, but was higher during anal sexual intercourse (Kooperman, Rosario, & Rotheram-Borus, 1994).

Research studies also show that homeless adolescents, in addition to participating in more sexual and drug use high-risk behaviors than the general adolescent population, are less knowledgeable about HIV/AIDS than the general adolescent population (Roth eram-B orus, Kooperman, & Ehrhardt, 1991). HIV and Racial/Ethnic Minority Adolescents

African-American and Hispanics are disproportionately represented in the number of reported AIDS cases. While African-Americans constitute only 12% of the United States total population, and Hispanics only 8%, they constitute 32% and 16%, respectively, of the total adult/adolescent AIDS cases. Additionally, African-Americans account for 55% of the pediatric AIDS cases and 33% of all AIDS cases for youths between the ages of 13 and 19. Hispanics between the ages of 13 and 19 make up 20% of the total AIDS cases for this age group (CDC, 1995).

Studies indicate that racial/ethnic minority adolescents are at increased risk for HIV infection. African-American teenage applicants to the U.S. military between October 1985 and March 1989, had an HIV seroprevalence rate of 1.06 per 1000 compared to an overall seroprevalence rate of .34 in 1000 (Burke, et





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al. 1990). Similarly, in a national study involving 16 to 21 year old entrants to the Job Corp between 1989 and 1990, African-American males and Hispanic males had H IV seropositivity rates of 5.5 and 3. 0 (per 1000), respectively, compared to white males who had a rate of 1.4 (St. Louis, et al., 1991).

In a national sample of 904 IDUs between the ages of 13 and 21, not in drug treatment, an overall 6.2% seropositivity rate was found. However, Afri can-Am eri cans had the highest rate (10.3%), followed by Whites (6.6%), and Hispanics (5.3%) (Williams, 1993).

Regarding HIV knowledge and attitude, DiClemente, Boyer, & Morales (1988) in a study of 261 White, 226 Black and 141 Latino adolescents enrolled in Family Life Education class at the 10 largest high schools in the San Francisco Unified School District, found substantial racial/ethnic differences. Black and Latino youth were less knowledgeable about AIDS and held more misconceptions than White youth. While all groups were aware that the disease could be acquired through sharing intravenous needles and having sexual intercourse With an infected person, only 59.9% of Black adolescents and 58.3% of Latino adolescents correctly reported that using a condom during sexual intercourse could lower risk of HIV transmission compared to 71.7% of White adolescents.

In contrast, some studies show little difference between ethnic/racial minorities and white adolescents. For example, Hingson, et al. (1990), in a telephone survey of 1,773 Massachusetts adolescents (age 16-19) in which 61 % had been sexually active in the past year, 28% of African-American compared to





21

31 % White reported always using a condom during sexual intercourse. Thirtynine percent of Hispanics reported always using a condom. Seventy-four percent of African-American adolescents admitted to having had sexual intercourse in the past year compared to 63% of Whites and 61 % Hispanics. Sixty-nine percent of African-Americans reported that they were worried about contracting AIDS compared to 73% of Whites and Hispanics. Additionally, in response to being asked if they had changed any of their behavior due to their worry over contracting the disease, 58% of Hispanics and 51 % of AfricanAmericans compared to 40% of Whites reported that they had made some changes.

A difference exists in the pattern of HIV transmission among minorities. African-American AIDS-diagnosed males are more likely than Hispanic and White male adolescents to have been involved in homosexual activity. Whereas, Hispanic males with AIDS are more likely than African-American males and White males to have injected drugs (Rotherman-Borus, & Kooperman 1991). Harper (1992), in a study exploring ethnic and gender differences in incarcerated adolescents' engagement in AIDS/HIV high risk behaviors, found that minority males and females were more likely than their white counterparts to engage in drug and alcohol use prior to sexual activity.

H IV and Incarcerated Youth
Youths incarcerated in detention facilities are predominantly males (more than 85%) and of racial or ethnic minority (Council on Scientific Affairs, 1990). AM can-Ameri cans comprise 42% of detained adolescents, while Hispanics





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account for 15% (Morris, Baker, & Huscroft, 1992). The majority of detained youths (82%) are between the ages of 14 and 17, with an average age of 15.7 years (Council on Scientific Affairs, 1990). The period of incarceration varies greatly and is influenced by a number of factors including the juvenile's current charge(s) and delinquent history, overcrowding of jail or detention facility, and the court calendar (Morrison, et al., 1994). As reported by the Council on Scientific Affairs (1990), short-term facilities, such as detention centers detain youth for an average of 12 days, while long-term facilities generally detain youth for an average of eight months. The majority of confined youth (95%) are detained due to legal offenses including, property offenses, offenses against persons, drug and alcohol use related offenses, and probation violations. Additionally, approximately 40% of youth referred to juvenile court have committed previous offenses.

The majority of individuals processed through urban jail systems have at least one illegal drug in their system at the time of arrest (McBride and Inciardi, 1990). In a recent NIDA-funded study of 12,000 injecting drug users (IDUs), 40% reported that they had spent some time in jail or prison Within the last six months (Baxter, 1991). IUD's are the second largest group with AIDS in the United States and the principle exposure group in the correctional system (60%) (Gellert, et al., 1993). In addition, IDUs are experiencing a greater increase in the number of new cases of AIDS than homosexual and bisexual men (Hammett & Moini, 1990b).

HIV Risk Behaviors

Incarcerated adolescents comprise a group at high risk for a number of health and health-related problems, including HIV and AIDS. According to the Council on Scientific Affairs (1990), youth detained in correctional facilities have





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a greater than expected rate of selected health problems, including substance abuse, sexually transmitted diseases, unplanned pregnancies, and psychiatric disorders due to their personal behavior and their lack of adequate prior health care services.
According to the National Commission on AIDS (1994), "research

suggests that incarcerated adolescents lack a future orientation, have poor selfimage, and perceive little or no value in modifying risk behavior" (p. 42).

Incarcerated youth participation in HIV high-risk activities is evidenced by the health status of these incarcerated youth (Council on Scientific Affairs, 1990). Blind studies involving 16- and 17-year olds incarcerated in detention centers in Los Angeles County, California revealed that three of 1,870 had a HIV seropositive test compared to 2 of 2,000 in 1989 and 4 of 2,000 in 1991 (Baker, & Morris, 1992).

In a study assessing sexually transmitted disease prevalence among females detained in the King, County, Washington, juvenile facility, it was revealed that 18% of 98 respondents were found to have N. gonorrhoea and 20% of 86 respondents were positive for C. trachomatis. Of 85 tested for Neisseria gonorrhoea and Chiamydia trachomatis, 32% were found to be infected with either one. However, none of the 61 detainees screened for syphilis tested positive. Sixty-seven percent of 98 respondents reported no contraceptive use, while 23% reported using foam and/or condoms and 8% reported oral hormone use (Bell, Farrow, Stamm, Critchlow, & Holmes, 1985).
In a similar study examining sexual behavior and sexually transmitted diseases among 966 detained male adolescents, 4.5% of detainees were infected with Neisseria gonorrhoea, 6.9% Chlamydia trachomatis, and 0.9% of detainees had a reactive syphilis serological test. Twelve percent of those tested for all three infections had at least one STD. Fifty-nine percent of those





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responding reported using a condom during their last sexual encounter and 37% reported consistent condom in the previous four months (Oh, Cloud, Wallace, Reynolds, Sturdevant, & Feinstein, 1994).

Pre-test counseling for voluntary HIV antibody testing conducted among 16 and 17 year old juveniles incarcerated in juvenile detention centers in Los Angeles County, California exposed a group at very high risk for contracting HIV. More than 90% of these youth admitted to having had sexual intercourse. Also, these detainees had a history of multiple sexual partners, low condom use, high incidence of previous treatment for sexually transmitted diseases (STDs), and high prevalence of multiple drug use, including 9% injecting drug use (IDU) (Baker, & Morris, 1992).

Drug and alcohol use by this population is higher than among the general adolescent population and may increase the likelihood that these adolescents may engage in high-risk sexual practices. According to the Council on Scientific Affairs (1990), a nationwide survey of detained juveniles revealed that 63% of respondents used drugs regularly, and 32% and 39% respectively, were under the influence of alcohol and another drug when they committed their offense.

Melchert and Burnett (1990) in a study to examine the high-risk sexual behaviors of 212 adolescents involved with Dane County, Wisconsin juvenile detention facility found that, compared to adolescents in the general population, these respondents had a very early mean age (12.5 years) at first intercourse and a high rate of pregnancy (27%).

Morrison, et al. (1994), in a study of 119 juveniles in a detention facility found these adolescents to be at high risk for HIV infection, relative to the general adolescent population. These juveniles had their first sexual intercourse at an early age (12.5), had high rates of heterosexual activity, and had high numbers of sexual partners. Additionally, one-third of these adolescents had





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used condoms the last time they engaged in sexual activity with their primary or steady partner, while about half had used condoms with their casual partners.

Results from a study involving incarcerated adolescents and public high school students also found that incarcerated youth tended to have higher rates of HIV risk behaviors. Ninety-nine percent of detained youth reported being sexually experienced compared to 28% of their school-based counterparts. Fifty-two percent of incarcerated youth reported sexual onset by age 12, compared to 26% of the high school sample. Additionally, 73% of incarcerated youth reported two or more sexual partners during the past year, compared to 8% of public school youth (DiClemente, et al, 1991).

Results from a study assessing beliefs about condoms and their

association with intention to use condoms among 201 juveniles in a detention facility indicate that these adolescents "had engaged in behaviors that put them at high risk of acquired immunodeficiency syndrome (AIDS) and other sexually transmitted diseases" (Gillmore, Morrison, Lowery, & Baker, 1994, P. 228.) Knowledge and Attitudes about HIV

In a study assessing knowledge and attitudes among 119 juveniles in a

detention center, it was revealed that these adolescents had moderately positive attitudes towards condom use and were generally knowledgeable about AIDS. However, these adolescents were at high risk, relative to the general adolescent population. (Morrison, et al., 1994).

Lanier and McCarthy (1 989a), in a study to assess incarcerated

adolescents' knowledge and concern about AIDS, found that most of the 393 juveniles who comprised 86% of the custodial population of the Alabama Division for Youth Services (DYS) were aware that AIDS is preventable, that it is not casually transmitted, and that sharing IV drug needles is a high-risk





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behavior. However, one-third believed that condoms are not effective means of preventing transmission. While 60% of these juveniles were concerned about their own risk of acquiring AIDS and 57% were concerned about their friends becoming infected, a large minority (18%) agreed with the statement "AIDS is a made up problem by the government to decrease drug use and sexual activity'. Eleven percent was uncertain. In a study comparing beliefs about AIDS among four subgroups of adolescents: urban public school students; suburban private school students; youth incarcerated in a detention facility; and gay adolescents, incarcerated adolescents were less knowledgeable, in lower agreement with AIDS health guidelines, had lower perceived personal threat of acquiring AIDS, and had lower personal self efficacy, compared to the other three groups (Nader, Wexler, Patterson, McKusick, & Coates, 1989).

DiClemente, et al. (1991) compared HIV knowledge data of incarcerated adolescents with that of public high school students and found that, while both populations demonstrated a high level of AIDS knowledge, substantial differences were present. Mainly, incarcerated youth were less aware of risk reduction behaviors. For example, only 56% of incarcerated youth correctly identified "not having sexual intercourse with a person who uses illegal drugs that can be injected" as a risk-reduction strategy, compared to 72% of public school youths.

Katz, Mills, Singh, and Best (1995) in a study comparing AIDS
knowledge and attitudes of 802 public high school students, incarcerated delinquents, and emotionally disturbed adolescents, found that while AIDS knowledge was moderately high in all three groups, incarcerated adolescents were slightly less informed about AIDS, less likely to believe that condoms can prevent disease transmission, more likely to feel powerless to protect themselves, and more sexually permissive.





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HIV Prevention Programs and Adolescents

Public education and voluntary behavior changes have been cited by the U.S. Surgeon General as being the most effective means to combat the spread of HIV disease (Surgeon General's Report, 1986). The U.S. public school system has the capacity to reach 45.5 million school-age youth annually (Allensworth, & Symons, 1989).

In response to a 1986 Surgeon General's report and in an attempt to curb the spread of HIV within the adolescent population, many public school systems hastily developed and implemented knowledge-based AIDS education programs which generally lacked a theoretical framework (Siegel, 1993). According to the National Commission on AIDS (1994), "if information about the consequences of unhealthy or risky behaviors were sufficient to motivate people to adopt health behaviors, no one would smoke, everyone would wear a seat belt, all doctors' recommendations about diet and exercise would be followed, and there would be no drunk driving" (pp. 45-46).

In order to be most effective, comprehensive HIV prevention programs must utilize strategies which combine cognitive and behavioral skills training, must be designed to be age appropriate, sensitive to cultural values, religious beliefs, sex roles, and attitudes and customs within the targeted population, and must provide access to services (Boyer, & Kegeles, 1991; DiClemente, 1 993a; DiClemente, Brown, et al., 1993; Fisher & Fisher, 1992; Gillmore, Morrison, Richey, Balassone, Gutierrez, & Farnis, 1997; Kooperman, et al, 1994; & National Commission on AIDS, 1994; ). Additionally, according to Boyer and





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Kegeles (1991), "Effective prevention programs should be based on models and theories of risk behavior so that the programs can be designed to change those factors which lead to the undesirable risky behaviors" (p. 11). Several theories have evolved that attempt to explain and predict human health behavior.

The Health Belief Model (Becker, 1974) has been widely used by health education professionals in explaining and predicting health behavior. The Health Belief Model (HBM), originally developed as a conceptual framework for explaining preventive behaviors, was formulated in the 1950s by a group of social psychologists, including Hochbaum, Leventhal, Kegeles, and Rosenstock. It is derived from the social-psychological theory of Lewin, Becker and others. Dimensions of the HBM include perceived susceptibility (subjective perception of the risk of contracting a health condition), perceived severity (personal evaluation of medical/clinical and social consequences posed by the health condition), perceived benefits (assessment of the effectiveness of actions recommended to reduce the disease threat), and perceived barriers (feelings related to negative consequences of the recommended health action). In an effort to improve its predictive power, the HBM was later expanded to include self-efficacy (Janz and Becker, 1984; Rosenstock, Strecher, and Becker, 1988). The Theory of Self-efficacy, first presented by Bandura (1977) is defined as ones perception that one can successfully perform preventive behaviors. According to Bandura (1977), "expectations of personal efficacy are derived from four principal sources of information: performance accomplishments, vicarious experience, verbal persuasion, and physiological states. The more





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dependable the experiential sources, the greater are the changes in perceived self-efficacy" (p. 191).

Although a significant amount of research suggest difficulties of the HBM in predicting HIV-related behaviors (Brown, DiClemente, & Reynolds, 1991; Montgomery, Joseph, Becker, Ostrow, Kessler, & Kirscht, 1989), several studies have validated the HBM's, (or more frequently, constructs of the model) usefulness in successfully predicting HIV-preventive behaviors. For example, in a study of 1, 1773 Massachusetts youth between the ages of 16-19, Hingson, et al. (1990) found that respondents were "more likely to always use condoms if they felt susceptible to AIDS; believed condoms are effective; perceived few barriers to condom use; and were exposed to more cues to action" (p. 296). Similarly, data from a study of 424 male and female undergraduate students at six United States schools revealed that, "susceptibility, self-efficacy, and social support were the most important predictors for current sexual behavior and for sexual behavior changes" (Steers, Elliott, Nemiro, Ditman, and Oskamp, 1996, p. 107).

Further support for the utility of the HBM to predict health behavior is evidenced in a study by Petosa and Wessinger (1990) to determine the HIV education needs of seventh, ninth, and eleventh grade adolescents. Results suggest that while these youth perceived themselves to be highly susceptible to contracting HIV, they failed to understand the severity of the disease. Additionally, a large minority reported that condoms are embarrassing to use and that it is difficult to discuss sexual histories with a partner.





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The Theory of Reasoned Action (Fishbein, & Ajzen, 1975) is a cognitive theoretical model suggesting that specific behavioral intentions are the determinants of behavior and that, the intention to perform a particular behavior is determined by the attitude towards performing the behavior and the perceived social norms regarding the behavior.

The AIDS Risk Reduction Model (ARRM) (Catania, Kegeles, & Coates, 1990) is a psychosocial conceptual model designed to examine people's efforts to change sexual behavior in order to avoid contracting HIV through sexual transmission. The ARRM incorporates elements of several prior models including the Health Belief Model, self-efficacy theory, the Theory of Reasoned Action, the Theory of Planned Behavior, emotional influences, and interpersonal processes. According to the ARRM, behavior change is a process occurring in three stages: (1) recognition and labeling of one's sexual behaviors as high risk for contracting HIV; (2) making a commitment to reduce high-risk sexual contacts and increase low-risk activities; and (3) seeking and enacting strategies to obtain these goals. Variables hypothesized to influence the recognition and labeling stage include knowledge of sexual activities associated with HIV transmission, the belief that one is personally susceptible to contracting HIV, the belief that having AIDS is undesirable (aversive emotions), and social influences, including social networks and social norms.

The commitment stage is reflective of a decision-making process that may also include decisions to remain undecided, wait for the problem to resolve itself or resign oneself to the problematic issue. Factors hypothesized to influence





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this stage include perceived costs and benefits, self-efficacy, knowledge and perception of enjoyment and risk reduction, and social influences.

The final stage, enactment includes information-seeking, obtaining

remedies, enacting solutions and social influences. Verbal communication with sexual partners regarding sexual issues is a key component of the enactment stage. According to Catania, et al. (1990), the ARRM is based on the premise that progress from one stage to the next is expected to be dependent on successfully completing the goals of the prior stage.

While the ARRM was originally developed to examine sexual behaviors and to be used With adult populations, with minor modifications, it is believed to be applicable to other HIV risk behaviors, as well as to adolescent populations (Catania, et al., 1990; and Boyer, & Kegeles, 1991).

The majority of the HIV/AIDS studies that have examined the utility of the ARRM have provided either supportive or mixed results. Kowalewski, Longshore, and Anglin (1994) in a study to examine the predictive ability of the first two stages of the ARRM for intentions to use condoms among 21-59 year old injecting drug users (IDUs) who had used them in the year prior to the interview and IDUs who had not found that, drug users' intentions to use condoms were strongly related to their social network.

Malow, Corrigan, Cunningham, West, and Pena (1993) in a study to

assess psychological factors associated with condom use among adult AfricanAmerican drug abusers, also presented data in support of key constructs of the ARRM. Condom users reported significantly higher levels of self efficacy,





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communication skills, condoms use skills, and communication skills than noncondom users.

Results from a study to examine the ability of the ARRM to explain factors motivating condom use among HIV-infected women (Kline and VanLandingham, 1994) suggest that, HIV-positive women who use condoms possess higher levels of perceived self-efficacy to influence the partner's sexual behavior than those who do not use condoms.

Lanier (1996), in a study to examine the primary constructs of the ARRM among juveniles detained by the Department of Youth Services in a southern state, found that response efficacy was significantly related to every aspect of the AIDS reduction behavior, and that knowledge and susceptibility were "highly associated with several specific AIDS reduction behaviors with high marginal influence" (p. 545).

Adolescents

Although school-based HIV prevention programs are a requirement of the majority of states and school districts, the initial focus of these programs was on increasing students' knowledge and changing their attitudes. Several of these knowledge-based programs have proven to be highly successful. For example, Brown, Fritz, Barone (1989), in a pilot study to assess the impact of an AIDS education program on 313 seventh and tenth grade students, found that students demonstrated an increase in AIDS information, positive attitudes toward prevention, and tolerance for people with AIDS after participation in the program. The intervention covered two class periods and included lecture and video material regarding HIV transmission and prevention. A study by Huszti, Clopton, and Mason (1989) also assessed the efficacy of a lecture/video





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education program presented to tenth grade students enrolled at two suburban public schools in the Oklahoma City area. Participants were randomly assigned to one of three groups; an intervention group receiving HIV/AIDS information via lecture, an intervention group receiving HIV/AIDS information via video, or to a control group receiving no educational intervention. Intervention group students demonstrated a greater increase in AIDS knowledge, more acceptance of people with AIDS, and more positive attitudes toward HIV risk reduction behavior than the control group. The effects of lecture were more effective than the effects of the video.

Ruder, Flam, Flatto, and Curran (1990) evaluated the impact of an HIV education program that consisted of a lecture presented by the Westchester County (New York) Health Department to junior and senior high school students. Results revealed that, students who received a brief 1-1 /4 hour Al DS-information presentation demonstrated a significant increase in knowledge compared to students who did not received the presentation. Brown, Barone, Fritz, Cebollero & Nassau (1991) evaluated the efficacy of a state-mandated AIDS education program on a sample of 2,709 middle- and high-school student and found that, students receiving the educational intervention demonstrated greater increases in knowledge about AIDS, tolerance for people with AIDS, and future intentions to engage in risk reduction risk behaviors, compared with students in the control group. The educational program was composed of approximately five hours of information regarding the nature of AIDS and AIDS transmission and prevention. It utilized a variety of strategies including, lecture, audiovisual presentations, class discussion, handouts, and guest speakers.

Dixon (1994), in a study of 184 students assessed the effectiveness of an HIV education program presented to three groups of 9-18 year old preadolescents and adolescents. The program incorporated group discussions, a





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question/answer session and a vignette that involved students playing the role of the virus. Results reveal that knowledge was increased in all three groups. In an evaluation of a discussion format-HIV/AIDS education program presented to 2,169 St. Louis high school students, Morton, Nelson, Walsh, Zimmerman, and Coe (1996) found that the educational intervention successfully increased students' knowledge of HIV/AIDS.
School-based HIV prevention programs have been proven to be

efficacious in their ability to increase adolescents' knowledge and, to some degree, create desired attitudes about HIV and risk-taking behaviors. However, many of these programs appear to have failed in their ability to significantly delay and/or reduce HIV high risk behaviors among adolescents (Kirby, Korpi, Adivi, & Weissman, 1997; Newman, DuRant, Ashworth, & Gaillard, 1993; & Walter & Vaughan, 1993)

Research suggests that the most successful school-based HIV prevention program are those programs that are theory-based, include both cognitive and behavioral aspects, and are skilled-based (Allensworth & Symons, 1989; Longshore, 1990; Boyer & Kegeles, 1991; Fisher & Fisher, 1992; Jemmott, Jemmott, & Fong, 1992; DiClemente, 1993; & National Commission on AIDS, 1994). However, only three states currently provide school-based programs that address cognitive, affective, and skills domains (DiClemente, 1993). According to DiClemente (1993), the failure of schools to incorporate all three domains in prevention programs is the result of social and political barriers.

To date, only a few of these programs have been evaluated. Main,
Iverson, McGloin, Banspach, Collins, Rugg, and Kolbe (1994) evaluated the impact of a 15-session (day) skills-based curriculum on 979 urban ninth- and eleventh-grade students enrolled in seventeen Colorado schools. The education program was based on the Social Cognitive Theory and the Theory of





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Reasoned Action. Twenty-five teachers, the majority of whom taught health, implemented the program after a five-day, 40 hour training program. However, the program failed in its attempt to postpone the onset of sexual intercourse and reduce the percentage of students currently engaging in sexual and drug use behaviors that place them at risk for HIV infection. The intervention students demonstrated greater knowledge regarding HIV and greater intent to engage in HIV risk reduction behaviors, and were more likely to believe that adolescents their age who participate in HIV high risk behaviors are susceptible to HIV infection than comparison group students. Additionally, at the 6-month followup, sexually active-intervention students reported fewer sexual partners and greater frequency of condom use.

In a study to assess the effectiveness of a teacher-delivered HIV riskreduction program in modifying AIDS-related knowledge, beliefs, self-efficacy and behaviors among 867 ninth- and eleventh-grade students, Walter and Vaughan (1993) found "Significant (albeit modest) effect favoring intervention were observed for knowledge, beliefs, self-efficacy, and risk behaviors scores at a three month follow-up" (p. 725). The cognitive-, behavioral- and skills-based education program was based on the Health Belief Model, the Social Cognitive Theory, and a model of social influence. The 6 one-class period lessons conducted on consecutive days were implemented by regular classroom teachers who had received eight hours of in-service training.

Boyer, Shafer, and Tschann's (1997) evaluation of a knowledge- and cognitive-behavioral skills-building intervention to prevent STDs and HIV infection in high school students revealed that, although the intervention did not have a significant impact on HIV knowledge and high risk behaviors, it did enhance intervention-group participants' skills to prevent risky sexual and substance use behaviors.





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High-risk Adolescents

Adolescents who are at highest risk for becoming HIV infected are also those youths who have, more than likely, dropped out of school and thus lack the opportunity to benefit from school-based education programs (National Commission on AIDS, 1994). Additionally, in-school youth that have high rates of absenteeism do not benefit fully from school-based HIV/AIDS prevention programs.

According to the National Commission on AIDS (1994), "Out of school youth have been documented as suffering from depression, anxiety, and low self-esteem" (p. 42). These youths often engage in HIV high-risk sexual behaviors as well as use drugs, including alcohol. Additionally, minority youth, particularly African-American youth, are a growing segment of the population who engage in HIV high risk behaviors as evidenced by high STD and pregnancy rates. In order to effectively address the specific HIV educational needs of these youth, HIV prevention programs targeting African-American youth, must address the attitudes and cultural values related to sexuality issues (Pittman, Wilson, Adams-Taylor, & Randolph, 1992).

Several studies have evaluated the efficacy of non-school- based HIV

education programs. A few of these programs targeting adolescents at highest risk for HIV infection have demonstrated effectiveness among runaway, minority, and substance abusing adolescent populations. Rotheram-Borus, Kooperman, Haignere, and Davies (1991) in a study to assess the impact of a skill-based HIV prevention program among 145 runaways between the ages of 11 and 18 at two New York City publicly funded runaway shelters found that, as the number of interventions sessions increased, so did the adolescents' reports of consistent condoms use and decreases in engagement of high risk behaviors at three- and six-month follow-ups. Seventy-eight runaways at the intervention shelter





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participated in an average of 11 (minimum of three) prevention sessions that presented general information regarding HIV/AIDS information and addressed coping skills, access to health care and other resources, and individual barriers to safer sex. Sixty-seven runaways at another shelter, comparable to the intervention site shelter served as the comparison group.

Jemmott, et al. (1992) conducted and evaluated an H IV reductionprogram with inner city Africa n-American males. The program was successful in reducing HIV high-risk behaviors among adolescents who received the intervention. A total of 157 participants with a mean age of 14.64 were recruited from a Philadelphia outpatient medical clinic, a local high school, and a local YMCA. Participants were randomly assigned to a 5-hour small-group AIDS riskreduction intervention or to a control group receiving a career opportunity workshop. Compared to control group participants, intervention group participants demonstrated greater AIDS knowledge and reported less sexual activity, fewer sexual partners and greater condom use at the 3-month follow-up.

Kipke, et al. (1993) assessed whether inner-city minority adolescents who were randomly assigned to an AIDS Risk Reduction Education and Skills Training (ARREST) program would demonstrate greater pre- to post-test knowledge and attitudes about HIV/AIDS, perception of risk and self-efficacy in prevention, and behavioral skills for reducing HIV risk than would those assigned to a wait-list control group. The sample consisted of eighty-seven Latinos (59%) and African-American adolescents, ages 12-16 years who were recruited from three New York City community-based agencies. Forty-one ARREST program adolescents participated in three 90-minute weekly sessions facilitated by two AIDS educators and consisting of small group discussions and skills-building activities. Results reveal that the ARREST program intervention was ineffective in modifying adolescents' high-risk sexual behaviors, such as





38


number of sexual encounters, number of sexual partners, and use of condoms. However, compared to the comparison group, the ARREST group demonstrated greater HIVIAIDS knowledge, decreases in negative attitudes, perceived risk of infection, and assertiveness and behavioral skills,

St. Lawrence, Brasfield, Jefferson, Alleyne, O'Bannon, and Shirley (1995) assessed the impact of a cognitive-behavioral intervention on African-American adolescents' risk for HIV infection. Two hundred forty-six African-American adolescents were randomly assigned to an 8-week HIV/AIDS prevention program, receiving a combination of HIV/AIDS education and behavior skills training, including condom use, social competency skills, and cognitive competency skills or an educational intervention, receiving HIV/AIDS information only. The results show that adolescents participating in the educational/behavior skills program demonstrated a greater increase in condom use and risk reduction skill compared to participants receiving the educational program post-intervention and through a 1 -year follow-up. Additionally, among adolescents who were sexually abstinent upon beginning the educational programs, adolescents receiving the education/behavior skills program delayed the onset sexual activity to a greater degree compared to the educational program participants.

Regarding substance-abusing adolescents, St. Lawrence, Jefferson, Banks, Cline, Alleyne, and Brasfield (1994) developed and assessed the effectiveness of a cognitive-behavioral HIV/AIDS prevention program on lowering substance-dependent adolescents' risk for acquiring HIV. Nineteen adolescents residing in the only residential treatment program serving substance-dependent minors in the state of Mississippi received a 5-session HIV risk-reduction program that included risk education, social competency skills, technical skills, and problem-solving skills. Results reveal an "increased





39


knowledge about HIVYAIDS, more favorable attitudes toward prevention, greater internal and lower external locus of control scores, more favorable attitudes toward condom use, increased self-efficacy, and greater recognition of HIV vulnerability" (p. 425).

In a similar study with similar results, 34 adolescents in a residential

substance abuse treatment program were randomly assigned to a standard HIV education program or a 6-session risk-reduction program that combined HIV education and behavior skills training. Adolescents participating in the education/behavior skills program demonstrated increased HIWAIDS knowledge, more positive attitudes toward HIV risk-reduction behaviors and condom use, more internal locus of control and increased self-efficacy and increase recognition of personal risk for HIV infection compared to the education program adolescents (St. Lawrence, Jefferson, Alleyne, & Brasfield, 1995).

Only a few studies have targeted youth in juvenile facilities and to date, none have considered adolescents incarcerated in adult facilities. Lanier and McCarthy (1989b) assessed the AIDS knowledge, attitudes, and behaviors of adolescents in a detention facility and evaluated the impact of an AIDS educational program among these adolescents. Results indicate that the intervention successfully increased juveniles' HIWAIDS knowledge and influences their attitudes toward AIDS.

Summary/Conclusion

Adolescents in general are at risk for HIV infection due to their

participation in high-risk behaviors, such as drug use and unprotected sexual intercourse. Research reveals that minority youth, homeless youths and runaways, and incarcerated youth are subgroups of adolescents who are at





40


increased risk due higher prevalence of HIV high risk behaviors. Compared to the general adolescent population, incarcerated adolescents, the majority of whom are of ethnic or racial minority status are slightly less knowledgeable, tend to have more sexual partners, are more likely to use injecting drugs, more likely to use alcohol and drugs and less likely to use condoms.

Recently, adolescents have been acknowledged as one of three groups among who AIDS incidence rates are growing at the fastest rate. Although the gains in HIV knowledge from educational interventions since the beginning of the AIDS epidemic up to this point are indisputable, these gains have not translated into positive behavioral changes among adolescents. Thus, general agreement exists among HIV and AIDS experts that knowledge alone is not sufficient to eliminate or reduce adolescents' participation in HIV high-risk behaviors. As a result, there is increased awareness of the need for developmentally appropriate, culturally sensitive comprehensive HIV prevention programs that incorporate accurate information, exploration of values and attitudes, skills building, and access to services (National Commission on AIDS, 1994).













CHAPTER 3
METHODS AND MATERIALS
Introduction

This study identified specific HIV/AIDS education needs of juveniles

incarcerated in the Escambia County, Florida jail and developed an appropriate educational intervention for these youth to reduce their risk for contracting HIV/AIDS. The intervention will enable educators to more effectively educate incarcerated juveniles about high-risk behaviors including substance abuse and unsafe sex practices. The objectives of this study were to determine the:

1 Demographic characteristics that describe juveniles incarcerated in an

adult facility who are at high risk for HIV infection;

2. High-risk behaviors related to HIV/AIDS reported by juveniles detained in

these correctional facilities;

3. Level of HIV/AIDS knowledge of juveniles detained in these correctional

facilities;

4. Attitudes related to HIV/AIDS of juveniles detained in these facilities; 5. Components of a potentially effective HI V/AIDS prevention program

based on the AIDS Risk Reduction Model for juveniles detained in an

adult correctional facility.

Each objective was analyzed utilizing information obtained from the UCF AIDS/HIV Questionnaire (Appendix A) and the UCF AIDS/HIV Risk Assessment


41





42


Interview (Appendix B). For objectives one through four, responses from the juveniles in the adult correctional facility were compared with those of youth detained in a juvenile detention facility.

This chapter includes the following sections: (1) research participants, (2) settings, (3) instrumentation (4) procedures and (5) data analysis.

Approval for this study was obtained through the University of Florida Institutional Review Board (Appendix C).

Research Participants

The study was conducted between the months of March and October 1996. Survey participants consisted of a total of 124 juveniles (107 males, 16 females, one missing observation). Interview participants consisted of a total of 45 juveniles (41 males and 4 females). Participants were detained in two correctional facilities, an adult facility (Escambia County, Florida jail) and a juvenile detention center (DISC Village). Seventy-nine of the survey participants (65 males and 13 females) and 23 of the interview participants (19 males and 4 females) were under the supervision of DISC Village detention facility. All detention center female participants were in the RAFT program located in Woodville, Florida. Male participants were detained in Greenville Hills Academy located in Greenville, Florida. Forty-five survey participants (42 males and 3 females) and 22 interview participants (all males) were detained at the Escambia County, Florida jail located in Pensacola, Florida. Study participants were between the ages of 11 and 18. Any Escambia County, Florida jail juvenile who is at least 18 years old or who reaches the age of 18 while detained in the jail is





43

automatically adjudicated an adult and is then housed in the adult section of the jail. As a result, no 18 year-olds were included in the jail group.

All juveniles incarcerated in the two facilities between March-October, 1996 were invited to participate in the study.

Research Settings

This study was conducted in two northwest Florida correctional facilities, an adult facility and a juvenile detention facility (DISC Village). Research participants detained in the adult facility were detained in the Escambia County, Florida jail, located in Pensacola, Florida. Male participants were located in the juvenile section of the jail while female participants were detained in the jail's infirmary. The Escambia County, Florida jail maintains a daily population of approximately 42 juveniles with an average age of 16. The majority of juveniles are of racial/ethnic minority status (61 %) and male (98%). The average length of stay is 6 months. None have been sentenced. Once a juvenile has been sentenced or reaches age 18, he/she is adjudicated an adult. The majority have not attended school in the last two years and the reading level is low. Two to three may be considered mildly mentally retarded or borderline intellectual functioning. The majority of these juveniles live with relatives (aunts, uncles, grandparent, or parents) and one to two are in the custody of the Florida Department of Children and Families.

Participants incarcerated in DISC Village Detention facility were housed in two separate facilities located approximately 75 miles apart. Female participants were located in Woodville, Florida, a community approximately 20





44

miles south of Tallahassee. Male participants were incarcerated in Greenville Hills Academy, located approximately 60 miles east of Tallahassee in the town of Greenville, Florida.

Instrumentation

This study employed two instruments. First, the University of Central

Florida (UCF) AIDS/HIV Questionnaire (Appendix A) was developed specifically to determine AIDS-related knowledge, attitudes and behaviors of adolescents (Lanier, 1989) and has been used extensively in assessing and predicting incarcerated adolescents' AI DS-related knowledge, attitudes, and behaviors (Lanier & McCarthy, 1 989a; Lanier & McCarthy, 1 989b; Lanier, DiClemente, & Horan, 1992; Lanier and Gates, 1993; & Barthlow, Horan, DiClemente, & Lanier, 1995). The instrument was initially developed by selecting items from previous epidemiological studies of adolescents' knowledge, attitudes, and high risk behaviors regarding AIDS (Lanier and McCarthy, 1989). The questionnaire included 73 items and was divided into 4 sections for analysis: knowledge (19 items), attitude (26 items), behavior (23 items), and socio-demographic (5 items).

A brief description of each construct follows:

1 Knowledge items measured objective knowledge including methods of

transmissions and means of preventing/reducing risk for infection.

2. Attitudes measured included self-efficacy, personal risk, friends' risk for

becoming infected, and magnitude of HIV/AIDS epidemic.

3. Self-reported high-risk behaviors included unprotected sex, sex with

multiple partners and injecting drug use with needle sharing.





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4. Socio-demographics including age, race/ethnicity, gender, length of time

incarcerated, and geographical location.

A panel of three national experts on AIDS and adolescence affirmed content validity (Barthlow, Horan, DiClemente, & Lanier, 1995). The questionnaire was pilot-tested with a group of 34 detained juveniles and was subsequently modified to reflect an elementary reading level. Several HIV/AIDS research studies reflect successful use of the questionnaire: Knowledge and concern about AIDS among incarcerated juvenile offenders (Lanier & McCarthy, 1989); AIDS awareness and the impact of AIDS education in juvenile corrections (Lanier & McCarthy, 1989); HIV knowledge and behaviors of incarcerated youth; a comparison of high and low risk locales (Lanier, DiClemente, & Horan, 1991); and correlates of condom use among incarcerated adolescents in a rural state (Barthlow, Horan, DiClemente, & Lanier, 1995).

Second, the University of Central Florida (UCF) AIDS/HIV Risk

Assessment Interview consisted of 37 open-ended questions that cover the majority of issues measured by the AIDS/HIV Questionnaire, allowing for elaboration and in-depth discussion (Appendix B).

Data Collection Procedures

Approval for the study was obtained from the University of Florida

Institutional Review Board (Appendix C). All research participants were advised that participation in the study was strictly voluntary and there would be no penalty if they chose not to participate. Also, participants were informed that they would not be awarded compensation of any kind and were given assurance





46


that they would have complete confidentiality. In order to assist in maintaining participants' privacy and confidentiality, participants were specifically asked not to identify themselves on the questionnaire and not to reveal their names during the subsequent interviews. Each research participant consented to participate in the study by signing the appropriate assent form (Appendix D) provided by the University of Florida. Parental/legal guardian consent was obtained for each of the Escambia County, Florida jail participants (Appendix E). Escambia County, Florida jail juveniles' participation in the study was solicited by, first securing verbal permission from the jail administration; Major White and Captain Cornish; and the jail's Department of Forensics, Dr. S. K. Zoss, Coordinator of Adult Forensics Unit and JJ Crater, Licensed Mental Health Counselor. Study participants were recruited by visiting each cell and providing each juvenile with information regarding the research study.

DISC Village participants were recruited as part of a Florida Department of Children and Families (Formerly Florida Department of Health and Rehabilitative Services) funded research project sponsored by the University of Central Florida, Orlando, Florida.

At the beginning of each jail visit and prior to talking to juveniles, the jail's adolescent mental health counselor provided a current roster of inmates. Those inmates agreeing to participate in the study signed the appropriate consent form. Parents/legal guardians of those inmates consenting to participate were first contacted by telephone or via a home visit and provided information regarding the research study. J.J. Crater, Licensed Mental Health Counselor, provided the





47


names, addresses, and telephone numbers parents/legal guardians of juveniles consenting to participate in the study. Those parents/legal guardians agreeing to have their child participate in the study were either hand delivered or mailed the appropriate consent form. In the event a parent/legal guardian was unwilling or unable to have the consent delivered, the consent form along with a return address stamped-envelope was mailed to them. Parents/legal guardians not having a telephone service were visited at home.

The UCF AIDS/HIV Questionnaire was administered to Escambia County jail participants over several days to groups of approximately six to eight male inmates in the group room located in the jail infirmary. The three female inmates were housed in the jail infirmary and were administered the questionnaire in their cell. All DISC Village male participants received the questionnaire on the same day, at the same time. DISC Village female participants received the survey at the same time on the same day as DISC Village male participants. The researcher provided reading assistance on a group and an individual basis as needed to participants demonstrating a low reading level.

Additionally, 50% of Escambia County, Florida jail participants

and 13% randomly selected DISC Village participants (detention facility) received a 45-60 minute AIDS/HIV Risk Assessment Interview. All Interviews were conducted by the researcher among jail group participants and detention group participants on an individual basis and in a private setting.

The HIV/AIDS educational program was developed for juveniles

incarcerated in the Escambia County, Florida jail. It was developed utilizing





48


information obtained from the UCF AIDS/HIV Questionnaire (Appendix A) and the AIDS/HIV Risk Assessment Interview (Appendix B).

Analysis of Data

All data entry and analysis for the needs assessment component of this

study were conducted using SPSS for Windows, Version 6.0. Double data entry involved taking each of the 45 surveys and visually comparing the responses to the questions with the entries in the data set. This procedure revealed no errant entries.

An additional data verification technique was employed during the data entry process. Any survey that appeared to be completed in a random manner, a systematically untruthful manner, or in a manner that suggested overt hostility toward the survey process as evidenced by hostile comments or sayings written on the survey were marked as being possibly invalid by the data entry personnel. There were no such surveys.

The conclusion based on this conservative procedure is that any error from data entry is extremely minimal and non-systematic in nature. Thus, the data set is presumed to be clean and valid, representing the subject's true response to the survey instrument.

To date, data analysis has been limited to analysis of frequency

distributions, descriptive statistics, and Chi-square analysis. Chi-square is useful in determining if significant differences between levels of variables exist between the jail group and the detention center group, a group of 79 participants who were incarcerated in a different facility. Descriptive statistics were used to





49

address research objectives one through five. Information obtained from the University of Central Florida (UCF) AIDS/HIV Questionnaire and AIDS/HIV Risk Assessment Interview data were employed in meeting research objective five.












CHAPTER 4
RESULTS

In this chapter, the results of the University of Central Florida (UCF)

AIDS/HIV Questionnaire and the University of Central Florida (UCF) AIDS/H IV Risk Assessment Interview are presented. The UCF AIDS/HIV Questionnaire was developed specifically to determine AIDS-related knowledge, attitudes and behaviors of adolescents (Lanier, 1989). The University of Central Florida (UCF) AIDS/H IV Risk Assessment Interview (Lanier, 1996) consisted of 37 open-ended questions that covered the majority of issues measured by the UCF AIDS/HIV Questionnaire, allowing for elaboration and in-depth discussion.

Survey participants consisted of 45 juveniles (42 males and 3 females)

incarcerated in the Escambia County, Florida jail and 79 juveniles (65 males, 13 females, one missing observation) detained in DISC Village detention facility. DISC Village detention center males were located at Greenville Hills Academy, Greenville, Florida and females were detained at the RAFT Program, Woodville, Florida. Survey participants in the jail were between the ages of 13 and 17 with a little over a half age 17. Ninety-three percent were male. Almost three-fourths were African -American, a fifth White, 2.3% Hispanic, and 4.5% Asian. Survey participants in the detention center were between the ages of 11 and 18. Almost three-fourths were between the ages of 13 and 16. Over four-fifths were male.



50





51

More than half were African-American, one-third White, 2.6% Hispanic, and

2.6% Asian.

Interview participants consisted of approximately 50% (N=22) of the

Escambia County Jail participants and 30% (N=23) randomly selected detention center participants. Interview participants in the jail consisted of 22 males between the ages of 14 and 17 with an average age of 15.7. A little over fourfifths were African-American and a little less than a fifth were White. Interview participants in the detention center consisted of 19 males and four females between the ages of 11 and 17 with an average age of 14. Fifty-two percent were African-American and forty-eight were White.

This study had several objectives. For objectives one through four,

responses from the juveniles in the adult correctional facility are compared with those of youth detained in a juvenile detention facility. The results will be described by study objectives. The two groups were significantly different on a total of four variables, one socio-demographic variable and three behavior variables. However, since there are so few differences, these could be Type I errors.

Socio-demographics

The first objective was to determine the socio-demographic characteristics that describe juveniles incarcerated in an adult facility who are at high risk. Five questions from the UCF AIDS/H IV Questionnaire assessed juveniles' sociodemographic including age, race/ethnicity, gender, location and length of time incarcerated. As Table 4-1 demonstrates, the demographic profiles of the two





52

populations are similar. The majority are male, of ethnictracial minority status (African-American), and over half had been incarcerated over 60 days. The two groups were found to be significantly different on only one demographic variable, age (Table 4-2).

More than half of the Escambia County, Florida jail participants were age 17, while almost three-fourths of DISC Village participants were between the ages of 13 and 16. The jail did not contain any participants between the ages of 11 and 12.

The majority of jail group and detention group participants were male.

African-Americans comprised almost three-fourths of the jail group participants and just over half of the detention group, Whites one-fifth of the jail group and one third of the detention center group, Hispanics 2.3% of the jail group and

2.6% of the detention center group, Asian 4.5% of jail group and 2.6% of detention center group, and other 2.3% jail group and 6.4% detention center group.

Regarding length of stay, 15.6% of the Escambia County jail juveniles had been incarcerated 1-30 days, 26.7% 31-60 days, 28.9% 61-90 and 29.9% had been detained over 91 days. Almost 21 % of DISC Village detention center juveniles had been incarcerated 1-30 days, 19.5% 31-60 days, 16.9% 61-90 days, and 42,9% had been incarcerated over 91 days (Table 4-1).

HIV/AIDS Risk Behaviors

The second objective was to identify high-risk behaviors related to

HIV/AIDS reported by juveniles detained in these correctional facilities, Twenty-





53


three questions assessed juveniles' HIV risk behaviors and behavioral intentions (Table 4-3). HIV-related behavioral risk items included sexual activity, multiple sexual partners, same sex relationships, failure to use condoms, failure to ask sexual partners about their sexual history, sexual abuse, injecting drug use, noninjecting drug use, failure to take special precautions to prevent contracting HIV and sharing items that have the potential to be contaminated with HIV transmissible body fluids. Participants in both groups reported several high-risk behaviors. Almost all participants are sexually experienced, over half reported at least six lifetime sexual partners, two-fifths use condoms consistently, less than half ask their sexual partners about their sexual history, over half report that they would have sex with an attractive partner if no condom were available and over four-fifth have used marijuana.

The two groups were found to be significantly different on three behavior variables, sexual abuse (Table 4-5), number of sexual partners in the last three months (Table 4-6), and number of same sex relationships (Table 4-7).

Regarding high-risk behaviors among jail participants, overall, juveniles incarcerated in the Escambia County jail reported more sexual risk behaviors than their detention center counterparts. Almost 98% of jail group participants and 92.3% of the detention center group participants reported that they were sexually experienced. Over half (51.1 %) of jail participants reported having had 10 or more lifetime sexual partners, compared to almost two-fifths of the detention center group. The two groups were found to be significantly different (p< 0.05) (See Table 4-6) in the number of sexual partners in the last three





54


months, In response to question #65, "how many sexual partners have you had in the last three months", half of jail participants compared to almost threefourths of the detention group participants reported that they had not had any sex partners in the last three months. Regarding juveniles incarcerated in jail, a fifth reported that they had one partner in the last three months, over a fifth reported 2-5 partners, 6.8% reported 6-10 partners and none reported over 10 partners in the last three months. Among the detention group, 11.5% reported one partner, 7.7% reported 2-5 partners, 1.3% reported 6-10 partners and 6.4% reported over 10 partners in the last three months.

Although almost three-fourths of juveniles in both groups reported that they frequently take special precautions to prevent catching AIDS, specific responses indicate behaviors to the contrary. In response to the question (#32), "in the last 5 times you had sex, how many times did you use a condom", twofifths of both groups reported that they used a condom each of the last five times they had sex. Over half of both groups reported that they would have sex with an attractive partner if no condom were available. More than a fourth of jail participants and over two-thirds of detention center participants reported that they would trust a sexual partner if they said they were free from disease. Additionally, although almost all participants in both samples reported plans to use a condom if unsure of their partners' sexual history, only two-fifths of jail participant and two-thirds detention center participants reported that they frequently ask partners about their sexual history.





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Regarding drug use, more than four-fifths of both groups reported that they had used marihuana.

Jail group participants reported several low-risk behaviors. With respect to same sex behavior, the two groups were significantly different (p< 0.05) (See Table 4-7) in reporting the number of same sex relationships. Jail participants were less likely than their detention counterparts to report being at risk. In response to the question (#66), "with how many partners have you had a same sex relationship", almost all jail group participants responded 'none", compared to close to three-fourths of detention group participants. A little over 2% of intervention group participants reported one same sex relationship, while 6.4% of the comparison group participants reported one same sex relationship, 14.1 % reported 2-5, 2.6% reported 6-10, and 2.6% reported over 10 same sex relationship.

In regard to sexual abuse, the two groups were significantly different (p<

0.05) (See Table 4-4). A little over 4% of jail participants compared to 18.4% of detention center participants reported ever being sexually abused. Although not statistically significantly different, jail participants were less likely to report physical abuse than detention center participants were.

With respect to behavioral intention, approximately three-fourths of both group respondents reported that, in the future they will frequently demand the use of a condom for their own protection as well as for their partner's protection. None of the jail juveniles and 6.5% of detention group juveniles responded yes to the question, "have you ever 'shot up' drugs. Almost all respondents in both





56

groups reported that in the future, they do not plan to inject drug or share a needle in order to body pierce.

Over half of jail participants respondents and almost three-fourths of detention center participants reported that they had been tested for HIV. No positive results were reported among either group.

HIWAIDS Knowledge

Objective three assessed the level of HIV/AIDS knowledge of juveniles

detained in these correctional facilities. The HIV/AIDS knowledge portion of the questionnaire consisted of nineteen items that were answered on a yes, no, or don't know basis (Table 4-8). These items assessed juveniles' knowledge regarding modes of transmission, risk groups/behaviors, risk reduction and general knowledge. The majority of participants in both groups reported high levels of HIV/AIDS knowledge regarding modes of transmission, high-risk behaviors and HIV prevention. Survey results revealed no significant differences between the jail group and the detention center group on any of the knowledge variables.

Although less knowledgeable in some areas than in others, overall, these juveniles reported a high level of HIWAIDS knowledge. Regarding transmission through casual contact, approximately three-fourths of both group respondents correctly reported that AIDS cannot be caught from sharing a glass of water with an infected person and that one cannot acquire AIDS by eating food prepared by a person who has AIDS. Just over three-fourths of jail group participants and two-thirds of detention group participants correctly reported that AIDS could not





57

be caught from a toilet seat. Four-fifths of the jail group and a little over twothirds of the detention group knew that AIDS could not be caught if a person with AIDS sneezes on you. In response to the question "AIDS can be caught from sharing marijuana pipes or cigarettes", the majority of both groups responded correctly. The vast majority of the jail and detention group participants knew that AIDS is not transmissible through shaking hands. Almost 90% of both groups were aware that AIDS is not transmissible by kissing on the cheek.

Considering actual transmission knowledge, almost all jail group

participants and three-fourths of detention group participants knew that sharing razor blades and tattoo needles are means of HIV transmission. All jail group respondents and almost all detention group respondents were aware that AIDS is transmissible through sharing drug needles.

Participants demonstrated that they were less knowledgeable in several areas relating to actual transmission of the virus. For example, one-third of jail group participants and less than one-fifth of detention group respondents were aware that AIDS could not be acquired through donating blood. A little less than two-fifths of both groups reported that AIDS could not be caught from heavy tongue kissing. In response to the statement, "AIDS can be caught if the hospital has to give you blood", approximately two- thirds of both groups responded correctly.

Relative to general knowledge, the vast majority of both group knew that a virus causes AIDS. The majority of juveniles were aware that the disease is not confined to certain segments of the population. For example, In response to the





58


question, "AIDS is harder to catch if you are young and healthy", approximately three-fourths of both groups responded correctly. In response the question, "All gay men (homosexuals) have AIDS", three-fourths of jail group participants and over half of detention group participants correctly responded "no."

Although not significantly different, jail group participants demonstrated a higher level of prevention knowledge than did detention group participants. For example, more than four-fifths of the jail group and two-thirds of the detention group were aware that using a condom would help reduce risk for acquiring the virus.

Attitudes Regarding HIV/AIDS

The fourth objective was to determine the attitudes related to HIV/AIDS of juveniles detained in these facilities. Twenty-six items examined juveniles' attitudes toward HIV/AIDS (Tables 4-9 and 4 -10). Almost all participants in both groups were aware of the severity of the AIDS problem in the United States, most reported that they worry about contracting HIV, almost all were aware that it is possible to have AIDS and not know it and about a fourth believed themselves to be at high risk for contracting HIV. The two groups were not significantly different on any of the attitude variables.

The majority of both groups believed that AIDS is a big problem in

America. Close to 14% of jail group participants and 22.1% of detention group respondents considered AIDS to be a fabricated problem by the government. However, the reported perceived risk of infection for self and for friends was low. Approximately a fourth of both groups perceived themselves to be personally





59


vulnerable to becoming infected. About a quarter of jail group and forty percent of detention group respondents reported their friends to be at high risk for becoming infected.

Regarding self- and response-efficacy, about half of jail group participants and a third of comparison group participants agreed that individuals are responsible for protecting themselves against HIV infection. The vast majority believed that persons can take action to prevent this disease (Tables 4-10 and 4-11). In response to the statement, "there is a cure for AIDS but it is too expensive for most people, about a fourth of both groups agreed.

In response to perceived norms of sexual behaviors among friends, a fifth of jail group participants and a third of detention group participants believed that their friends have had over 10 lifetime sexual partners. Approximately 90% of both group respondents believed that their friends had not had a homosexual relationship. Three-fourths of jail group participants and more than half of detention group participants would like to be tested for AIDS, while almost twothirds of jail group participants and close to three-fourths of detention group participants would like their friends to be tested.

Regarding worry, only a small percentage of juveniles from both groups considered themselves to be at low risk for becoming HIV infected. Threefourths of both groups reported that they worry a lot about catching AIDS. Finally, more than half of the respondents from both groups reported that they worry about their friends catching AIDS.





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Considering perceived knowledge, two-thirds of both groups reported

that, compared to most people, they feel that they know a lot about AIDS. Jail group participants reported that the majority of their knowledge was learned from public school, while detention groups reported youth services as the source of the majority of their knowledge.

Overall, participants held few HIV/AIDS misconceptions. In response to the statement, "only homosexuals catch AIDS," 6.7% of jail group participants and 5.2% of detention group participants agreed. Almost 7% of jail group and

8.9% of detention participants believed that white people have less of a chance of catching AIDS.

UCF AIDS/HIV Risk Assessment Interview Results

All 22 of the Escambia County, Florida jail sample confirmed that they

were sexually active, compared to over four fifths of the detention group sample. More than two-fifths of jail participants and a little more than one-third of the detention group sample reported that they discuss their partners' sexual history with them. None of the jail group participants and only one detention group participant reported sexual intercourse with someone of the same sex. In response to the question, "Have you ever shared a needle for tattooing, drugs, body piercing, for any other reason," all jail participants reported no, while less than one-fifth of detention participants reported that they had shared a needle for body piercing. About two-thirds of both samples reported that they have been tested for HIV. No HIV positive results were reported.





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I n response to the question "How much do you know about HIV/AIDS?", over two-thirds of the jail sample responded "not much." Other responses included, "enough to keep from getting it", "enough to use a condom," "can die from it," "can get it from sharing needles," and "can it get from blood transfusion." The majority of the jail sample reported that they were aware of HIV modes of transmission and methods of prevention. A few reported, "I know enough to protect myself'. In reply to the question, "Many juveniles have HIV. What could be done to keep this number from increasing?," the most frequent responses from the jail sample included, "use condoms," "don't know," "education," "don't sleep around," "abstinence," and "nothing." Eleven of 23 detention juveniles reported that protective sex/condom use is a means of preventing HIV transmission among juveniles. Fourjuveniles proposed sexual abstinence, two suggested education, and one recommended not using IN. needles.

All participants in both samples reported that they believe "AIDS is a big problem in America". In response to the question, "Are you at risk for HIV?," almost a third of the jail group sample and more than half of the detention group sample responded "yes." More half of the jail sample and almost three-fourths of the detention sample reported that their friends are at risk for HIV. In response to the question, Who's at risk for HIV?" the most frequent response for both samples was "any/everybody." The vast majority of both samples believed that condoms should be made available in schools.





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Summary of Survey and Interview Results

Survey and interview data results revealed very few differences between the jail group and the detention center group. The two groups were significantly different on one socio-demographic variable, age and three behavioral variables, sexual abuse, number of sexual partners in the last three months, and number of same sex relationships

Survey results revealed that, socio-demographically almost all survey and interview participants were male. The majority of survey and interview participants in the jail and survey participants in the detention center were African-American. Interview participants in the detention were almost equally divided between Afri can-Ameri cans and Whites. Survey and interview participants in the jail were slightly older than their detention center counterparts. Almost 29% of jail participants had been incarcerated over three months compared to almost 43% of detention center participants.

Almost all of these juveniles are sexually experienced and over half of the survey participants have had ten lifetime sexual partners. The majority do not use condoms consistently, and a vast majority had used marihuana. Jail group participants and detention group participants were significantly different on three behavior variables, sexual abuse, number of sexual partners in the last three months, and number of same sex partners.

Overall, participants demonstrated moderate to high levels of knowledge regarding prevention, mode transmission, high-risk behaviors and general knowledge. Additionally, participants were aware that the disease is not





63

confined to certain segments of the population. The two groups were not significantly different on any knowledge variables.

Participants reported an awareness of the severity of the AIDS problem in the U.S. However, group participants reported attitudes that increase their risk for becoming infected with HIV. For example, the majority of the survey sample did not perceive themselves or their friends to be at high risk for contracting HIV. More than half of the interview participants in the detention center and almost a third of the jail group reported that they are at risk. Additionally, a large minority believed there is a cure for AIDS. The two groups were not significantly different on any attitude variables

Results from the UCF AIDS/HIV Questionnaire and the UCF Risk Assessment Interview were used to plan and develop the educational intervention.





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HIV/AIDS Educational Program for Juveniles Incarcerated in a County Jail
Based on the AIDS Risk Reduction Model (ARRM)

Program Overview and Theoretical Framework

Research suggests that the most successful HIV prevention programs are those programs that are theory- and skills-based, and include both cognitive and behavioral aspects (Allensworth & Symons, 1989; Longshore, 1990; Boyer & Kegeles, 1991; Fisher & Fisher, 1992; Jemmott, Jemmott, & Fong, 1992; DiClemente, 1993; National Commission on AIDS, 1994; and Jemmott, Jemmott, & Fong, 1998). Additionally, these comprehensive programs must be ageappropriate, sensitive to cultural values, provide access to services, and include adolescents' attitudes and customs, religious beliefs, and sex roles (Boyer, & Kegeles, 1991; DiClemente, 1993a; DiClemente, Brown, et al., 1993; Fisher & Fisher, 1992; Gillmore, Morrison, Richey, Balassone, Gutierrez, & Farris, 1997; Kooperman, et al, 1994; & National Commission on AIDS, 1994).

This 8-hour HIV educational program, based upon the AIDS Risk Reduction Model (ARRM) (Catania, et al., 1990) is a knowledge based, cognitive-behavioral-skills intervention. The ARRM is a psychosocial conceptual model designed to examine people's efforts to change sexual behavior in order to avoid contracting HIV through sexual transmission. According to the ARRM, in order to reduce their risk for contracting HIV, adolescents must first recognize and label their behavior as at-risk for contracting HIV (stage one), they must make a commitment to reduce high risk sexual contacts and increase low risk





65


behaviors (stage two), and they must seek and enact strategies to execute recommended risk reduction activities (stage three).

Variables hypothesized to influence stage one include knowledge of sexual activities associated with HIV transmission, the belief that one is personally susceptible to contracting HIV, and social influences. Factors hypothesized to influence stage two, commitment include perceived costs and benefits, self-efficacy, knowledge and perception of enjoyment and risk reduction, and social influences. Stage three, enactment, includes informationseeking, obtaining remedies, applying solutions and social influences. Verbal communication with sexual partners regarding sexual issues is a key component of the enactment stage.

The results of the survey data led to the development of the following

HIV/AIDS educational program, designed specifically for juveniles incarcerated in an adult facility. It was developed utilizing information obtained from the results of a survey administered to this same population. It is theory-based (AIDS Risk Reduction Model) with emphasis on cognitive-behavioral skills. It incorporates those components determined by research to be characteristic of effective prevention programs such as, age appropriate, culturally sensitive and provides access to services.

As previously stated, survey results revealed that the majority of

Escambia County, Florida jail participants were age 17 and African American, almost all are sexually experienced, most have a high number of life time sexual partners, do not use condoms consistently when participating in sexual activity,





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harbor HlV/AlDS misconceptions, have a history of marihuana use, and do not consider themselves to be at high risk for contracting HIV. These characteristics were utilized in developing program goals and objectives. Program Goals

The overall goals of this program are to: 1) decrease number of sexual partners with whom they engage in unsafe sexual practices; 2) increase participants' perceived susceptibility of their own risk for contracting HIV; 3) increase the consistent and correct use of latex condoms and other barrier methods during sexual intercourse; 4) eliminate or decrease frequency of drug use in situations that may lead to sexual activity; and 5) increase/reinforce HIV/AIDS knowledge

Program Obiectives

By the end of this educational intervention, participants will be able to: 1) identify and discuss HIV high-risk behaviors; 2) identify major modes of HIV transmission; 3) identify ways in which HIV is not transmitted; 4) personalize own risk for contracting HIV; 5) describe methods of HIV prevention; 6) describe and utilize appropriate communication/partner negotiation skills; 7) describe and utilize appropriate decision making/problem solving skills; 8) describe correct condom use; 9) identify where/how to obtain latex condoms; and 10) identify community resources, including drug treatment facilities, mental health facilities, local public health unit, HIV test sites, and self-help groups such as Alcoholics Anonymous (AA) Cocaine Anonymous (CA) and Narcotics Anonymous (NA).





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The 8-hour program, designed to be presented in four 2-hour modules is similar in length to previous interventions that have been successful in reducing risk for HIV infection among high-risk groups.

This educational program addresses stage one of the ARRIVI, recognizing and labeling by providing adequate and correct information regarding HIV, including modes of transmission and high-risk behaviors. Additionally, each participant is provided the opportunity (anonymously) to assist in personalizing their own risk and recognizing if they are personally susceptible to contracting HIV. Stage two, commitment involves motivating individuals to change risk behavior. It includes deciding if the risky behaviors can be changed and if the benefits outweigh the costs (i.e, condoms decrease pleasure). Responseefficacy and self-efficacy are addressed through providing information on condom efficacy and the health utility and enjoyability of various sexual practices. If one knows that condoms reduce the risk of contracting HIV and that there are ways that they can be used during sexual activity to make sex fun, one maybe more likely to use condoms. Participants' self- efficacy is increased if they are knowledgeable about where and how to obtain condoms and how to use them correctly. The cost/benefits factor is addressed through providing the opportunity for social/peer reinforcement and positive reinforcement for reporting a desire and plan to engage in HIV low-risk activities. Additionally, group discussions would be used as a means of assisting participants in realizing that benefits outweigh the barriers or negative consequences of the high-risk behavior. Questions such as, "who will have your girl/boyfriend" if you contract





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and/or die from HIV disease would be asked, Although some research indicate that youth can be motivated by fear (Job, 1988; Rhodes, MacDonald, & ElderTarizy, 1990), the use of fear/scare tactics will be avoided based on evidence that they have the potential to be counterproductive field (Hein, 1993: Airhihenbuwa, DiClemente, Wingood, & Lowe, 1992; & Rotheram-Borus, et al., 1995). Regarding stage three, enactment, participants are provided appropriate information and the opportunity to develop behavioral skills through decision making activities, group discussions, and a culturally sensitive video that focuses on decision making and communication skills, including partner negotiation. Community resources such as the local county public health unit, HIV testing sites, self help groups and drug treatment programs are identified. In consideration of social influences, mainly reference group norms, participants who engage in or support low risk activities are encouraged to share their feelings, thoughts and experiences with the group.

A variety of methods are utilized including group discussion, role play,

games, videos, question/answer session, HIV/AIDS risk assessment (completed anonymously) to assist with recognition and labeling of one's behaviors as high risk, and skill-based activities including decision making/problem solving and communication/partner negotiation. These methods have proven successful in similar HIV prevention programs, particularly programs targeting AfricanAmericans, as well as other high-risk adolescents (Boyer, et al., 1997; Dixon, 1994; Jemmott, et al., 1998; Jemmott, et al., 1992; Kipke, et al., 1993; St. Lawrence, Brasfield, et al., 1995; & St. Lawrence, Jefferson, et. al., 1994).





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Cognitive-behavioral skills, derived from the Social Learning Theory (Bandura, 1977) are essential to make healthy choices and to put choices into action. Skills-building interventions have been shown to be effective in changing adolescents' HIV high-risk sexual behaviors (Boyer, et al., 1997; Jemmott, et al., 1998; Kipke, et al. 1993); Rotheram-Borus, et al, 1995; St. Lawrence, Brasfield et al., 1995; St. Lawrence, Jefferson, et al., 1995; St. Lawrence, Jefferson, et al., 1994; & Schinke, Botvin, Orlandi, Schilling, & Gordon, 1990). There were two key skills that were involved, decision making and partner negotiation.

Decision making, as defined by decision theorists is "the process of

making choices among competing courses of action (Beyth-Maron, Fischoff, & Jacobs Quadrel and Furby, 1991, p. 20). The "normative" theory of decision making, in principle, considers whether a proposed solution to a problem is sufficient to that particular problem. Additionally, it considers the goal of the decision-maker and whether fortune/misfortune has a role in what takes place with the decision-maker. Thus, the normative theory of decision making "is couched in terms of the processes that people follow in order to have the best chance of reaching their goal" (Beyth-Maron, et al., 1991, p. 21). According to most of these general models, a person faced with a decision should first identify relevant alternatives. Second, the person should identify possible consequences of each action. Third, the person should evaluate the likelihood of each consequence occurring for each action. Next, the person should determine the relative significance of each consequence. Finally, the person





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facing a decision should integrate the information from each step to identify the most appealing course of action.

DiClemente (1993) states, "communication and negotiation skills that promote safer sexual interactions and the use of condoms could provide adolescents with a repertoire of responses that could be employed to avoid highrisk situations" (p. 163). Comm un i cation/partner negotiation skill development focuses on assertive behavior. This program utilized a widely used formula developed by Bower and Boser (1976) and referred to as DESC (Describe, Express, Specify, and Choose). The DESC formula involves the following: Describing the other person's behavior or the situation objectively; Expressing your feelings about the other person's behavior or the situation that you just described; Specifying changes you would like to see made; and Choosing the consequence you are prepared to carry out. Decision- making and partner negotiation skills are incorporated in this education program. Both are addressed in video and through role-play.

Although engagement in same sex behavior was reported by a small

percentage of juveniles in this study, the high-risk nature of this type of sexual behavior accompanied by the failure of many African-American communities to discuss this behavior, indicate a need for its inclusion in this educational intervention. According to Stevenson and Davis (1994), "Many AfricanAmericans do not wish to discuss their sexuality with others for fear that they will be negatively perceived as promiscuous, dirty, and responsible for current sexual disease epidemics" (p. 42). Additionally, 33% of the total number of





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AIDS cases among males between the ages of 13-19 are reported in the "men who have sex with men" CDC exposure category (CDC, 1996).





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TABLE 4-1: Socio-demographic Characteristics

Escambia County, Florida Jail

Number Group %

Age 11-12 0 0
13-14 3 6.7
15-16 18 40.0
17-18 24 53.3

Gender Male 42 93.3
Female 3 6.7

Race/Ethnicity White 9 20.5
Afr.-Am. 31 70.5
Hispanic 1 2.3
Asian 2 4.5
Other 1 2.2

Length of Stay 1-30 days 7 15.6
31-60 days 12 26.7
61-90 days 13 28.9
> 91 days 13 28.9

DISC Villa-ge Detention Facilit,

Age 11-12 8 10.3
13-14 25 32.1
15-16 33 42.3
17-18 12 15.4

Gender Male 65 83.3
Female 13 16.7

Race/Ethnicity White 26 33.3
Afr. Am. 43 55.1
Hispanic 2 2.6
Asian 2 2.6
Other 5 6.4

Length of Stay 1-30 days 16 20.8
31-60 days 15 19.5
61-90 days 13 16.9
> 91 days 33 42.9





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Table 4-2 Significant Difference Between Jail Group and Detention Group Demographic Variable: UCF AIDS/HIV Questionnaire, Question # 58, What is your age?

Age Detention Group Jail Group

13-14 35.7% 6.7%
15-16 47.1% 40.0%
17-18 17.1% 53.3%

Chi-square Value D. F. SiQnificance
Pearson 21.268 2 .000


N = 70 Detention Group N = 45 Jail Group

*Significant at level 0.05





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Table 4-3: UCF AIDSIHIV Questionnaire Escarnbia County Jail Group HIVIAIDS Risk Behavior Questions

Frequently Sometimes Never

In the future, I will use a condom if unsure of my partners sexual history. 82.2% 15.6% 2.2%

1 would have sex with an attractive partner if no condom was available. 13.3% 37.8% 45.9% In the future I plan to inject drugs. 2.3% 0% 97.8%

1 would trust a sex partner if she/ he said they are free from disease. 4.4% 24.4% 71.1%

1 would have sex without a condom if I had a negative AIDS test. 6.8% 20.5% 72.7%

In the future, I will demand the use of a condom (rubber) for my own protection. 77.8% 20.0% 2.2%

In the future, I will demand the use of a condom (rubber) for my partner's protection. 73.3% 17.8% 8.9%

1 take special precautions to prevent catching AIDS. 71.7% 24.4% 4.4%

1 ask sex partners about their sexual history. 40.9% 43.2% 15.9%

1 share IN. drug needles. 0% 2.2% 97.8%

In the future I will share IN. drug needles. 4.4% 0% 95.6%





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Table 4-3: Continued
Yes No Unsure/Don't Know

In order to body pierce, I would share a needle. 2.2% 93.3% 4.4%

1 have had a blood test for AIDS. 51.1% 42.2% 6.7%

1 have tested positive for HIV. 0% 88.9% 11.1%

I have been sexually abused. 4.4% 95.6% 0%

I have been physically abused 11.1% 84.4% 4.4%

Have you ever used marijuana? 82.2% 17.8% 0%

Have you ever "shot up" drugs? 0% 100.0% 0%

Have you injected drugs in the last
3 months? 0% 100.0% 0%

In the last 5 times you had sex, how many times did you use a condom?
0 1 2 3 4 5
11.1% 4.4% 6.7% 15.6% 22.2% 40.0%

With how many partners have you had sexual intercourse? none 1 2-5 6-10 Over 10
2.2% 6.7% 24.4% 15.6% 51.1%

How many sexual partners have you had in the last 3 months? none 1 2-5 6-10 Over 10
50.0% 20.5% 22.7% 6.8% 0%

With how many partners have you had a same sex relationship? None 1 2-5 6-10 Over 10
97.7% 0% 0% 0% 2.3%





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Table 4-4: UCF AIDS/HIV Questionnaire DISC Village Detention Facility HIVIAIDS Risk Behavior Question

Frequently Sometimes Never


In the future, I will use a condom if unsure of my partners sexual history. 72.2% 27.8% 0% I would have sex with an attractive partner if no condom was available. 10.1% 44.3% 45.6% In the future I plan to inject drugs. 5.1% 1.3% 93.7%

1 would trust a sex partner if she/ he said they are free from disease. 5.1% 30.4% 64.6%

1 would have sex without a condom if I had a negative AIDS test. 12.7% 29.1% 58.2%

In the future, I will demand the use of a condom (rubber) for my own protection. 74.7% 16.5% 8.9%

In the future, I will demand the use of a condom (rubber) for my partner's protection. 78.2% 12.8% 9.0%

1 take special precautions to prevent catching AIDS. 70.9% 22.8% 6.3%

1 ask sex partners about their sexual history. 34.2% 36.7% 29.1%

1 share I.V. drug needles. 0% 0% 100.0%

In the future I will share I.V. drug needles. 0% 0% 100.0%





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Table 4-4: Continued

Yes No Unsure/Don't Know

In order to body pierce, I would share a needle. 3.9% 92.2% 3.9%

1 have had a blood test for AIDS. 70.5% 26.9% 2.6%

1 have tested positive for HIV. 5.2% 79.2% 15.6%

1 have been sexually abused. 18.4% 78.9% 2.6%

1 have been physically abused 26.0% 70.0% 3.9%

Have you ever used marijuana? 87.2% 12.8% 0%

Have you ever "shot up" drugs? 6.5% 93.5% 0%

Have you injected drugs in the last
3 months? 3.9% 96.1% 0%

In the last 5 times you had sex, how many times did you use a condom?
0 1 2 3 4 5
17.6% 5.4% 18.9% 10.8% 5.4% 41.9%

With how many partners have you had sexual intercourse? None 1 2-5 6-10 Over 10
7.7% 7.7% 30.8% 15.4% 38.5%

How many sexual partners have you had in the last 3 months? None 1 2-5 6-10 Over 10
73.1 11.5% 7.7% 1.3% 6.4%

With how many partners have you had a same sex relationship? None 1 2-5 6-10 Over 10
74.4% 6.4% 14.1% 2.6% 2.6%





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Table 4- 5 Significant Difference Between Jail Group and Detention Group HIV/AIDS Risk Behavior Variable: UCF AIDS/HIV Questionnaire, Question # 15 I have been sexually abused.

Detention Group Jail Group

No 81.1% 95.6%
Yes 18.9% 4.4%

Chi-square Value D. F. Significance
Pearson 5.038 1 .025*

N = 74 Detention Group N = 45 Jail Group
*Significant at level 0.05


Table 4- 6 Significant Difference Between Jail Group and Detention Group HIV/AIDS Risk Behavior Variable: UCF AIDS/HIV Questionnaire, Question # 65 How many sexual partners have you had in the last 3 months?

Detention Group Jail Group

None 73.1% 50.0%
1 11.5% 20.5%
2-5 7.7% 22.7%
6 or More 7.7% 6.8%

Chi-square Value D.F. Significance
Pearson 8.707 3 .033*

N = 78 Detention Group N = 44 Jail Group
*Significant at level 0.05





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Table 4- 7 Significant Difference Between Jail Group and Detention Group HIV/AIDS Risk Behavior Variable: UCF AIDS/HIV Questionnaire, Question # 66 With how many partners have you had a same sex relationship?

Detention Group Jail Group

None 74.4% 97.7%
At least 1 25.6% 2.3%

Chi-square Value D.F. Significance
Pearson 10.780 1 .001*

N = 78 Detention Group N = 44 Jail Group



*Significant at level 0.05





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Table 4- 8: UCF AIDSIHIV Questionnaire HIV/AIDS Knowledge Questions % Correct Significance

Jail Detention Pearson

AIDS can be caught from sharing a glass of water with an infected person. 75.6% 73.1% .95120 AIDS can be caught from toilet seats. 77.8% 66.7% .33610 AIDS can be caught from kissing on the cheek. 88.9% 89.9% .50371

AIDS can be caught from heavy (tongue) kissing. 37.8% 39.2% .58488

AIDS can be caught from sharing marijuana pipes or cigarettes. 84.4% 70.5% .11669

AIDS can be caught from sharing drug needles. 100% 97.4% .27880

AIDS can be caught from donating blood. 33.3% 17.9% .13481

AIDS can be caught from sharing tattoo needles. 95.6% 92.2% .471

AIDS can be caught from sharing cigarettes. 88.9% 76.9% .22697

AIDS can be caught if a person with AIDS sneezes on you. 80.0% 67.9% .27892

AIDS can be caught if a hospital has to give you blood. 60.0% 66.7% .46167

AIDS is harder to catch if you are young and healthy. 73.3% 75.6% .64028

Using a condom (rubber) will help prevent catching AIDS. 84.4% 66.7% .09245





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Table 4- 8: Continued % Correct Significance

Jail Detention Pearson

You can catch AIDS by shaking hands with a person who has AIDS. 88.9% 87.2% .74416

AIDS can be caught from sharing razor blades. 90.9% 75.6% .07497

If a restaurant cook has AIDS, you wi I I catch AIDS if you eat food the cook prepared. 77.8% 71.8% .41384

All gay men (homosexuals) have AIDS. 75.6% 54.4% .06543 Babies can be born with AIDS, 97.9% 96.2% .75144

AIDS is caused by a virus. 91.1% 87.3% .77504



Significant at level 0.05





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Table 4- 9: UCF AIDS/HIV Questionnaire HIVIAIDS Attitude Questions Jail Group

Don't
Agree Disagree Know

My chances of catching AIDS are great. 22.3% 53.3% 24.4% My friends have a high chance of catching AIDS. 26.6% 17.8% 55.6%

White people have less of a chance of catching AIDS. 6.6% 75.5% 17.8%

There is a cure for AIDS but it is too expensive for most people. 24.4% 44.5% 31.1%

If I caught AIDS, I would tell any sex partners. 54.5% 18.2% 27.3%

If I caught AIDS, I would not tell anyone. 22.2% 48.8% 28.9%

If I caught AIDS, I would tell close friends. 48.9% 28.8% 22.2%

If I caught AIDS, I would not have sex again. 44.4% 22.2% 33.3%

AIDS is a big problem in America. 95.6% 4.4% 0%

I worry a lot about catching AIDS. 71.1% 22.3% 6.7%

1 worry a lot about my friends
catching AIDS. 53.4% 24.4% 22.2%

Only homosexuals catch AIDS. 6.7% 86.7% 6.7%

If you catch AIDS, it's your own fault. 56.8% 43.2% 0% There is nothing you can do to prevent catching AIDS. 9.3% 83.8% 7.0%





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Table 4- 9: Continued

Don't
Agree Disagree Know

AIDS is a made up problem by the government to decrease drug use and sexual activity. 13.7% 72.8% 13.6%

You can have AIDS and not know it. 93.2% 2.3% 4.5%

If you catch AIDS, you will die within ten years. 22.7% 40.9% 36.4%

It is possible for someone to have AIDS, not know it and infect others. 88.6% 6.8% 4.5%

Compared to most people I feel that I know a lot about AIDS. 65.9% 13.7% 20.5%

Did the AIDS training you got here influence your intentions? 79.1% 21.0% 0%

Yes No Don't
Know

I would like to be blood tested for AIDS. 13.3% 75.6% 11.1%

I would like my friends to be blood tested for AIDS. 6.8% 65.9% 27.3%

How many of your friends do you think have had a homosexual relationship? None 1 2-5 6-10 Over 10
90.9% 0% 9.1% 0% 0%

How many sex partners do you think most of your friends have had? None 1 2-5 Over 6 Don't Know
11.1% 2.2% 8.9% 20.0% 55.6%

Where did you learn the most about AIDS?
relatives, friends 17.9%
books, magazines 10.3%
television, radio 10.3%
public school 43.6%
youth services 17.9%





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Table 4- 9: Continued

Where have you heard the most talk about AIDS?
parents, guardians 29.3
friends 4.9
public school 31.7
youth services 12.2
television or radio 22.0





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Table 4-10: UCF AIDSIHIV Questionnaire HIVIAIDS Attitude Questions Detention Group

Don't
Agree Disagree Know

My chances of catching AIDS are great. 29.1% 36.5% 34.2% My friends have a high chance of catching AIDS. 40.5%. 15.2% 44.3%

White people have less of a chance of catching AIDS. 8.9% 62.9% 28.2%

There is a cure for AIDS but it is too expensive for most people. 27.9% 43.0% 29.1%

If I caught AIDS, I would tell any
sex partners. 51.9% 26.9% 21.5%

If I caught AIDS, I would not tell
anyone. 18.0% 60.3% 21.8%

If I caught AIDS, I would tell close friends. 41.8% 24.1% 34.2%

If I caught AIDS, I would not have sex again. 30.4% 35.5% 34.2%

AIDS is a big problem in America. 92.4% 3.8% 3.8%

1 worry a lot about catching AIDS. 71.5% 24.7% 3.9%

1 worry a lot about my friends
catching AIDS. 59.8% 28.6% 11.7%

Only homosexuals catch AIDS. 7.8% 83.1% 9.1%

If you catch AIDS, it's your own fault. 37.7% 45.5% 16.9% There is nothing you can do to prevent catching AIDS. 14.3% 72.7% 13.0%





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Table 4-10: Continued Don't
Agree Disagree Know

AIDS is a made up problem by the government to decrease drug use and sexual activity. 22.1% 54.6% 23.4%

You can have AIDS and not know it. 85.7% 9.1% 5.2%

If you catch AIDS, you will die within ten years. 27.6% 47.4% 25.0%

It is possible for someone to have AIDS, not know it and infect others. 80.5% 7.8% 11.7%

Compared to most people I feel that I know a lot about AIDS. 66.3% 18.2% 15.6%

Did the AIDS training you got here influence your intentions? 68.4% 31.6%

Don't
Yes No Know

I would like to be blood tested for AIDS. 56.4% 26.9% 16.7%

1 would like my friends to be blood tested for AIDS. 72.2% 12.7% 15.2%

How many of your friends do you think have had a homosexual relationship? None 1 2-5 6-10 Over 10
89.5% 5.3% 2.6% 0% 2.6%

How many sex partners do you think most of your friends have had? None 1 2-5 Over 6 Don't Know
9.0% 2.6% 11.5% 34.6% 42.3%

Where did you learn the most about AIDS?
Relatives, friends 21.4%
Books, magazines 12.9%
Television, radio 8.6%
Public school 27.1%
Youth services 30.0%





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Table 4-10: Continued

Where have you heard the most talk about AIDS?

Parents, guardians 16.4%
Friends 16.4%
Public school 24.7%
Youth services 32.9%
Television or radio 9.6%












CHAPTER 5
DISCUSSION, CONCLUSIONS AND IMPLICATIONS

The study was undertaken to assess the education needs of juveniles incarcerated in an adult facility and develop an appropriate educational intervention for these juveniles. The UCF AIDS/HIV Questionnaire and the UCF AIDS/H IV Assessment Interview assessed the knowledge, attitudes, and behaviors of juveniles incarcerated in the Escambia County, Florida jail. Responses from juveniles incarcerated in the adult facility were compared with those of youth detained in a juvenile detention facility to determine if their needs were comparable. Escambia County, Florida jail (survey) participants consisted of 45 adolescents detained in the juvenile section and the infirmary of the Escambia County jail. Detention group (survey) participants were comprised of 79 adolescents incarcerated in two facilities in Northwest Florida. The jail group participants and detention group participants were significantly different on four variables, age, sexual abuse, number of sexual partners in the last three months, and number of same sex relationship.

The results of Escambia County jail survey data led to the development of an HIV/AIDS educational program designed specifically for juveniles incarcerated in an adult facility. The educational intervention is based upon the AIDS Risk Reduction Model (ARRM) (Catania, Kegeles, & Coates, 1990) and emphasizes cognitive-behavioral skills.

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This chapter discusses the results and implications of the results. It is divided into four sections, Socio-demographics, HIV Risk behaviors, knowledge and attitudes about HIV/AIDS, and HIV/AIDS prevention programs. There have been few studies of incarcerated youth conducted previously.

Socio-demograghics

Research studies reveal that youth incarcerated in detention facilities are predominantly male (more than 85%), of racial or ethnic minority (42% AfricanAmerican), between the ages of 14 and 17 (average age 15.7) and are generally

detained for an average of eight months (Council on Scientific Affairs, 1990).

Socio-demographic characteristics of Juveniles incarcerated in the Escambia

County, Florida jail were comparable to incarcerated juveniles, nationally

regarding ethnicity and gender. The majority (83.3%) of Escambia County,

Florida jail participants were male. Afri can-Ameri cans comprised almost threefourths of the jail sample. Escambia County, Florida jail participants were

between the ages of 13 and 17. However, over half were age 17, somewhat older than the national average of 15.7 years. Over a fourth of the jail juveniles had been detained over 3 months compared to a national average of 8 months.

HIV/AIDS Risk Behaviors

Incarcerated youth have been identified as a subgroup of adolescents who are at increased risk for infection due to a higher prevalence of HIV highrisk behaviors (Council on Scientific Affairs, 1990). Results of this study duplicated results of other studies. Morrison et al. (1994), in a study of 119 juveniles in a detention facility found these adolescents to be at high risk relative





90

to the general population, These youth had high rates of sexual activity, a high number of sexual partners and a low rate of condom use. For example, onethird of these juveniles had used condoms the last time they engaged in sexual intercourse with their primary or steady partner, while about half had used condoms with their casual partners. Additionally, in a study involving incarcerated adolescents and public high school students, 99% of detained youth reported being sexually active and 73% reported two or more sexual partners during the past year (DiClemente, et al., 1990). Regarding drug use, a nationwide survey of detained juveniles revealed that 63% of respondents used drugs regularly (Council on Scientific Affairs, 1990). The vast majority (98%) of Escambia County, Florida jail participants were sexually experienced. Over half reported 10 lifetime sexual partners and two-fifths reported consistent condom use. Over four-fifths had used marihuana. Additionally, the majority of these youth did not perceive themselves or their friends to be at high risk for contracting HIV. Lanier and McCarthy (1989), in a study assessing HIV awareness of juveniles detained in a detention center had similar results. Over three fourths of these juveniles reported that they did not feel they were at high risk for HIV infection and almost as many believed the same about their friends' risk for becoming infected.

Knowledge and Attitudes about HIV/AIDS

Research studies reveal that, although incarcerated adolescents tend to be less knowledgeable than the general adolescent population, they demonstrate high levels of AIDS knowledge (DiClemente, et al., 1991).





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Similarly, Escambia County, Florida jail participants reported high levels of HIV/AIDS knowledge regarding modes of transmission, high-risk group/behaviors, and risk- reduction activities. Some studies show that incarcerated youth are in lower agreement with AIDS health guidelines, have lower perceived personal threat of acquiring AIDS, and have lower personal selfefficacy compared to youth who were not incarcerated (Nader, Wexler, Patterson, McKusick, & Coates, 1989). These results were duplicated in this study. A little over one-fifth of Escambia County, Florida jail participants perceived themselves to be at risk for HIV infection and about half agreed that individuals are responsible for preventing their infection with HIV.

HIV Prevention Programs and Incarcerated Adolescents

The results of the UCFAIDS/HIV Questionnaire and the AIDS/HIV Risk Assessment Interview were used to plan and develop an educational intervention for juveniles incarcerated in the Escambia County, Florida jail. This intervention is based on the AIDS Risk Reduction Model (ARRM) and is designed to be presented in four 2-hour modules. It is skill-based and incorporates cognitive and behavioral aspects. The overall goals of the program are to: 1) decrease number of sexual partners with whom they engage in unsafe sexual practices; 2) increase participants' perceived susceptibility of their own risk for contracting HIV; 3) increase the consistent and correct use of latex condoms and other barrier methods during sexual intercourse; 4) eliminate or decrease frequency of drug use in situations that may lead to sexual activity; and 5) increase/reinforce HIV/AIDS knowledge. By the end of this educational





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intervention, participants will be able to: 1) identify and discuss HIV high-risk behaviors; 2) identify major modes of HIV transmission; 3) identify ways in which HIV is not transmitted; 4) personalize own risk for contracting HIV; 5) describe methods of HIV prevention; 6) describe and utilize appropriate communication/partner negotiation skills; 7) describe and utilize appropriate decision making/problem solving skills; 8) describe correct condom use; 9) identify where/how to obtain latex condoms; and 10) identify community resources, including drug treatment facilities, mental health facilities, local public health unit, HIV test sites, and self-help groups such as Alcoholics Anonymous

(AA) Cocaine Anonymous (CA) and Narcotics Anonymous (NA).

Research suggest that the most successful risk-reduction programs are those programs that are theory-based, include both cognitive and behavioral aspects, and are skilled-based (Allensworth & Symons, 1989; Longshore, 1990; Boyer & Kegeles, 1991; fisher & Fisher, 1992; Jemmott, Jemmott, & Fong, 1992; & Jemmott, Jemmott, & Fong, 1998). This education program is similar to other prevention programs that have proven efficacious in reducing adolescents' risk for contracting HIV in several ways. It is based upon the AIDS Risk Reduction Model (ARRM) and incorporates two key skills included in most successful prevention programs, decision-making and communication/partner negotiation. Additionally, this education intervention is sensitive to cultural values, taking into account the ethnicity of participants. A major difference in this educational program and other risk-reduction programs is that it was





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developed utilizing information obtained from the results of a survey and interview administered to this same population.

Implications and Conclusions

Survey results revealed that juveniles incarcerated in the Escambia County, Florida jail and the DISC Village detention center are at high risk for exposure to and infection with HIV, the primary causal factor of AIDS. One of the main educational implications of these findings is that while adolescents are knowledgeable about HIV, they are also engaging in high-risk behaviors. These findings are similar to finding in other studies involving adolescent among the general population (DiClemente, et al., 1986; DiClemente, et al., 1993) as well as among incarcerated adolescents (Morrison, Baker, & Gillmore, 1994; Lanier, et al., 1991; DiClemente, et al., 1991; & Lanier, & McCarthy, 1989b). Additionally, these juveniles do not perceive themselves to be at high risk for infection. These results compare to the results of other studies among incarcerated adolescents (Katz, et al., 1995; Nader, et al., 1989; & Lanier, & McCarthy, 1989b).

A second implication of the findings of this study is the need for more

HIV/AIDS research that evaluates the specific education needs of the targeted population. In order for HIV programs, to be successful, they must address the particular high-risk behaviors of that particular population. This educational program focused on perceived susceptibility; communication skills, especially regarding partner's sexual history and negotiation regarding condom and




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DEVELOPMENT OF AN EDUCATIONAL INTERVENTION TO
REDUCE THE RISK OF HIV/AIDS FOR INCARCERATED
ADOLESCENTS DETAINED IN A COUNTY JAIL
BY
SADIE B. SANDERS
A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
DOCTOR OF PHILOSOPHY
UNIVERSITY OF FLORIDA
1998

DEDICATION
This dissertation is dedicated to my mother, Julia Sanders (December 20,
1916 - March 07, 1998). Her courage, strength, love and passion for living life
to the fullest have been and continue to be an inspiration to me.

ACKNOWLEDGEMENTS
I would like to thank all those who were instrumental in helping me
achieve a lifelong goal--my doctor of philosophy degree. My committee chair,
Barbara A. Rienzo, provided unyielding support, encouragement, and
professional guidance. My committee members, William Chen, Paul Duncan,
and David Miller, graciously offered their time, professional expertise and
professional guidance.
All my sisters and brothers, especially my sisters Mary S. Robbins and
Sallie S. Shoemo and their families; my sister-in-law, Mary A. Sanders; and my
niece, Christine Arnold, provided me unyielding support and love. My dearest
friends, Lorraine Austin-McLeod, Carolyn Taylor, Edna Williams, Robert Joseph,
Cynthia Ward, Evelyn Joseph, Margaret Gooden, Drucilla Washington and Alvin
Lyons; and the New Macedonia Baptist Church family provided me ongoing
encouragement and support. Melissa Silhan, Vice President of Lakeview
Center, Inc., provided me a variety of professional opportunities. J. J. Crater
and S. Kathy Zoss, Department of Forensics, eagerly offered me an opportunity
to conduct my research in the Escambia Florida, jail.
Foremost, I would like to thank my brother and hero, David L. Sanders, for
a lifetime of caring and support of ail my educational endeavors.

TABLE OF CONTENTS
page
DEDICATION ii
ACKNOWLEDGEMENTS iii
ABSTRACT vi
CHAPTERS
1 INTRODUCTION 1
Statement of the Research Problem 2
Purpose of the Study 3
Significance of the Study 3
Delimitations 4
Limitations 5
Assumptions 6
Research Objectives 6
Definitions of Terms 7
2 REVIEW OF THE LITERATURE 11
Introduction 11
HIV and Adolescents 12
HIV and High-risk Adolescents 17
HIV and Incarcerated Youth 21
HIV Prevention Programs and Adolescents 27
Summary/Conclusion 39
3 MATERIALS AND METHODS 41
Introduction 41
Research Participants 42
Research Settings 43
Instrumentation 44
Data Collection Procedures 45
Analysis of Data 48
iv

4 RESULTS 50
Socio-demographics 51
HIV/AIDS Risk Behaviors 52
HIV/AIDS Knowledge 56
Attitudes Regarding HIV/AIDS 58
UCF AIDS/HIV Risk Assessment Interview Results 61
Summary of Survey and Interview Results 62
HIV/AIDS Educational Program for Juveniles Incarcerated in a
Count Jail Based on the AIDS Risk Reduction Model
(ARRM) 64
5 DISCUSSION, CONCLUSIONS AND IMPLICATIONS 88
Socio-demographics 89
HIV/AIDS Risk Behaviors 89
Knowledge and Attitudes about HIV/AIDS 90
HIV Prevention Programs and Incarcerated Adolescents 91
Implications and Conclusions 93
Recommendations for Future Research 96
APPENDICES
A UCF AIDS/HIV Questionnaire 100
B AIDS/HIV Risk Assessment Interview 108
C Institutional Review Board Approval Letter 114
D Assent Form 115
E Consent Form 116
F HIV/AIDS Educational Program Detailed Description 117
REFERENCES 129
BIOGRAPHICAL SKETCH
140

Abstract of Dissertation Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Doctor of Philosophy
DEVELOPMENT OF AN EDUCATIONAL INTERVENTION TO REDUCE THE
RISK OF HIV/AIDS FOR INCARCERATED ADOLESCENTS
DETAINED IN A COUNTY JAIL
BY
Sadie B. Sanders
August 1998
Chairperson: Barbara A. Rienzo
Major Department: Health and Human Performance (Health Science Education)
Research reveals that youth who are detained or incarcerated in
correctional facilities constitute a subgroup of adolescents at high risk for HIV
infection due to their engagement in considerably more HIV-related sexual and
drug use behaviors than the general adolescent population. Although AIDS
cases among adolescents appear to be low (less than 1 % of total reported AIDS
cases), the majority of AIDS cases (64%) are diagnosed in persons aged 20-39,
indicating that initial infection frequently occurred during the teenage years and
early twenties due to the 9-15 year latency period.
Few studies have focused on HIV prevention among incarcerated
adolescents and none to date have addressed juveniles who are incarcerated in
adult facilities. This study identified specific HIV/AIDS education needs of
juveniles incarcerated in the Escambia County, Florida, jail and developed an
VI

appropriate educational intervention for these youth based on the AIDS Risk
Reduction Model (ARRM) (Catania, Kegeles, & Coates). Survey data results
revealed that, socio-demographically, these juveniles are predominantly male,
they are between the ages of 13 and 17, the majority are of ethnic/racial minority
status (70.5% African-American), and more than a fourth have been incarcerated
over three months. Regarding HIV high-risk behaviors, almost all of these
juveniles are sexually experienced (98%), more than half have had over 10
lifetime partners, the majority do not use condoms consistently, and a vast
majority (82.3%) had used marijuana. Research studies have found that non¬
injecting drug use, including alcohol, is associated with high-risk sexual
behaviors. Non-injecting drug use may increase adolescents’ sexual risk for
HIV infection indirectly by lowering inhibitions and impairing judgement. In
reference to HIV/AIDS knowledge and attitudes, overall, these juveniles
possessed moderate to high levels of HIV/AIDS knowledge regarding,
prevention, mode of transmission, and high-risk behaviors. However, they
reported attitudes that potentially may increase their risk for becoming exposed
to and infected with HIV. For example, the majority of these youth did not
perceive themselves to be a high risk for contracting HIV and a large minority
believed that there is a cure for AIDS. These findings were used to develop a
theoretically sound prevention education program for these youths.
vii

CHAPTER 1
INTRODUCTION
Acquired Immunodeficiency Syndrome (AIDS) continues to present itself
as one of the most devastating epidemics of the nation and the world. HIV is
beset by medical, legal, psychological, and social complexities. Although now
treatable, AIDS remains a fatal disease. Infection with human immunodeficiency
virus (HIV), the primary causal factor of AIDS, has the potential to severely
disrupt the lives of individuals, families, and communities. It is often
characterized by shame, guilt, fear, loss of dignity, financial ruin, and
abandonment. Nelkin, Willis, and Paris (1990) declare, “AIDS in no 'ordinary ‘
epidemic. More than a passing tragedy, it will have long-term, broad-ranging
effects on personal relationships, social institutions, and cultural configurations”
(p. 1).
Through December 1996, a total of 1,599,021 cases of AIDS had been
reported worldwide (PAHOAA/HO, 1997). The World Health Organization
(WHO) estimated that 29.4 million people (worldwide) have been infected with
HIV since the start of the pandemic in the late 1970s to early 1980s
(PAHOAA/HO, 1997). Well over 6,000 people become infected each day and an
estimated average of 40 million people worldwide will become infected by the
year 2000 (WHO, 1995).
l

2
In the United States, as of December 31, 1996 over 581,000 cases of
AIDS have been reported to the Centers for Disease Control and Prevention
(CDC, 1996). Adults/adolescents have a 62.3 case-fatality rate, while pediatrics
(children < 13 years old) have a 57.8 case-fatality rate (CDC, 1996). According
to the CDC, as of January 31, 1995 AIDS is the leading cause of death in men
and women aged 25-44 and the fifth leading cause of childhood deaths. To
date, no AIDS cure is available and no vaccine for preventing infection with HIV
exists. Currently, education appears to be the most viable weapon against the
spread of HIV/AIDS.
Statement of the Research Problem
The total number of infected teenagers is unknown. Research studies
reveal varying infection rates. Stein (1993) estimated that teenagers comprise
approximately 20% of the HIV-infected population. In the United States, the
majority of teenage AIDS cases (13-19 year olds) occur through transfusion of
blood products or heterosexual transmission (HIV/AIDS surveillance report,
1995). Although AIDS cases among adolescents appear to be low (less than 1%
of total reported AIDS cases), the majority of AIDS cases (64%) are diagnosed in
persons aged 20-39, indicating that initial infection occurred during the teenage
years and early twenties due to the 9-15 year latency period (HIV/AIDS
surveillance report, 1995).
Youths who are detained or incarcerated in correctional facilities
represent a medically underserved population that is at high risk for a host of
preexisting medical and emotional disorders (Council on Scientific Affairs, 1990).

3
These youths constitute a subgroup of adolescents at high risk for HIV infection
due to their engagement in considerably more HIV-related sexual and drug use
behaviors than the general adolescent population (DiClemente, Lanier, Horan,
and Lodico, 1991).
This study identified specific HIV/AIDS education needs of juveniles
incarcerated in the Escambia County, Florida, jail and developed an appropriate
educational intervention for these youth utilizing survey data results. The
educational intervention is based on the AIDS Risk Reduction Model (ARRM)
(Catania, Kegeles, & Coates, 1990).
Purpose of the Study
The purpose of this study was to identify specific HIV/AIDS education
needs of juveniles incarcerated in the Escambia County, Florida jail and develop
an appropriate educational intervention for these youth, to enable educators to
more effectively educate incarcerated juveniles about high-risk behaviors
including substance abuse and unsafe sexual practices.
Significance of the Study
Several research studies have focused on the issue of AIDS education
within the correctional setting. However, few to date have targeted the jail
system and even fewer have considered incarcerated youth. Jails are
potentially effective vehicles for reaching drug users and individuals engaged in
unsafe sex practices.
The criminal justice population, because illicit drug use and unsafe sexual
practices are prevalent in their backgrounds, is at particularly high risk of HIV

4
infection (Stevens, 1993). AIDS is rapidly becoming the leading cause of death
among correctional inmates (Gellert, Maxwell, Higgins, Pendergast, & Wilker,
1993). According to Pagliaro and Pagliaro (1992), "Inmates generally engage in
a greater number of these high-risk behaviors, (e.g. anal intercourse, needle
sharing) more frequently than members of the general population" (p. 205).
Through October 1989, a total of 5,411 cases of AIDS had been reported among
inmates in state/federal correctional systems and 30 large city/county jail
systems (Hammett & Moini, 1990a). Incarcerated youth are among those at risk
for HIV infection due to their participation in high-risk behaviors such as illicit
drug use, sexual activity with multiple partners, and/or failure to use condoms
(Harper, 1992). As of 1989, approximately 94,000 10-17 year olds were
detained in juvenile facilities and during 1990, an estimated 6,000 juveniles were
incarcerated in local jails or in State or Federal prisons. Polonsky, Kerr, Harris,
Gaiter, Fichtner, and Kennedy (1994) report that "Education and prevention
counseling are at present the least controversial ways to control the spread of
HIV infection" (p. 621). Education is a potentially viable prevention strategy
crucial for the promotion of risk-reduction behaviors among incarcerated
adolescents.
Delimitations
1. Juveniles incarcerated in the juvenile section of the Escambia County
(Florida) jail and in DISC Village (Tallahassee, Florida) were invited to
participate in the study.

5
2. Data were collected from juveniles incarcerated during the months of
March-October, 1996.
3. The UCF AIDS/HIV Questionnaire (Appendix A) and the UCF AIDS/HIV
Interview Questions (Appendix B) were used to assess knowledge,
attitudes, behaviors, and socio-demographics of juveniles detained in the
Escambia County, Florida Jail and DISC Village, Tallahassee, Florida.
4. The intervention, based on the AIDS Risk Reduction Model was
developed using information obtained from the UCF AIDS/HIV
Questionnaire and the UCF AIDS/HIV Interview Questions.
5. Health risk behaviors regarding substance use and sexual practices were
determined by subject self-report.
Limitations
1. Participants incarcerated in the juvenile section of the Escambia County,
Florida jail and participants incarcerated in the DISC Village detention
facility (Tallahassee, Florida) may not represent the population of all
subjects in such settings.
2. Participants obtained were incarcerated youth available during March
through October of 1996. Participation was strictly voluntary.
3. Findings from the study were limited by the ability of the UCF AIDS/HIV
Questionnaire and the UCF Interview Questions to accurately assess
participants' knowledge, attitudes, behaviors, and socio-demographics.
4. Reliance on self-reported history of sexual and drug use behaviors.

6
Assumptions
1. Participants obtained for the study are representative of Escambia
County, Florida jail.
2. Juveniles incarcerated during the months of the study are not dissimilar to
juveniles detained in other months.
3. Data obtained by subject self-report were not dissimilar to that of inmates
detained in other months.
4. Instruments were adequate for the purpose of the study.
Research Objectives
This study has several objectives. For all these objectives, responses
from the juveniles in the adult correctional facility will be compared with those of
youth detained in a juvenile detention facility to determine if their education
needs are comparable. The objectives of this study are to determine the:
1. Demographic characteristics that describe juveniles incarcerated in an
adult facility who are at high risk for HIV infection;
2. High-risk behaviors related to HIV/AIDS reported by juveniles detained in
these correctional facilities;
3. Level of HIV/AIDS knowledge of juveniles detained in these correctional
facilities;
4. Attitudes related to HIV/AIDS of juveniles detained in these facilities;
5. Components of a potentially effective HIV/AIDS prevention program
based on the AIDS Risk Reduction Model for juveniles detained in an
adult correctional facility. The UCF AIDS/HIV Questionnaire (Appendix A)

7
and the UCF Risk Assessment Interview (Appendix B) were used to plan
the educational Intervention.
Definitions of Terms
Acquired Immunodeficiency Syndrome (AIDS) - the final, life-threatening stage
of infection with human immunodeficiency virus (HIV) (The World Book
Encyclopedia, 1995, p. 163).
Adolescence - transitional phase of growth and development between childhood
and adulthood. “Adolescence” is a convenient label for the period in the life
span between 12 and 20 and is roughly equivalent to the term “teen” (The New
Encyclopedia Britannica, 199, p. 104.
Centers for Disease Control and Prevention (CPC) - the federal agency
operating under the U. S. Department of Health and Human Services, Public
Health Services, that is responsible for protecting the public health of the nation
by instituting measures for the prevention and control of diseases, epidemics,
and public health emergencies. Founded in 1946 (Huber, 1993, p. 32).
High-risk Adolescents - adolescents at high risk for HIV/AIDS include those who
engage in unprotected sex, have multiple sexual partners, share needles and
other injected drug equipment, or have sex with a “high-risk” person (Bowler,
Sheon, D’Angelo, & Vermund, p. 345).
Human Immunodeficiency Virus (HIV1 - the virus that causes Acquired
Immunodeficiency Syndrome (AIDS). It is a retrovirus that infects the T4
lymphocyte cells, monocyte-macrophage cells, certain cell populations in the
brain and spinal cord, and colorectal epithelial cells. HIV-infected cells weaken

8
the immune system. Individuals infected with the human immunodeficiency virus
do not necessarily have AIDS. Previously called lymphadenopathy virus, human
T-cell leukemia virus III, and human T-cell lymphotrophic virus III (Huber, 1993,
p. 76).
Jails - facilities designed for detaining people awaiting trial and for people
serving sentences of less than one year (Polonsky, Kerr, Gaiter, Fichtner, &
Kennedy, 1994, p. 615).
Juvenile - a young person who has not yet attained the age at which he or she
should be treated as an adult for purposes of criminal law. In some states, this
age is seventeen. Under the federal Juvenile Delinquency Act, a “juvenile” is a
person who has not attained his eighteenth birthday (18 U.S.C.A. section 5031)
(Black’s Law Dictionary, 1993, p. 867).
Juvenile Facility - may include public or private detention centers, training
schools, shelters, halfway houses, and the like (Polonsky et al., 1994, p. 625).
Substance Abuse - the Diagnostic and Statistical Manual of Mental Disorders
Fourth Edition Criteria for Substance Abuse:
A. A maladaptive pattern of substance use leading to clinically significant
impairment or distress, as manifested by one or more of the following,
occurring within a 12-month period:
(1) recurrent substance use resulting in a failure to fulfill major role
obligations at work, school, or home (e.g., repeated absences or
poor work performance related to substance use; substance-
related absences, suspensions, or expulsions from school; neglect
of children or household)
(2) recurrent substance use in situations in which it is physically
hazardous (e.g., driving an automobile or operating a machine
when impaired by substance use)

9
(3) recurrent substance-related legal problems (e.g., arrests for
substance-related disorderly conduct)
(4) continued substance use despite having persistent or recurrent
social or interpersonal problems caused or exacerbated by the
effects of the substance (e.g., arguments with spouse about
consequences of intoxication, physical fights)
B. The symptoms have never met the criteria for Substance Dependence for
this class of substance (APA DSM IV, 1994, pp. 182-183.)
Substance Dependence - the Diagnostic and Statistical Manual of Mental
Disorders Fourth Edition Criteria for Substance Dependence: A maladaptive
pattern of substance use, leading to clinically significant impairment or distress,
as manifested by three (or more) of the following, occurring at any time in the
same 12-month period:
(1) tolerance, as defined by either of the following:
(a) a need for markedly increased amounts of the substance to
achieve intoxication or desired effect
(b) markedly diminished effect with continued use of the same
amount of the substance
(2) withdrawal, as manifested by either of the following:
(a) the characteristic withdrawal syndrome for the substance
(refer to Criteria A and B of the criteria sets for withdrawal
from the specific substances)
(b) the same (or closely related) substance is taken to relieve or
avoid withdrawal symptoms
(3) the substance is often taken in larger amounts or over a longer
period than was intended
(4) there is a persistent desire or unsuccessful efforts to cut down or
control substance use
(5) a great deal of time is spent in activities necessary to obtain the
substance (e.g., visiting multiple doctors or driving long distances),
use the substance (e.g., chain-smoking), or recover from its effects
(6) important social, occupational, or recreational activities are given
up or reduced because of substance use
(7) the substance use is continued despite knowledge of having
persistent or recurrent physical or psychological problem that is
likely to have been caused or exacerbated by the substance (e.g.,
current cocaine use despite recognition of cocaine-induced
depression, or continued drinking despite recognition that an ulcer

10
was made worse by alcohol consumption) (APA DSM IV, 1995, p.
181)
World Health Organization (WHO) -founded in 1948, this international
organization is the health agency of the United Nations. Its goal is to achieve
the optimum level of health care for all people. Objectives of the WHO include
directing and coordinating international health work, ensuring technical
cooperation, promoting research, preventing and controlling disease, and
generating and disseminating information. The Organization emphasizes and
supports the health needs of developing countries; establishes standards for
biological, food, and pharmaceutical needs; and determines environmental
health criteria (Huber, 1993, p. 162).

CHAPTER 2
REVIEW OF THE LITERATURE
Introduction
A healthy, productive generation of adolescents in the 1990s will ensure
that America has the healthy generation of adults needed to support the
growing elderly population in the 21st century. The AIDS epidemic
threatens the viability, perhaps the very existence, of this next generation.
The social and economical well-being of this first "AIDS generation" may
well predict the future well-being of this nation as a whole in the next
century. (Hein, 1992, p. 3)
Medical interventions relating to HIV disease will have a significant
economic impact upon the health care industry. In 1993, $940 billion were spent
on health care in the United States-12.1% of the gross national product.
According to Healthy People 2000, 75% of health care dollars are spent on
chronic illnesses and only 1 % on preventing these same illnesses. Given the
long latency period and the development of effective HIV treatments, AIDS, a
chronic disease has the potential to consume a large portion of U. S. health
care dollars. Jonsen and Stryker (1993) report that in the U.S., AIDS is
responsible over 200,000 people receiving services from the health care system
over the last 10 years, and an estimated one million are expected to receive
services in this decade, many of whom are uninsured or underinsured.
li

12
The cost of AIDS is defined in terms of non-monetary and monetary costs.
Non-monetary costs, according to Bloom and Carliner (1988), "include the value
that AIDS patients, their families and friends, and other members of society
place on the suffering and death of AIDS patients and on the need to behave
differently to avoid contracting AIDS" (p. 604). Monetary costs include both
direct and indirect costs. Direct costs are personal medical care costs such as
diagnosis and treatment, and non-medical costs include research and
prevention. Indirect costs represent the production lost to society due to the
disease's morbidity and mortality (Farnham, 1994).
The literature focusing on Human Immunodeficiency Virus (HIV) disease
among adolescents is presented in this chapter. This chapter will review
literature on (1) HIV and adolescents, (2) HIV and high-risk adolescents, and (3)
HIV prevention programs and adolescents.
HIV and Adolescents
In general, the nature of adolescence places teenagers at risk for
becoming exposed to and infected with HIV. Adolescence is characterized by
the desire to seek independence from parents and other authority figures,
conform to peers, take risks, and to experiment. According to Rotherman-Borus
and Kooperman (1991), "The three behaviors that place persons at highest risk
for HIV are typically initiated during this developmental period: unprotected
sexual intercourse, IV drug use and the use of drugs and alcohol that disinhibit
sexual behavior or lead to IV drug use" (p. 67).

13
Behaviors
While some research studies reveal that persons who are more
knowledgeable about AIDS engage in low risk behaviors, others show that
persons who are more knowledgeable about AIDS engage in unsafe sexual
practices (Morrison, Baker, & Gillmore, 1994).
A number of studies attest to youth engagement in high-risk behaviors for
contracting HIV. Results from the 1993 Youth Risk Behavior Surveillance
System revealed that nationally, 53% of high school students had engaged in
sexual intercourse at least once; 18.5% of high school students had four or more
sex partners; 58.2% of sexually active high school students had used a condom
during their last sexual encounter; 32.8% ever used marijuana; and 1.4% of high
school students had injected an illegal drug at least once during their lifetime
(Kann, Warren, Harris, Collins, Douglas, Collins, Williams, Ross, & Kolbe,
1995). Lifetime prevalence data from the National Institute on Drug Abuse 1988
Drug Abuse Study revealed that nine million 12-17 year olds had ever used
alcohol; 2.3 million had used marijuana; 3.4% had used illicit drugs; and 590,000
had used cocaine (NIDA, 1993). The 1987 National Adolescent Student Health
Survey (NASHS) revealed that among a national sample of 8th- and 10th-grade
students, 77% of eight-grade students and 89% of tenth-grade students had
ever used alcohol, 15% of eighth graders and 35% of tenth graders had used
marijuana and 4% of eighth graders and 6% of tenth graders had used cocaine
(CDC, 1989).
In a survey of 1,773 Massachusetts adolescents between the ages 16
and 19, 61% reported that they had engaged in sexual intercourse in the past
year. Among sexually active respondents, only 33% reported always using a
condom, 32% reporting using a condom sometimes, and 37% reporting never
using a condom. Regarding alcohol and drug use, those adolescents who

14
consumed five or more drinks per day were 2.8 times less likely to use condoms
while those who used marijuana in the past month were 1.9 times less likely
(Hingson, Strunin, Berlin, & Heeren, 1990).
A number of studies indicate that the use of non-injected drugs, including
alcohol can increase one's risk for becoming HIV infected due to decreased
inhibitions, impaired judgement, and the reduction of reluctance to participate in
unprotected sexual intercourse. Hingson, et al. (1990) in a study of 1,773
Massachusetts 16-19 year-olds found that adolescents who consumed an
average of five or more drinks per day were less likely to always use condoms
than adolescents who were abstainers (29% versus 35%). Furthermore, those
adolescents who had used other psychoactive drugs in the month prior to the
survey were not as likely to always use condoms as adolescents who did not use
psychoactive drugs.
Additionally, the association of drug abuse among adolescents and the
exchange of sex for drugs, money, food, and shelter is well documented (CDC,
1993a).
Regarding intravenous drug use, I DUs are experiencing a greater
increase in the number of new cases of AIDS than homosexual and bisexual
men (Hammett & Moini, 1990). In a national sample of 904 IDUs between the
ages of 13 and 21 (92% between the ages of 18 and 21) not in drug treatment, a
6.2% seropositivity rate was found. Although, not statistically significant,
females (7.2%) had a slightly higher rate than males (5.9%). Respondents who
reported engaging in sexual activity with someone of the same sex or with both
sexes, exchanging sex for money, or reported a previous history of syphilis,
demonstrated the highest rates of HIV infection (Williams, 1993). According to
the Centers for Disease Control and Prevention (CDC), youth between the ages
of 13 and 19 constitute approximately 1% of the total number of AIDS cases

15
(HIV/AIDS surveillance report, 1995). Although the actual number of HIV
infected adolescents is unknown, it is believed to be much higher than the
adolescent AIDS prevalence due to the 9-15 year incubation period for HIV
(CDC, 1995). To date, a few national studies have focused on HIV prevalence
among adolescents. Teenage applicants to the U.S. military between October
1985 and March 1989 had an overall seroprevalence rate of .34 in 1000. The
rates for males and females were comparable, .35 and .32 per 1000,
respectively (Burke, Brundage, Goldenbaum, Garner, Peterson, Visintine,
Redfield, & the Walter Reed Retrovirus Research Group, 1990). Entrants to the
Job Corp between 1987 and 1990, age 16-21, had an HIV seropositivity rate of
3.6 per 1000. The overall rate was higher in males (3.7 per 1000) than in
females (3.2 per 1000). However, for entrants ages 16 and 17, the rate was
higher in females (2.3 per 1000) than in males (1.5 per 1000). Geographically,
the overall highest prevalence rate was found in the northeast, followed by the
South, Midwest and West (St. Louis, Conway, Hayman, Miller, Petersen, &
Dondero, 1991).
High teenage pregnancy rate and the increasing number of teenagers
receiving treatment for STDs provide indirect indicators of sexual intercourse
without the use of a condom. In the Unites States, each year, one million
teenage females become pregnant and 3 million teenagers are infected with an
STD (Kolbe, 1992).
Knowledge and Attitudes
In one of the first studies to assess adolescents' knowledge and
attitudes, Price, Desmond, and Kukulka (1985) found that, among 250 Ohio high
school students only 27% of respondents were personally worried about
contracting AIDS and between one half and three-fourths of these adolescents

16
did not understand how HIV is transmitted although they were knowledgeable
about high-risk groups. In contrast, DiClemente, Zorn and Temoshok, (1986) in
a survey of 1,326 adolescents enrolled in Family Life Education classes at 10
high schools in San Francisco, found that 92% of respondents were aware that
HIV could be transmitted through sexual intercourse. However, only 60%
correctly reported that using a condom during sexual intercourse could lower the
risk of HIV transmission. Although 66% of the San Francisco respondents
reported being worried about AIDS, over half reported that they are "less likely
than most people to get AIDS."
DiClemente, et al. (1986) attributed the apparent greater knowledge and
higher awareness of the San Francisco group to the location of participants near
the AIDS epicenter. However, DiClemente, Brown, Beausoleil and Lodico
(1993) compared knowledge, attitude and behavior data of adolescents living in
low AIDS or HIV prevalence communities with that of adolescents living in high
AIDS prevalence communities and found that although both populations
revealed high levels of AIDS knowledge, those adolescents in a rural area were
more knowledgeable about AIDS than their inner-city counterparts.
In a study assessing AIDS knowledge and attitudes of 90 9th- and 10th-
grade students from two Tennessee urban high schools before and after an
AIDS education program, 75% or more of male and 75% of female respondents
correctly answered 64% and 55%, respectively, of the knowledge questions
(Steitz & Munn, 1993). DuRant, et al. (1992) assessed the knowledge and
perceived risk of 2,483 11th- and 12th-grade students in a southeastern
community and found that 97.3% of the students knew that sharing needles with
an infected person was a means of HIV transmission. However, some
adolescents held several misconceptions about prevention that could increase
their risk for becoming infected with HIV. For example, 17.4% of the students

17
believed that birth control pills are effective in preventing HIV transmission.
Additionally, a large minority (25.7%) thought it possible to determine the HIV
status of another person by looking at them.
HIV and High-risk Adolescents
Adolescents who engage in unprotected sexual intercourse, those who
have multiple sexual partners, and adolescents who use illicit drugs and alcohol
are at highest risk for becoming HIV seropositive (Melchert & Burnett, 1990;
Morrison, et al., 1994; National Commission on AIDS, 1994; Rotherman-Borus, &
Kooperman, 1991; Yarber, & Parrillo, 1992). Several subgroups of adolescents,
including homeless and runaway youth, minority youth, and incarcerated youth,
engage in more than one of these high risk activities, and thus are considered
most vulnerable for contracting HIV (DiClemente, Lanier, Horan, & Lodico, 1991;
Fullilove, Golden, Fullilove ill, Lennon, Porterfield, Schwartz, & Bolán, 1993;
National Commission on AIDS, 1994; Rotheram-Borus, Kooperman, & Ehrhardt,
1991; Stricoff, Kennedy, Nattell, Weisfuse, & Novick, 1991; Strunin, 1991).
Runaway and Homeless Youth
Homeless youth, because of participation in high-risk behaviors, are
emerging as a subgroup of adolescents at high risk for HIV infection. Homeless
youth, totaling about 1.5 million in the United States are defined by Rotheram-
Borus, Kooperman, and Ehrhardt (1991) as "those who have left their homes
without a parent's or guardian's consent (runaways), those who are thrown out of
their homes (throwaways), those who leave problematic social service
placements (system kids), and those lacking basic shelter (street youths)" (p.
1188). Homeless youth are at risk for HIV infection due to their drug abuse and
sexual behaviors, as well as other problem behaviors that reduce their ability to

18
demonstrate effective coping responses. According to Rotheram-Borus,
Kooperman, and Ehrhardt (1991), in order to survive economically, homeless
youth are subject to live in neighborhood with high HIV prevalence rates and to
become involved in sexual and substance abuse behaviors that increase their
risk for becoming infected with HIV. Moreover, the National Commission on
AIDS (1994) reports that approximately 1 to 1.3 million teenagers, in an attempt
to escape conflict, violence and abuse, run away from home every year. Many
of these runaways engage in the exchange of sexual activity for money, food
shelter, or drugs, thus increasing their risk for contracting HIV. Stricoff, et al.,
(1991) in a study of runaway and homeless youth at Covenant House, a facility
serving runaway and homeless youth in New York, found an overall HIV
prevalence rate of 5.3%. Research participants consisted of adolescents
between the ages of 15 and 20 who were receiving health care. Over a 27-
month period, 2,667 specimens were analyzed. Ninety-one percent of
participants were sexually active, with an average 2.8 and a range of 1 to 20
sexual partners per week. Twenty-nine percent had ever exchanged sex for
food, money, shelter, or drugs. Drug use was extremely high, with 80%
admitting to using alcohol, 68% marihuana, 48% cocaine, 38% crack, and 6%
intravenous drug use.
In a study of 302 runaways (154 males, 148 females), aged 11-19,
residing in four New York City area residential facilities, drug and alcohol use
was prevalent and was found to be significantly related to an increased number
of sexual partners and low condom use. Seventy percent of runaways in this

19
study reported ever using alcohol, while 43% admitted to ever using marijuana,
19% crack/cocaine, and 14% hallucinogens. The majority (63%) of runaways
admitted to current sexual activity, with an average of two sexual partners. Only
half of those participating in penile-vaginal intercourse reported using condoms.
Condom use during oral sexual encounters was also very low, but was higher
during anal sexual intercourse (Kooperman, Rosario, & Rotheram-Borus, 1994).
Research studies also show that homeless adolescents, in addition to
participating in more sexual and drug use high-risk behaviors than the general
adolescent population, are less knowledgeable about HIV/AIDS than the general
adolescent population (Rotheram-Borus, Kooperman, & Ehrhardt, 1991).
HIV and Racial/Ethnic Minority Adolescents
African-American and Hispanics are disproportionately represented in the
number of reported AIDS cases. While African-Americans constitute only 12%
of the United States total population, and Hispanics only 8%, they constitute
32% and 16%, respectively, of the total adult/adolescent AIDS cases.
Additionally, African-Americans account for 55% of the pediatric AIDS cases and
33% of all AIDS cases for youths between the ages of 13 and 19. Hispanics
between the ages of 13 and 19 make up 20% of the total AIDS cases for this age
group (CDC, 1995).
Studies indicate that racial/ethnic minority adolescents are at increased
risk for HIV infection. African-American teenage applicants to the U.S. military
between October 1985 and March 1989, had an HIV seroprevalence rate of 1.06
per 1000 compared to an overall seroprevalence rate of .34 in 1000 (Burke, et

20
al. 1990). Similarly, in a national study involving 16 to 21 year old entrants to
the Job Corp between 1989 and 1990, African-American males and Hispanic
males had HIV seropositivity rates of 5.5 and 3.0 (per 1000), respectively,
compared to white males who had a rate of 1.4 (St. Louis, et al., 1991).
In a national sample of 904 IDUs between the ages of 13 and 21, not in
drug treatment, an overall 6.2% seropositivity rate was found. However,
African-Americans had the highest rate (10.3%), followed by Whites (6.6%), and
Hispanics (5.3%) (Williams, 1993).
Regarding HIV knowledge and attitude, DiClemente, Boyer, & Morales
(1988) in a study of 261 White, 226 Black and 141 Latino adolescents enrolled
in Family Life Education class at the 10 largest high schools in the San
Francisco Unified School District, found substantial racial/ethnic differences.
Black and Latino youth were less knowledgeable about AIDS and held more
misconceptions than White youth. While all groups were aware that the disease
could be acquired through sharing intravenous needles and having sexual
intercourse with an infected person, only 59.9% of Black adolescents and 58.3%
of Latino adolescents correctly reported that using a condom during sexual
intercourse could lower risk of HIV transmission compared to 71.7% of White
adolescents.
In contrast, some studies show little difference between ethnic/racial
minorities and white adolescents. For example, Hingson, et al. (1990), in a
telephone survey of 1,773 Massachusetts adolescents (age 16-19) in which 61%
had been sexually active in the past year, 28% of African-American compared to

21
31% White reported always using a condom during sexual intercourse. Thirty-
nine percent of Hispanics reported always using a condom. Seventy-four
percent of African-American adolescents admitted to having had sexual
intercourse in the past year compared to 63% of Whites and 61% Hispanics.
Sixty-nine percent of African-Americans reported that they were worried about
contracting AIDS compared to 73% of Whites and Hispanics. Additionally, in
response to being asked if they had changed any of their behavior due to their
worry over contracting the disease, 58% of Hispanics and 51% of African-
Americans compared to 40% of Whites reported that they had made some
changes.
A difference exists in the pattern of HIV transmission among minorities.
African-American AIDS-diagnosed males are more likely than Hispanic and
White male adolescents to have been involved in homosexual activity.
Whereas, Hispanic males with AIDS are more likely than African-American
males and White males to have injected drugs (Rotherman-Borus, & Kooperman
1991). Harper (1992), in a study exploring ethnic and gender differences in
incarcerated adolescents' engagement in AIDS/HIV high risk behaviors, found
that minority males and females were more likely than their white counterparts to
engage in drug and alcohol use prior to sexual activity.
HIV and Incarcerated Youth
Youths incarcerated in detention facilities are predominantly males (more
than 85%) and of racial or ethnic minority (Council on Scientific Affairs, 1990).
African-Americans comprise 42% of detained adolescents, while Hispanics

22
account for 15% (Morris, Baker, & Huscroft, 1992). The majority of detained
youths (82%) are between the ages of 14 and 17, with an average age of 15.7
years (Council on Scientific Affairs, 1990). The period of incarceration varies
greatly and is influenced by a number of factors including the juvenile's current
charge(s) and delinquent history, overcrowding of jail or detention facility, and
the court calendar (Morrison, et al., 1994). As reported by the Council on
Scientific Affairs (1990), short-term facilities, such as detention centers detain
youth for an average of 12 days, while long-term facilities generally detain youth
for an average of eight months. The majority of confined youth (95%) are
detained due to legal offenses including, property offenses, offenses against
persons, drug and alcohol use related offenses, and probation violations.
Additionally, approximately 40% of youth referred to juvenile court have
committed previous offenses.
The majority of individuals processed through urban jail systems have at
least one illegal drug in their system at the time of arrest (McBride and Inciardi,
1990). In a recent NIDA-funded study of 12,000 injecting drug users (IDUs),
40% reported that they had spent some time in jail or prison within the last six
months (Baxter, 1991). lUD’s are the second largest group with AIDS in the
United States and the principle exposure group in the correctional system (60%)
(Gellert, et al., 1993). In addition, IDUs are experiencing a greater increase in
the number of new cases of AIDS than homosexual and bisexual men (Hammett
& Moini, 1990b).
HIV Risk Behaviors
Incarcerated adolescents comprise a group at high risk for a number of
health and health-related problems, including HIV and AIDS. According to the
Council on Scientific Affairs (1990), youth detained in correctional facilities have

a greater than expected rate of selected health problems, including substance
abuse, sexually transmitted diseases, unplanned pregnancies, and psychiatric
disorders due to their personal behavior and their lack of adequate prior health
care services.
According to the National Commission on AIDS (1994), "research
suggests that incarcerated adolescents lack a future orientation, have poor self-
image, and perceive little or no value in modifying risk behavior" (p. 42).
Incarcerated youth participation in HIV high-risk activities is evidenced by
the health status of these incarcerated youth (Council on Scientific Affairs,
1990). Blind studies involving 16- and 17-year olds incarcerated in detention
centers in Los Angeles County, California revealed that three of 1,870 had a HIV
seropositive test compared to 2 of 2,000 in 1989 and 4 of 2,000 in 1991 (Baker,
& Morris, 1992).
In a study assessing sexually transmitted disease prevalence among
females detained in the King, County, Washington, juvenile facility, it was
revealed that 18% of 98 respondents were found to have N. gonorrhoea and
20% of 86 respondents were positive for C. trachomatis. Of 85 tested for
Neisseria gonorrhoea and Chlamydia trachomatis, 32% were found to be
infected with either one. However, none of the 61 detainees screened for
syphilis tested positive. Sixty-seven percent of 98 respondents reported no
contraceptive use, while 23% reported using foam and/or condoms and 8%
reported oral hormone use (Bell, Farrow, Stamm, Critchlow, & Holmes, 1985).
In a similar study examining sexual behavior and sexually transmitted
diseases among 966 detained male adolescents, 4.5% of detainees were
infected with Neisseria gonorrhoea, 6.9% Chlamydia trachomatis, and 0.9% of
detainees had a reactive syphilis serological test. Twelve percent of those
tested for all three infections had at least one STD. Fifty-nine percent of those

24
responding reported using a condom during their last sexual encounter and 37%
reported consistent condom in the previous four months (Oh, Cloud, Wallace,
Reynolds, Sturdevant, & Feinstein, 1994).
Pre-test counseling for voluntary HIV antibody testing conducted among
16 and 17 year old juveniles incarcerated in juvenile detention centers in Los
Angeles County, California exposed a group at very high risk for contracting HIV.
More than 90% of these youth admitted to having had sexual intercourse. Also,
these detainees had a history of multiple sexual partners, low condom use, high
incidence of previous treatment for sexually transmitted diseases (STDs), and
high prevalence of multiple drug use, including 9% injecting drug use (IDU)
(Baker, & Morris, 1992).
Drug and alcohol use by this population is higher than among the general
adolescent population and may increase the likelihood that these adolescents
may engage in high-risk sexual practices. According to the Council on Scientific
Affairs (1990), a nationwide survey of detained juveniles revealed that 63% of
respondents used drugs regularly, and 32% and 39% respectively, were under
the influence of alcohol and another drug when they committed their offense.
Melchert and Burnett (1990) in a study to examine the high-risk sexual
behaviors of 212 adolescents involved with Dane County, Wisconsin juvenile
detention facility found that, compared to adolescents in the general population,
these respondents had a very early mean age (12.5 years) at first intercourse
and a high rate of pregnancy (27%).
Morrison, et al. (1994), in a study of 119 juveniles in a detention facility
found these adolescents to be at high risk for HIV infection, relative to the
general adolescent population. These juveniles had their first sexual intercourse
at an early age (12.5), had high rates of heterosexual activity, and had high
numbers of sexual partners. Additionally, one-third of these adolescents had

25
used condoms the last time they engaged in sexual activity with their primary or
steady partner, while about half had used condoms with their casual partners.
Results from a study involving incarcerated adolescents and public high
school students also found that incarcerated youth tended to have higher rates
of HIV risk behaviors. Ninety-nine percent of detained youth reported being
sexually experienced compared to 28% of their school-based counterparts.
Fifty-two percent of incarcerated youth reported sexual onset by age 12,
compared to 26% of the high school sample. Additionally, 73% of incarcerated
youth reported two or more sexual partners during the past year, compared to
8% of public school youth (DiClemente, et al, 1991).
Results from a study assessing beliefs about condoms and their
association with intention to use condoms among 201 juveniles in a detention
facility indicate that these adolescents "had engaged in behaviors that put them
at high risk of acquired immunodeficiency syndrome (AIDS) and other sexually
transmitted diseases" (Gillmore, Morrison, Lowery, & Baker, 1994, P. 228.)
Knowledge and Attitudes about HIV
In a study assessing knowledge and attitudes among 119 juveniles in a
detention center, it was revealed that these adolescents had moderately positive
attitudes towards condom use and were generally knowledgeable about AIDS.
However, these adolescents were at high risk, relative to the general adolescent
population. (Morrison, et al., 1994).
Lanier and McCarthy (1989a), in a study to assess incarcerated
adolescents' knowledge and concern about AIDS, found that most of the 393
juveniles who comprised 86% of the custodial population of the Alabama
Division for Youth Services (DYS) were aware that AIDS is preventable, that it is
not casually transmitted, and that sharing IV drug needles is a high-risk

26
behavior. However, one-third believed that condoms are not effective means of
preventing transmission. While 60% of these juveniles were concerned about
their own risk of acquiring AIDS and 57% were concerned about their friends
becoming infected, a large minority (18%) agreed with the statement "AIDS is a
made up problem by the government to decrease drug use and sexual activity'.
Eleven percent was uncertain. In a study comparing beliefs about AIDS among
four subgroups of adolescents: urban public school students; suburban private
school students; youth incarcerated in a detention facility; and gay adolescents,
incarcerated adolescents were less knowledgeable, in lower agreement with
AIDS health guidelines, had lower perceived personal threat of acquiring AIDS,
and had lower personal self efficacy, compared to the other three groups (Nader,
Wexler, Patterson, McKusick, & Coates, 1989).
DiClemente, et al. (1991) compared HIV knowledge data of incarcerated
adolescents with that of public high school students and found that, while both
populations demonstrated a high level of AIDS knowledge, substantial
differences were present. Mainly, incarcerated youth were less aware of risk
reduction behaviors. For example, only 56% of incarcerated youth correctly
identified "not having sexual intercourse with a person who uses illegal drugs
that can be injected" as a risk-reduction strategy, compared to 72% of public
school youths.
Katz, Mills, Singh, and Best (1995) in a study comparing AIDS
knowledge and attitudes of 802 public high school students, incarcerated
delinquents, and emotionally disturbed adolescents, found that while AIDS
knowledge was moderately high in all three groups, incarcerated adolescents
were slightly less informed about AIDS, less likely to believe that condoms can
prevent disease transmission, more likely to feel powerless to protect
themselves, and more sexually permissive.

27
HIV Prevention Programs and Adolescents
Public education and voluntary behavior changes have been cited by the
U.S. Surgeon General as being the most effective means to combat the spread
of HIV disease (Surgeon General's Report, 1986). The U.S. public school
system has the capacity to reach 45.5 million school-age youth annually
(Allensworth, & Symons, 1989).
In response to a 1986 Surgeon General's report and in an attempt to curb
the spread of HIV within the adolescent population, many public school systems
hastily developed and implemented knowledge-based AIDS education programs
which generally lacked a theoretical framework (Siegel, 1993). According to the
National Commission on AIDS (1994), "If information about the consequences of
unhealthy or risky behaviors were sufficient to motivate people to adopt health
behaviors, no one would smoke, everyone would wear a seat belt, all doctors'
recommendations about diet and exercise would be followed, and there would
be no drunk driving" (pp. 45-46).
In order to be most effective, comprehensive HIV prevention programs
must utilize strategies which combine cognitive and behavioral skills training,
must be designed to be age appropriate, sensitive to cultural values, religious
beliefs, sex roles, and attitudes and customs within the targeted population, and
must provide access to services (Boyer, & Kegeles, 1991; DiClemente, 1993a;
DiClemente, Brown, etal., 1993; Fisher & Fisher, 1992; Gillmore, Morrison,
Richey, Balassone, Gutierrez, & Farris, 1997; Kooperman, et al, 1994; &
National Commission on AIDS, 1994; ). Additionally, according to Boyer and

28
Kegeles (1991), "Effective prevention programs should be based on models and
theories of risk behavior so that the programs can be designed to change those
factors which lead to the undesirable risky behaviors" (p. 11). Several theories
have evolved that attempt to explain and predict human health behavior.
The Health Belief Model (Becker, 1974) has been widely used by health
education professionals in explaining and predicting health behavior. The
Health Belief Model (HBM), originally developed as a conceptual framework for
explaining preventive behaviors, was formulated in the 1950s by a group of
social psychologists, including Hochbaum, Leventhal, Kegeles, and Rosenstock.
It is derived from the social-psychological theory of Lewin, Becker and others.
Dimensions of the HBM include perceived susceptibility (subjective perception of
the risk of contracting a health condition), perceived severity (personal
evaluation of medical/clinical and social consequences posed by the health
condition), perceived benefits (assessment of the effectiveness of actions
recommended to reduce the disease threat), and perceived barriers (feelings
related to negative consequences of the recommended health action). In an
effort to improve its predictive power, the HBM was later expanded to include
self-efficacy (Janz and Becker, 1984; Rosenstock, Strecher, and Becker, 1988).
The Theory of Self-efficacy, first presented by Bandura (1977) is defined as
ones perception that one can successfully perform preventive behaviors.
According to Bandura (1977), "expectations of personal efficacy are derived
from four principal sources of information: performance accomplishments,
vicarious experience, verbal persuasion, and physiological states. The more

29
dependable the experiential sources, the greater are the changes in perceived
self-efficacy" (p. 191).
Although a significant amount of research suggest difficulties of the HBM
in predicting HIV-related behaviors (Brown, DiClemente, & Reynolds, 1991;
Montgomery, Joseph, Becker, Ostrow, Kessler, & Kirscht, 1989), several studies
have validated the HBM's, (or more frequently, constructs of the model)
usefulness in successfully predicting HIV-preventive behaviors. For example, in
a study of 1,1773 Massachusetts youth between the ages of 16-19, Hingson, et
al. (1990) found that respondents were "more likely to always use condoms if
they felt susceptible to AIDS; believed condoms are effective; perceived few
barriers to condom use; and were exposed to more cues to action" (p. 296).
Similarly, data from a study of 424 male and female undergraduate students at
six United States schools revealed that, "susceptibility, self-efficacy, and social
support were the most important predictors for current sexual behavior and for
sexual behavior changes" (Steers, Elliott, Nemiro, Ditman, and Oskamp, 1996, p.
107).
Further support for the utility of the HBM to predict health behavior is
evidenced in a study by Petosa and Wessinger (1990) to determine the HIV
education needs of seventh, ninth, and eleventh grade adolescents. Results
suggest that while these youth perceived themselves to be highly susceptible to
contracting HIV, they failed to understand the severity of the disease.
Additionally, a large minority reported that condoms are embarrassing to use
and that it is difficult to discuss sexual histories with a partner.

30
The Theory of Reasoned Action (Fishbein, & Ajzen, 1975) is a cognitive
theoretical model suggesting that specific behavioral intentions are the
determinants of behavior and that, the intention to perform a particular behavior
is determined by the attitude towards performing the behavior and the perceived
social norms regarding the behavior.
The AIDS Risk Reduction Model (ARRM) (Catania, Kegeles, & Coates,
1990) is a psychosocial conceptual model designed to examine people's efforts
to change sexual behavior in order to avoid contracting HIV through sexual
transmission. The ARRM incorporates elements of several prior models
including the Health Belief Model, self-efficacy theory, the Theory of Reasoned
Action, the Theory of Planned Behavior, emotional influences, and interpersonal
processes. According to the ARRM, behavior change is a process occurring in
three stages: (1) recognition and labeling of one's sexual behaviors as high risk
for contracting HIV; (2) making a commitment to reduce high-risk sexual contacts
and increase low-risk activities; and (3) seeking and enacting strategies to
obtain these goals. Variables hypothesized to influence the recognition and
labeling stage include knowledge of sexual activities associated with HIV
transmission, the belief that one is personally susceptible to contracting HIV, the
belief that having AIDS is undesirable (aversive emotions), and social
influences, including social networks and social norms.
The commitment stage is reflective of a decision-making process that may
also include decisions to remain undecided, wait for the problem to resolve itself
or resign oneself to the problematic issue. Factors hypothesized to influence

31
this stage include perceived costs and benefits, self-efficacy, knowledge and
perception of enjoyment and risk reduction, and social influences.
The final stage, enactment includes information-seeking, obtaining
remedies, enacting solutions and social influences. Verbal communication with
sexual partners regarding sexual issues is a key component of the enactment
stage. According to Catania, et al. (1990), the ARRM is based on the premise
that progress from one stage to the next is expected to be dependent on
successfully completing the goals of the prior stage.
While the ARRM was originally developed to examine sexual behaviors
and to be used with adult populations, with minor modifications, it is believed to
be applicable to other HIV risk behaviors, as well as to adolescent populations
(Catania, et al., 1990; and Boyer, & Kegeles, 1991).
The majority of the HIV/AIDS studies that have examined the utility of the
ARRM have provided either supportive or mixed results. Kowalewski,
Longshore, and Anglin (1994) in a study to examine the predictive ability of the
first two stages of the ARRM for intentions to use condoms among 21-59 year
old injecting drug users (IDUs) who had used them in the year prior to the
interview and IDUs who had not found that, drug users' intentions to use
condoms were strongly related to their social network.
Malow, Corrigan, Cunningham, West, and Pena (1993) in a study to
assess psychological factors associated with condom use among adult African-
American drug abusers, also presented data in support of key constructs of the
ARRM. Condom users reported significantly higher levels of self efficacy,

32
communication skills, condoms use skills, and communication skills than non¬
condom users.
Results from a study to examine the ability of the ARRM to explain factors
motivating condom use among HIV-infected women (Kline and VanLandingham,
1994) suggest that, HIV-positive women who use condoms possess higher
levels of perceived self-efficacy to influence the partner's sexual behavior than
those who do not use condoms.
Lanier (1996), in a study to examine the primary constructs of the ARRM
among juveniles detained by the Department of Youth Services in a southern
state, found that response efficacy was significantly related to every aspect of
the AIDS reduction behavior, and that knowledge and susceptibility were "highly
associated with several specific AIDS reduction behaviors with high marginal
influence" (p. 545).
Adolescents
Although school-based HIV prevention programs are a requirement of the
majority of states and school districts, the initial focus of these programs was on
increasing students' knowledge and changing their attitudes. Several of these
knowledge-based programs have proven to be highly successful. For example,
Brown, Fritz, Barone (1989), in a pilot study to assess the impact of an AIDS
education program on 313 seventh and tenth grade students, found that
students demonstrated an increase in AIDS information, positive attitudes
toward prevention, and tolerance for people with AIDS after participation in the
program. The intervention covered two class periods and included lecture and
video material regarding HIV transmission and prevention. A study by Huszti,
Clopton, and Mason (1989) also assessed the efficacy of a lecture/video

33
education program presented to tenth grade students enrolled at two suburban
public schools in the Oklahoma City area. Participants were randomly assigned
to one of three groups; an intervention group receiving HIV/AIDS information via
lecture, an intervention group receiving HIV/AIDS information via video, orto a
control group receiving no educational intervention. Intervention group students
demonstrated a greater increase in AIDS knowledge, more acceptance of people
with AIDS, and more positive attitudes toward HIV risk reduction behavior than
the control group. The effects of lecture were more effective than the effects of
the video.
Ruder, Flam, Flatto, and Curran (1990) evaluated the impact of an HIV
education program that consisted of a lecture presented by the Westchester
County (New York) Health Department to junior and senior high school students.
Results revealed that, students who received a brief 1-1/4 hour AIDS-information
presentation demonstrated a significant increase in knowledge compared to
students who did not received the presentation. Brown, Barone, Fritz, Cebollero
& Nassau (1991) evaluated the efficacy of a state-mandated AIDS education
program on a sample of 2,709 middle- and high-school student and found that,
students receiving the educational intervention demonstrated greater increases
in knowledge about AIDS, tolerance for people with AIDS, and future intentions
to engage in risk reduction risk behaviors, compared with students in the control
group. The educational program was composed of approximately five hours of
information regarding the nature of AIDS and AIDS transmission and prevention.
It utilized a variety of strategies including, lecture, audiovisual presentations,
class discussion, handouts, and guest speakers.
Dixon (1994), in a study of 184 students assessed the effectiveness of an
HIV education program presented to three groups of 9-18 year old pre¬
adolescents and adolescents. The program incorporated group discussions, a

34
question/answer session and a vignette that involved students playing the role of
the virus. Results reveal that knowledge was increased in all three groups. In
an evaluation of a discussion format-HIV/AIDS education program presented to
2,169 St. Louis high school students, Morton, Nelson, Walsh, Zimmerman, and
Coe (1996) found that the educational intervention successfully increased
students' knowledge of HIV/AIDS.
School-based HIV prevention programs have been proven to be
efficacious in their ability to increase adolescents' knowledge and, to some
degree, create desired attitudes about HIV and risk-taking behaviors. However,
many of these programs appear to have failed in their ability to significantly
delay and/or reduce HIV high risk behaviors among adolescents (Kirby, Korpi,
Adivi, & Weissman, 1997; Newman, DuRant, Ashworth, & Gaillard, 1993; &
Walter & Vaughan, 1993)
Research suggests that the most successful school-based HIV prevention
program are those programs that are theory-based, include both cognitive and
behavioral aspects, and are skilled-based (Allensworth & Symons, 1989;
Longshore, 1990; Boyer & Kegeles, 1991; Fisher & Fisher, 1992; Jemmott,
Jemmott, & Fong, 1992; DiClemente, 1993; & National Commission on AIDS,
1994). However, only three states currently provide school-based programs that
address cognitive, affective, and skills domains (DiClemente, 1993). According
to DiClemente (1993), the failure of schools to incorporate all three domains in
prevention programs is the result of social and political barriers.
To date, only a few of these programs have been evaluated. Main,
Iverson, McGloin, Banspach, Collins, Rugg, and Kolbe (1994) evaluated the
impact of a 15-session (day) skills-based curriculum on 979 urban ninth- and
eleventh-grade students enrolled in seventeen Colorado schools. The
education program was based on the Social Cognitive Theory and the Theory of

35
Reasoned Action. Twenty-five teachers, the majority of whom taught health,
implemented the program after a five-day, 40 hour training program. However,
the program failed in its attempt to postpone the onset of sexual intercourse and
reduce the percentage of students currently engaging in sexual and drug use
behaviors that place them at risk for HIV infection. The intervention students
demonstrated greater knowledge regarding HIV and greater intent to engage in
HIV risk reduction behaviors, and were more likely to believe that adolescents
their age who participate in HIV high risk behaviors are susceptible to HIV
infection than comparison group students. Additionally, at the 6-month follow¬
up, sexually active-intervention students reported fewer sexual partners and
greater frequency of condom use.
In a study to assess the effectiveness of a teacher-delivered HIV risk-
reduction program in modifying AIDS-related knowledge, beliefs, self-efficacy
and behaviors among 867 ninth- and eleventh-grade students, Walter and
Vaughan (1993) found "Significant (albeit modest) effect favoring intervention
were observed for knowledge, beliefs, self-efficacy, and risk behaviors scores at
a three month follow-up" (p. 725). The cognitive-, behavioral- and skills-based
education program was based on the Health Belief Model, the Social Cognitive
Theory, and a model of social influence. The 6 one-class period lessons
conducted on consecutive days were implemented by regular classroom
teachers who had received eight hours of in-service training.
Boyer, Shafer, and Tschann's (1997) evaluation of a knowledge- and
cognitive-behavioral skills-building intervention to prevent STDs and HIV
infection in high school students revealed that, although the intervention did not
have a significant impact on HIV knowledge and high risk behaviors, it did
enhance intervention-group participants' skills to prevent risky sexual and
substance use behaviors.

36
High-risk Adolescents
Adolescents who are at highest risk for becoming HIV infected are also
those youths who have, more than likely, dropped out of school and thus lack
the opportunity to benefit from school-based education programs (National
Commission on AIDS, 1994). Additionally, in-school youth that have high rates
of absenteeism do not benefit fully from school-based HIV/AIDS prevention
programs.
According to the National Commission on AIDS (1994), "Out of school
youth have been documented as suffering from depression, anxiety, and low
self-esteem" (p. 42). These youths often engage in HIV high-risk sexual
behaviors as well as use drugs, including alcohol. Additionally, minority youth,
particularly African-American youth, are a growing segment of the population
who engage in HIV high risk behaviors as evidenced by high STD and
pregnancy rates. In order to effectively address the specific HIV educational
needs of these youth, HIV prevention programs targeting African-American
youth, must address the attitudes and cultural values related to sexuality issues
(Pittman, Wilson, Adams-Taylor, & Randolph, 1992).
Several studies have evaluated the efficacy of non-school- based HIV
education programs. A few of these programs targeting adolescents at highest
risk for HIV infection have demonstrated effectiveness among runaway, minority,
and substance abusing adolescent populations. Rotheram-Borus, Kooperman,
Haignere, and Davies (1991) in a study to assess the impact of a skill-based HIV
prevention program among 145 runaways between the ages of 11 and 18 at two
New York City publicly funded runaway shelters found that, as the number of
interventions sessions increased, so did the adolescents' reports of consistent
condoms use and decreases in engagement of high risk behaviors at three- and
six-month follow-ups. Seventy-eight runaways at the intervention shelter

37
participated in an average of 11 (minimum of three) prevention sessions that
presented general information regarding HIV/AIDS information and addressed
coping skills, access to health care and other resources, and individual barriers
to safer sex. Sixty-seven runaways at another shelter, comparable to the
intervention site shelter served as the comparison group.
Jemmott, et al. (1992) conducted and evaluated an HIV reduction-
program with inner city African-American males. The program was successful in
reducing HIV high-risk behaviors among adolescents who received the
intervention. A total of 157 participants with a mean age of 14.64 were recruited
from a Philadelphia outpatient medical clinic, a local high school, and a local
YMCA. Participants were randomly assigned to a 5-hour small-group AIDS risk-
reduction intervention or to a control group receiving a career opportunity
workshop. Compared to control group participants, intervention group
participants demonstrated greater AIDS knowledge and reported less sexual
activity, fewer sexual partners and greater condom use at the 3-month follow-up.
Kipke, et al. (1993) assessed whether inner-city minority adolescents who
were randomly assigned to an AIDS Risk Reduction Education and Skills
Training (ARREST) program would demonstrate greater pre- to post-test
knowledge and attitudes about HIV/AIDS, perception of risk and self-efficacy in
prevention, and behavioral skills for reducing HIV risk than would those
assigned to a wait-list control group. The sample consisted of eighty-seven
Latinos (59%) and African-American adolescents, ages 12-16 years who were
recruited from three New York City community-based agencies. Forty-one
ARREST program adolescents participated in three 90-minute weekly sessions
facilitated by two AIDS educators and consisting of small group discussions and
skills-building activities. Results reveal that the ARREST program intervention
was ineffective in modifying adolescents' high-risk sexual behaviors, such as

38
number of sexual encounters, number of sexual partners, and use of condoms.
However, compared to the comparison group, the ARREST group demonstrated
greater HIV/AIDS knowledge, decreases in negative attitudes, perceived risk of
infection, and assertiveness and behavioral skills.
St. Lawrence, Brasfield, Jefferson, Alleyne, O'Bannon, and Shirley (1995)
assessed the impact of a cognitive-behavioral intervention on African-American
adolescents' risk for HIV infection. Two hundred forty-six African-American
adolescents were randomly assigned to an 8-week HIV/AIDS prevention
program, receiving a combination of HIV/AIDS education and behavior skills
training, including condom use, social competency skills, and cognitive
competency skills or an educational intervention, receiving HIV/AIDS information
only. The results show that adolescents participating in the
educational/behavior skills program demonstrated a greater increase in condom
use and risk reduction skill compared to participants receiving the educational
program post-intervention and through a 1-year follow-up. Additionally, among
adolescents who were sexually abstinent upon beginning the educational
programs, adolescents receiving the education/behavior skills program delayed
the onset sexual activity to a greater degree compared to the educational
program participants.
Regarding substance-abusing adolescents, St. Lawrence, Jefferson,
Banks, Cline, Alleyne, and Brasfield (1994) developed and assessed the
effectiveness of a cognitive-behavioral HIV/AIDS prevention program on
lowering substance-dependent adolescents’ risk for acquiring HIV. Nineteen
adolescents residing in the only residential treatment program serving
substance-dependent minors in the state of Mississippi received a 5-session HIV
risk-reduction program that included risk education, social competency skills,
technical skills, and problem-solving skills. Results reveal an "increased

39
knowledge about HIV/AIDS, more favorable attitudes toward prevention, greater
internal and lower external locus of control scores, more favorable attitudes
toward condom use, increased self-efficacy, and greater recognition of HIV
vulnerability" (p. 425).
In a similar study with similar results, 34 adolescents in a residential
substance abuse treatment program were randomly assigned to a standard HIV
education program or a 6-session risk-reduction program that combined HIV
education and behavior skills training. Adolescents participating in the
education/behavior skills program demonstrated increased HIV/AIDS knowledge,
more positive attitudes toward HIV risk-reduction behaviors and condom use,
more internal locus of control and increased self-efficacy and increase
recognition of personal risk for HIV infection compared to the education program
adolescents (St. Lawrence, Jefferson, Alleyne, & Brasfield, 1995).
Only a few studies have targeted youth in juvenile facilities and to date,
none have considered adolescents incarcerated in adult facilities. Lanier and
McCarthy (1989b) assessed the AIDS knowledge, attitudes, and behaviors of
adolescents in a detention facility and evaluated the impact of an AIDS
educational program among these adolescents. Results indicate that the
intervention successfully increased juveniles' HIV/AIDS knowledge and
influences their attitudes toward AIDS.
Summarv/Conclusion
Adolescents in general are at risk for HIV infection due to their
participation in high-risk behaviors, such as drug use and unprotected sexual
intercourse. Research reveals that minority youth, homeless youths and
runaways, and incarcerated youth are subgroups of adolescents who are at

40
increased risk due higher prevalence of HIV high risk behaviors. Compared to
the general adolescent population, incarcerated adolescents, the majority of
whom are of ethnic or racial minority status are slightly less knowledgeable, tend
to have more sexual partners, are more likely to use injecting drugs, more likely
to use alcohol and drugs and less likely to use condoms.
Recently, adolescents have been acknowledged as one of three groups
among who AIDS incidence rates are growing at the fastest rate. Although the
gains in HIV knowledge from educational interventions since the beginning of
the AIDS epidemic up to this point are indisputable, these gains have not
translated into positive behavioral changes among adolescents. Thus, general
agreement exists among HIV and AIDS experts that knowledge alone is not
sufficient to eliminate or reduce adolescents' participation in HIV high-risk
behaviors. As a result, there is increased awareness of the need for
developmental^ appropriate, culturally sensitive comprehensive HIV prevention
programs that incorporate accurate information, exploration of values and
attitudes, skills building, and access to services (National Commission on AIDS,
1994).

CHAPTER 3
METHODS AND MATERIALS
Introduction
This study identified specific HIV/AIDS education needs of juveniles
incarcerated in the Escambia County, Florida jail and developed an appropriate
educational intervention for these youth to reduce their risk for contracting
HIV/AIDS. The intervention will enable educators to more effectively educate
incarcerated juveniles about high-risk behaviors including substance abuse and
unsafe sex practices. The objectives of this study were to determine the:
1. Demographic characteristics that describe juveniles incarcerated in an
adult facility who are at high risk for HIV infection;
2. High-risk behaviors related to HIV/AIDS reported by juveniles detained in
these correctional facilities;
3. Level of HIV/AIDS knowledge of juveniles detained in these correctional
facilities;
4. Attitudes related to HIV/AIDS of juveniles detained in these facilities;
5. Components of a potentially effective HIV/AIDS prevention program
based on the AIDS Risk Reduction Model for juveniles detained in an
adult correctional facility.
Each objective was analyzed utilizing information obtained from the UCF
AIDS/HIV Questionnaire (Appendix A) and the UCF AIDS/HIV Risk Assessment
41

42
Interview (Appendix B). For objectives one through four, responses from the
juveniles in the adult correctional facility were compared with those of youth
detained in a juvenile detention facility.
This chapter includes the following sections: (1) research participants, (2)
settings, (3) instrumentation (4) procedures and (5) data analysis.
Approval for this study was obtained through the University of Florida
Institutional Review Board (Appendix C).
Research Participants
The study was conducted between the months of March and October
1996. Survey participants consisted of a total of 124 juveniles (107 males, 16
females, one missing observation). Interview participants consisted of a total of
45 juveniles (41 males and 4 females). Participants were detained in two
correctional facilities, an adult facility (Escambia County, Florida jail) and a
juvenile detention center (DISC Village). Seventy-nine of the survey participants
(65 males and 13 females) and 23 of the interview participants (19 males and 4
females) were under the supervision of DISC Village detention facility. All
detention center female participants were in the RAFT program located in
Woodville, Florida. Male participants were detained in Greenville Hills Academy
located in Greenville, Florida. Forty-five survey participants (42 males and 3
females) and 22 interview participants (all males) were detained at the Escambia
County, Florida jail located in Pensacola, Florida. Study participants were
between the ages of 11 and 18. Any Escambia County, Florida jail juvenile who
is at least 18 years old or who reaches the age of 18 while detained in the jail is

43
automatically adjudicated an adult and is then housed in the adult section of the
jail. As a result, no 18 year-olds were included in the jail group.
All juveniles incarcerated in the two facilities between March-October,
1996 were invited to participate in the study.
Research Settings
This study was conducted in two northwest Florida correctional facilities,
an adult facility and a juvenile detention facility (DISC Village). Research
participants detained in the adult facility were detained in the Escambia County,
Florida jail, located in Pensacola, Florida. Male participants were located in the
juvenile section of the jail while female participants were detained in the jail’s
infirmary. The Escambia County, Florida jail maintains a daily population of
approximately 42 juveniles with an average age of 16. The majority of juveniles
are of racial/ethnic minority status (61 %) and male (98%). The average length
of stay is 6 months. None have been sentenced. Once a juvenile has been
sentenced or reaches age 18, he/she is adjudicated an adult. The majority have
not attended school in the last two years and the reading level is low. Two to
three may be considered mildly mentally retarded or borderline intellectual
functioning. The majority of these juveniles live with relatives (aunts, uncles,
grandparent, or parents) and one to two are in the custody of the Florida
Department of Children and Families.
Participants incarcerated in DISC Village Detention facility were housed
in two separate facilities located approximately 75 miles apart. Female
participants were located in Woodville, Florida, a community approximately 20

44
miles south of Tallahassee. Male participants were incarcerated in Greenville
Hills Academy, located approximately 60 miles east of Tallahassee in the town
of Greenville, Florida.
Instrumentation
This study employed two instruments. First, the University of Central
Florida (UCF) AIDS/HIV Questionnaire (Appendix A) was developed specifically
to determine AIDS-related knowledge, attitudes and behaviors of adolescents
(Lanier, 1989) and has been used extensively in assessing and predicting
incarcerated adolescents' AIDS-related knowledge, attitudes, and behaviors
(Lanier & McCarthy, 1989a; Lanier & McCarthy, 1989b; Lanier, DiClemente, &
Horan, 1992; Lanier and Gates, 1993; & Barthlow, Horan, DiClemente, & Lanier,
1995). The instrument was initially developed by selecting items from previous
epidemiological studies of adolescents' knowledge, attitudes, and high risk
behaviors regarding AIDS (Lanier and McCarthy, 1989). The questionnaire
included 73 items and was divided into 4 sections for analysis: knowledge (19
items), attitude (26 items), behavior (23 items), and socio-demographic (5 items).
A brief description of each construct follows:
1. Knowledge items measured objective knowledge including methods of
transmissions and means of preventing/reducing risk for infection.
2. Attitudes measured included self-efficacy, personal risk, friends' risk for
becoming infected, and magnitude of HIV/AIDS epidemic.
Self-reported high-risk behaviors included unprotected sex, sex with
multiple partners and injecting drug use with needle sharing.
3.

45
4. Socio-demographics including age, race/ethnicity, gender, length of time
incarcerated, and geographical location.
A panel of three national experts on AIDS and adolescence affirmed
content validity (Barthlow, Horan, DiClemente, & Lanier, 1995). The
questionnaire was pilot-tested with a group of 34 detained juveniles and was
subsequently modified to reflect an elementary reading level. Several HIV/AIDS
research studies reflect successful use of the questionnaire: Knowledge and
concern about AIDS among incarcerated juvenile offenders (Lanier & McCarthy,
1989); AIDS awareness and the impact of AIDS education in juvenile corrections
(Lanier & McCarthy, 1989); HIV knowledge and behaviors of incarcerated youth;
a comparison of high and low risk locales (Lanier, DiClemente, & Horan, 1991);
and correlates of condom use among incarcerated adolescents in a rural state
(Barthlow, Horan, DiClemente, & Lanier, 1995).
Second, the University of Central Florida (UCF) AIDS/HIV Risk
Assessment Interview consisted of 37 open-ended questions that cover the
majority of issues measured by the AIDS/HIV Questionnaire, allowing for
elaboration and in-depth discussion (Appendix B).
Data Collection Procedures
Approval for the study was obtained from the University of Florida
Institutional Review Board (Appendix C). All research participants were advised
that participation in the study was strictly voluntary and there would be no
penalty if they chose not to participate. Also, participants were informed that
they would not be awarded compensation of any kind and were given assurance

46
that they would have complete confidentiality. In order to assist in maintaining
participants' privacy and confidentiality, participants were specifically asked not
to identify themselves on the questionnaire and not to reveal their names during
the subsequent interviews. Each research participant consented to participate in
the study by signing the appropriate assent form (Appendix D) provided by the
University of Florida. Parental/legal guardian consent was obtained for each of
the Escambia County, Florida jail participants (Appendix E). Escambia County,
Florida jail juveniles' participation in the study was solicited by, first securing
verbal permission from the jail administration; Major White and Captain Cornish;
and the jail's Department of Forensics, Dr. S. K. Zoss, Coordinator of Adult
Forensics Unit and J.J. Crater, Licensed Mental Health Counselor. Study
participants were recruited by visiting each cell and providing each juvenile with
information regarding the research study.
DISC Village participants were recruited as part of a Florida Department
of Children and Families (Formerly Florida Department of Health and
Rehabilitative Services) funded research project sponsored by the University of
Central Florida, Orlando, Florida.
At the beginning of each jail visit and prior to talking to juveniles, the jail's
adolescent mental health counselor provided a current roster of inmates. Those
inmates agreeing to participate in the study signed the appropriate consent form.
Parents/legal guardians of those inmates consenting to participate were first
contacted by telephone or via a home visit and provided information regarding
the research study. J.J. Crater, Licensed Mental Health Counselor, provided the

47
names, addresses, and telephone numbers parents/legal guardians of juveniles
consenting to participate in the study. Those parents/legal guardians agreeing
to have their child participate in the study were either hand delivered or mailed
the appropriate consent form. In the event a parent/legal guardian was unwilling
or unable to have the consent delivered, the consent form along with a return
address siarriped-envelope was mailed to them. Parents/legal guardians not
having a telephone service were visited at home.
The SJCF AIDS/HIV Questionnaire was administered to Escambia County
jail participants over several days to groups of approximately six to eight male
inmates in the group room located in the jail infirmary. The three female inmates
were housed in the jail infirmary and were administered the questionnaire in their
cell. All DISC Village male participants received the questionnaire on the same
day, at the same time. DISC Village female participants received the survey at
the same time on the same day as DISC Village male participants. The
researcher provided reading assistance on a group and an individual basis as
needed to participants demonstrating a low reading level.
Additionally, 50% of Escambia County, Florida jail participants
and 13% randomly selected DISC Village participants (detention facility)
received a 45-60 minute AIDS/HIV Risk Assessment Interview. All Interviews
were conducted by the researcher among jail group participants and detention
group participants on an individual basis and in a private setting.
The HIV/AIDS educational program was developed for juveniles
incarcerated in the Escambia County, Florida jail. It was developed utilizing

information obtained from the UCF AIDS/HIV Questionnaire (Appendix A) and
the AIDS/HIV Risk Assessment Interview (Appendix B).
48
Analysis of Data
All data entry and analysis for the needs assessment component of this
study were conducted using SPSS for Windows, Version 6.0. Double data entry
involved taking each of the 45 surveys and visually comparing the responses to
the questions with the entries in the data set. This procedure revealed no errant
entries.
An additional data verification technique was employed during the data
entry process. Any survey that appeared to be completed in a random manner,
a systematically untruthful manner, or in a manner that suggested overt hostility
toward the survey process as evidenced by hostile comments or sayings written
on the survey were marked as being possibly invalid by the data entry
personnel. There were no such surveys.
The conclusion based on this conservative procedure is that any error
from data entry is extremely minimal and non-systematic in nature. Thus, the
data set is presumed to be clean and valid, representing the subject's true
response to the survey instrument.
To date, data analysis has been limited to analysis of frequency
distributions, descriptive statistics, and Chi-square analysis. Chi-square is
useful in determining if significant differences between levels of variables exist
between the jail group and the detention center group, a group of 79 participants
who were incarcerated in a different facility. Descriptive statistics were used to

49
address research objectives one through five. Information obtained from the
University of Central Florida (UCF) AIDS/HIV Questionnaire and AIDS/HIV Risk
Assessment Interviewdata were employed in meeting research objective five.

CHAPTER 4
RESULTS
In this chapter, the results of the University of Central Florida (UCF)
AIDS/HIV Questionnaire and the University of Central Florida (UCF) AIDS/HIV
Risk Assessment Interview are presented. The UCF AIDS/HIV Questionnaire
was developed specifically to determine AIDS-related knowledge, attitudes and
behaviors of adolescents (Lanier, 1989). The University of Central Florida
(UCF) AIDS/HIV Risk Assessment Interview (Lanier, 1996) consisted of 37
open-ended questions that covered the majority of issues measured by the UCF
AIDS/HIV Questionnaire, allowing for elaboration and in-depth discussion.
Survey participants consisted of 45 juveniles (42 males and 3 females)
incarcerated in the Escambia County, Florida jail and 79 juveniles (65 males, 13
females, one missing observation) detained in DISC Village detention facility.
DISC Village detention center males were located at Greenville Hills Academy,
Greenville, Florida and females were detained at the RAFT Program, Woodville,
Florida. Survey participants in the jail were between the ages of 13 and 17 with a
little over a half age 17. Ninety-three percent were male. Almost three-fourths
were African -American, a fifth White, 2.3% Hispanic, and 4.5% Asian. Survey
participants in the detention center were between the ages of 11 and 18. Almost
three-fourths were between the ages of 13 and 16. Over four-fifths were male.
50

More than half were African-American, one-third White, 2.6% Hispanic, and
2.6% Asian.
51
Interview participants consisted of approximately 50% (N=22) of the
Escambia County Jail participants and 30% (N=23) randomly selected detention
center participants. Interview participants in the jail consisted of 22 males
between the ages of 14 and 17 with an average age of 15.7. A little over four-
fifths were African-American and a little less than a fifth were White. Interview
participants in the detention center consisted of 19 males and four females
between the ages of 11 and 17 with an average age of 14. Fifty-two percent
were African-American and forty-eight were White.
This study had several objectives. For objectives one through four,
responses from the juveniles in the adult correctional facility are compared with
those of youth detained in a juvenile detention facility. The results will be
described by study objectives. The two groups were significantly different on a
total of four variables, one socio-demographic variable and three behavior
variables. However, since there are so few differences, these could be Type I
errors.
Socio-demographics
The first objective was to determine the socio-demographic characteristics
that describe juveniles incarcerated in an adult facility who are at high risk. Five
questions from the UCF AIDS/HIV Questionnaire assessed juveniles’ socio¬
demographic including age, race/ethnicity, gender, location and length of time
incarcerated. As Table 4-1 demonstrates, the demographic profiles of the two

52
populations are similar. The majority are male, of ethnic/racial minority status
(African-American), and over half had been incarcerated over 60 days. The two
groups were found to be significantly different on only one demographic
variable, age (Table 4-2).
More than half of the Escambia County, Florida jail participants were age
17, while almost three-fourths of DISC Village participants were between the
ages of 13 and 16. The jail did not contain any participants between the ages of
11 and 12.
The majority of jail group and detention group participants were male.
African-Americans comprised almost three-fourths of the jail group participants
and just over half of the detention group, Whites one-fifth of the jail group and
one third of the detention center group, Hispanics 2.3% of the jail group and
2.6% of the detention center group, Asian 4.5% of jail group and 2.6% of
detention center group, and other 2.3% jail group and 6.4% detention center
group.
Regarding length of stay, 15.6% of the Escambia County jail juveniles had
been incarcerated 1-30 days, 26.7% 31-60 days, 28.9% 61-90 and 29.9% had
been detained over 91 days. Almost 21% of DISC Village detention center
juveniles had been incarcerated 1-30 days, 19.5% 31-60 days, 16.9% 61-90
days, and 42.9% had been incarcerated over 91 days (Table 4-1).
HIV/AIDS Risk Behaviors
The second objective was to identify high-risk behaviors related to
HIV/AIDS reported by juveniles detained in these correctional facilities. Twenty-

53
three questions assessed juveniles' HIV risk behaviors and behavioral intentions
(Table 4-3). HIV-related behavioral risk items included sexual activity, multiple
sexual partners, same sex relationships, failure to use condoms, failure to ask
sexual partners about their sexual history, sexual abuse, injecting drug use, non¬
injecting drug use, failure to take special precautions to prevent contracting HIV
and sharing items that have the potential to be contaminated with HIV
transmissible body fluids. Participants in both groups reported several high-risk
behaviors. Almost all participants are sexually experienced, over half reported
at least six lifetime sexual partners, two-fifths use condoms consistently, less
than half ask their sexual partners about their sexual history, over half report that
they would have sex with an attractive partner if no condom were available and
over four-fifth have used marijuana.
The two groups were found to be significantly different on three behavior
variables, sexual abuse (Table 4-5), number of sexual partners in the last three
months (Table 4-6), and number of same sex relationships (Table 4-7).
Regarding high-risk behaviors among jail participants, overall, juveniles
incarcerated in the Escambia County jail reported more sexual risk behaviors
than their detention center counterparts. Almost 98% of jail group participants
and 92.3% of the detention center group participants reported that they were
sexually experienced. Over half (51.1 %) of jail participants reported having had
10 or more lifetime sexual partners, compared to almost two-fifths of the
detention center group. The two groups were found to be significantly different
(p< 0.05) (See Table 4-6) in the number of sexual partners in the last three

54
months. In response to question #65, "how many sexual partners have you had
in the last three months", half of jail participants compared to almost three-
fourths of the detention group participants reported that they had not had any
sex partners in the last three months. Regarding juveniles incarcerated in jail, a
fifth reported that they had one partner in the last three months, over a fifth
reported 2-5 partners, 6.8% reported 6-10 partners and none reported over 10
partners in the last three months. Among the detention group, 11.5% reported
one partner, 7.7% reported 2-5 partners, 1.3% reported 6-10 partners and 6.4%
reported over 10 partners in the last three months.
Although almost three-fourths of juveniles in both groups reported that
they frequently take special precautions to prevent catching AIDS, specific
responses indicate behaviors to the contrary. In response to the question (#32),
"In the last 5 times you had sex, how many times did you use a condom", two-
fifths of both groups reported that they used a condom each of the last five times
they had sex. Over half of both groups reported that they would have sex with
an attractive partner if no condom were available. More than a fourth of jail
participants and over two-thirds of detention center participants reported that
they would trust a sexual partner if they said they were free from disease.
Additionally, although almost all participants in both samples reported plans to
use a condom if unsure of their partners’ sexual history, only two-fifths of jail
participant and two-thirds detention center participants reported that they
frequently ask partners about their sexual history.

55
Regarding drug use, more than four-fifths of both groups reported that
they had used marihuana.
Jail group participants reported several low-risk behaviors. With respect
to same sex behavior, the two groups were significantly different (p< 0.05) (See
Table 4-7) in reporting the number of same sex relationships. Jail participants
were less likely than their detention counterparts to report being at risk. In
response to the question (#66), "with how many partners have you had a same
sex relationship", almost all jail group participants responded 'none", compared
to close to three-fourths of detention group participants. A little over 2% of
intervention group participants reported one same sex relationship, while 6.4%
of the comparison group participants reported one same sex relationship, 14.1%
reported 2-5, 2.6% reported 6-10, and 2.6% reported over 10 same sex
relationship.
In regard to sexual abuse, the two groups were significantly different (p<
0.05) (See Table 4-4). A little over 4% of jail participants compared to 18.4% of
detention center participants reported ever being sexually abused. Although not
statistically significantly different, jail participants were less likely to report
physical abuse than detention center participants were.
With respect to behavioral intention, approximately three-fourths of both
group respondents reported that, in the future they will frequently demand the
use of a condom for their own protection as well as for their partner's protection.
None of the jail juveniles and 6.5% of detention group juveniles responded yes
to the question, "have you ever 'shot up1 drugs. Almost all respondents in both

56
groups reported that in the future, they do not plan to inject drug or share a
needle in order to body pierce.
Over half of jail participants respondents and almost three-fourths of
detention center participants reported that they had been tested for HIV. No
positive results were reported among either group.
HIV/AIDS Knowledge
Objective three assessed the level of HIV/AIDS knowledge of juveniles
detained in these correctional facilities. The HIV/AIDS knowledge portion of the
questionnaire consisted of nineteen items that were answered on a yes, no, or
don’t know basis (Table 4-8). These items assessed juveniles’ knowledge
regarding modes of transmission, risk groups/behaviors, risk reduction and
general knowledge. The majority of participants in both groups reported high
levels of HIV/AIDS knowledge regarding modes of transmission, high-risk
behaviors and HIV prevention. Survey results revealed no significant
differences between the jail group and the detention center group on any of the
knowledge variables.
Although less knowledgeable in some areas than in others, overall, these
juveniles reported a high level of HIV/AIDS knowledge. Regarding transmission
through casual contact, approximately three-fourths of both group respondents
correctly reported that AIDS cannot be caught from sharing a glass of water with
an infected person and that one cannot acquire AIDS by eating food prepared by
a person who has AIDS. Just over three-fourths of jail group participants and
two-thirds of detention group participants correctly reported that AIDS could not

57
be caught from a toilet seat. Four-fifths of the jail group and a little over two-
thirds of the detention group knew that AIDS could not be caught if a person with
AIDS sneezes on you. In response to the question 'AIDS can be caught from
sharing marijuana pipes or cigarettes", the majority of both groups responded
correctly. The vast majority of the jail and detention group participants knew
that AIDS is not transmissible through shaking hands. Almost 90% of both
groups were aware that AIDS is not transmissible by kissing on the cheek.
Considering actual transmission knowledge, almost all jail group
participants and three-fourths of detention group participants knew that sharing
razor blades and tattoo needles are means of HIV transmission. All jail group
respondents and almost all detention group respondents were aware that AIDS
is transmissible through sharing drug needles.
Participants demonstrated that they were less knowledgeable in several
areas relating to actual transmission of the virus. For example, one-third of jail
group participants and less than one-fifth of detention group respondents were
aware that AIDS could not be acquired through donating blood. A little less
than two-fifths of both groups reported that AIDS could not be caught from heavy
tongue kissing. In response to the statement, "AIDS can be caught if the
hospital has to give you blood", approximately two- thirds of both groups
responded correctly.
Relative to general knowledge, the vast majority of both group knew that a
virus causes AIDS. The majority of juveniles were aware that the disease is not
confined to certain segments of the population. For example, In response to the

58
question, "AIDS is harder to catch if you are young and healthy", approximately
three-fourths of both groups responded correctly. In response the question, "All
gay men (homosexuals) have AIDS", three-fourths of jail group participants and
over half of detention group participants correctly responded "no.”
Although not significantly different, jail group participants demonstrated a
higher level of prevention knowledge than did detention group participants. For
example, more than four-fifths of the jail group and two-thirds of the detention
group were aware that using a condom would help reduce risk for acquiring the
virus.
Attitudes Regarding HIV/AIDS
The fourth objective was to determine the attitudes related to HIV/AIDS of
juveniles detained in these facilities. Twenty-six items examined juveniles’
attitudes toward HIV/AIDS (Tables 4-9 and 4 -10). Almost all participants in
both groups were aware of the severity of the AIDS problem in the United States,
most reported that they worry about contracting HIV, almost all were aware that
it is possible to have AIDS and not know it and about a fourth believed
themselves to be at high risk for contracting HIV. The two groups were not
significantly different on any of the attitude variables.
The majority of both groups believed that AIDS is a big problem in
America. Close to 14% of jail group participants and 22.1 % of detention group
respondents considered AIDS to be a fabricated problem by the government.
However, the reported perceived risk of infection for self and for friends was low.
Approximately a fourth of both groups perceived themselves to be personally

59
vulnerable to becoming infected. About a quarter of jail group and forty percent
of detention group respondents reported their friends to be at high risk for
becoming infected.
Regarding self- and response-efficacy, about half of jail group participants
and a third of comparison group participants agreed that individuals are
responsible for protecting themselves against HIV infection. The vast majority
believed that persons can take action to prevent this disease (Tables 4-10 and
4-11). in response to the statement, “there is a cure for AIDS but it is too
expensive for most people, “ about a fourth of both groups agreed.
In response to perceived norms of sexual behaviors among friends, a fifth
of jail group participants and a third of detention group participants believed that
their friends have had over 10 lifetime sexual partners. Approximately 90% of
both group respondents believed that their friends had not had a homosexual
relationship. Three-fourths of jail group participants and more than half of
detention group participants would like to be tested for AIDS, while almost two-
thirds of jail group participants and close to three-fourths of detention group
participants would like their friends to be tested.
Regarding worry, only a small percentage of juveniles from both groups
considered themselves to be at low risk for becoming HIV infected. Three-
fourths of both groups reported that they worry a lot about catching AIDS.
Finally, more than half of the respondents from both groups reported that they
worry about their friends catching AIDS.

60
Considering perceived knowledge, two-thirds of both groups reported
that, compared to most people, they feel that they know a lot about AIDS. Jail
group participants reported that the majority of their knowledge was learned from
public school, while detention groups reported youth services as the source of
the majority of their knowledge.
Overall, participants held few HIV/AIDS misconceptions. In response to
the statement, “only homosexuals catch AIDS,” 6.7% of jail group participants
and 5.2% of detention group participants agreed. Almost 7% of jail group and
8.9% of detention participants believed that white people have less of a chance
of catching AIDS.
UCF AIDS/HIV Risk Assessment Interview Results
All 22 of the Escambia County, Florida jail sample confirmed that they
were sexually active, compared to over four fifths of the detention group sample.
More than two-fifths of jail participants and a little more than one-third of the
detention group sample reported that they discuss their partners' sexual history
with them. None of the jail group participants and only one detention group
participant reported sexual intercourse with someone of the same sex. In
response to the question, "Have you ever shared a needle for tattooing, drugs,
body piercing, for any other reason,” all jail participants reported no, while less
than one-fifth of detention participants reported that they had shared a needle
for body piercing. About two-thirds of both samples reported that they have
been tested for HIV. No HIV positive results were reported.

61
In response to the question "How much do you know about HIV/AIDS?”,
over two-thirds of the jail sample responded "not much.” Other responses
included, "enough to keep from getting it", "enough to use a condom,” "can die
from it,” "can get it from sharing needles,” and "can it get from blood transfusion.”
The majority of the jail sample reported that they were aware of HIV modes of
transmission and methods of prevention. A few reported, "I know enough to
protect myself'. In reply to the question, "Many juveniles have HIV. What could
be done to keep this number from increasing?,” the most frequent responses
from the jail sample included, "use condoms,” "don't know,” "education,” "don't
sleep around,” "abstinence,” and "nothing.” Eleven of 23 detention juveniles
reported that protective sex/condom use is a means of preventing HIV
transmission among juveniles. Four juveniles proposed sexual abstinence, two
suggested education, and one recommended not using I.V. needles.
All participants in both samples reported that they believe “AIDS is a big
problem in America”. In response to the question, “Are you at risk for HIV?,”
almost a third of the jail group sample and more than half of the detention group
sample responded “yes.” More half of the jail sample and almost three-fourths
of the detention sample reported that their friends are at risk for HIV. In
response to the question, Who’s at risk for HIV?” the most frequent response for
both samples was “any/everybody.” The vast majority of both samples believed
that condoms should be made available in schools.

62
Summary of Survey and Interview Results
Survey and interview data results revealed very few differences between
the jail group and the detention center group. The two groups were significantly
different on one socio-demographic variable, age and three behavioral variables,
sexual abuse, number of sexual partners in the last three months, and number of
same sex relationships
Survey results revealed that, socio-demographically almost all survey and
interview participants were male. The majority of survey and interview
participants in the jail and survey participants in the detention center were
African-American. Interview participants in the detention were almost equally
divided between African-Americans and Whites. Survey and interview
participants in the jail were slightly older than their detention center
counterparts. Almost 29% of jail participants had been incarcerated over three
months compared to almost 43% of detention center participants.
Almost all of these juveniles are sexually experienced and over half of the
survey participants have had ten lifetime sexual partners. The majority do not
use condoms consistently, and a vast majority had used marihuana. Jail group
participants and detention group participants were significantly different on three
behavior variables, sexual abuse, number of sexual partners in the last three
months, and number of same sex partners.
Overall, participants demonstrated moderate to high levels of knowledge
regarding prevention, mode transmission, high-risk behaviors and general
knowledge. Additionally, participants were aware that the disease is not

confined to certain segments of the population. The two groups were not
significantly different on any knowledge variables.
63
Participants reported an awareness of the severity of the AIDS problem in
the U.S. However, group participants reported attitudes that increase their risk
for becoming infected with HIV. For example, the majority of the survey sample
did not perceive themselves or their friends to be at high risk for contracting HIV.
More than half of the interview participants in the detention center and almost a
third of the jail group reported that they are at risk. Additionally, a large minority
believed there is a cure for AIDS. The two groups were not significantly different
on any attitude variables
Results from the UCF AIDS/HIV Questionnaire and the UCF Risk
Assessment Interview were used to plan and develop the educational
intervention.

64
HÃœV/AIDS Educational Program for Juveniles Incarcerated in a County Jail
Based on the AIDS Risk Reduction Mode! (ARRM)
Program Overview and Theoretical Framework
Research suggests that the most successful HIV prevention programs are
those programs that are theory- and skills-based, and include both cognitive and
behavioral aspects (Allensworth & Symons, 1989; Longshore, 1990; Boyer &
Kegeles, 1991; Fisher & Fisher, 1992; Jemmott, Jemmott, & Fong, 1992;
DiClemente, 1993; National Commission on AIDS, 1994; and Jemmott, Jemmott,
& Fong, 1998). Additionally, these comprehensive programs must be age-
appropriate, sensitive to cultural values, provide access to services, and include
adolescents' attitudes and customs, religious beliefs, and sex roles (Boyer, &
Kegeles, 1991; DiClemente, 1993a; DiClemente, Brown, etal., 1993; Fisher &
Fisher, 1992; Gillmore, Morrison, Richey, Balassone, Gutierrez, & Farris, 1997;
Kooperman, et al, 1994; & National Commission on AIDS, 1994).
This 8-hour HIV educational program, based upon the AIDS Risk
Reduction Model (ARRM) (Catania, et al., 1990) is a knowledge based,
cognitive-behavioral-skills intervention. The ARRM is a psychosocial conceptual
model designed to examine people's efforts to change sexual behavior in order
to avoid contracting HIV through sexual transmission. According to the ARRM,
in order to reduce their risk for contracting HIV, adolescents must first recognize
and label their behavior as at-risk for contracting HIV (stage one), they must
make a commitment to reduce high risk sexual contacts and increase low risk

65
behaviors (stage two), and they must seek and enact strategies to execute
recommended risk reduction activities (stage three).
Variables hypothesized to influence stage one include knowledge of
sexual activities associated with HIV transmission, the belief that one is
personally susceptible to contracting HIV, and social influences. Factors
hypothesized to influence stage two, commitment include perceived costs and
benefits, self-efficacy, knowledge and perception of enjoyment and risk
reduction, and social influences. Stage three, enactment, includes information¬
seeking, obtaining remedies, applying solutions and social influences. Verbal
communication with sexual partners regarding sexual issues is a key component
of the enactment stage.
The results of the survey data led to the development of the following
HIV/AIDS educational program, designed specifically for juveniles incarcerated
in an adult facility. It was developed utilizing information obtained from the
results of a survey administered to this same population. It is theory-based
(AIDS Risk Reduction Model) with emphasis on cognitive-behavioral skills. It
incorporates those components determined by research to be characteristic of
effective prevention programs such as, age appropriate, culturally sensitive and
provides access to services.
As previously stated, survey results revealed that the majority of
Escambia County, Florida jail participants were age 17 and African American,
almost all are sexually experienced, most have a high number of life time sexual
partners, do not use condoms consistently when participating in sexual activity,

66
harbor HIV/AIDS misconceptions, have a history of marihuana use, and do not
consider themselves to be at high risk for contracting HIV. These characteristics
were utilized in developing program goals and objectives.
Program Goals
The overall goals of this program are to: 1) decrease number of sexual
partners with whom they engage in unsafe sexual practices; 2) increase
participants’ perceived susceptibility of their own risk for contracting HIV; 3)
increase the consistent and correct use of latex condoms and other barrier
methods during sexual intercourse; 4) eliminate or decrease frequency of drug
use in situations that may lead to sexual activity; and 5) increase/reinforce
HIV/AIDS knowledge
Program Objectives
By the end of this educational intervention, participants will be able to: 1)
identify and discuss HIV high-risk behaviors; 2) identify major modes of HIV
transmission; 3) identify ways in which HIV is not transmitted; 4) personalize own
risk for contracting HIV; 5) describe methods of HIV prevention; 6) describe and
utilize appropriate communication/partner negotiation skills; 7) describe and
utilize appropriate decision making/problem solving skills; 8) describe correct
condom use; 9) identify where/how to obtain latex condoms; and 10) identify
community resources, including drug treatment facilities, mental health facilities,
local public health unit, HIV test sites, and self-help groups such as Alcoholics
Anonymous (AA) Cocaine Anonymous (CA) and Narcotics Anonymous (NA).

67
The 8-hour program, designed to be presented in four 2-hour modules is
similar in length to previous interventions that have been successful in reducing
risk for HIV infection among high-risk groups.
This educational program addresses stage one of the ARRM, recognizing
and labeling by providing adequate and correct information regarding HIV,
including modes of transmission and high-risk behaviors. Additionally, each
participant is provided the opportunity (anonymously) to assist in personalizing
their own risk and recognizing if they are personally susceptible to contracting
HIV. Stage two, commitment involves motivating individuals to change risk
behavior. It includes deciding if the risky behaviors can be changed and if the
benefits outweigh the costs (i.e. condoms decrease pleasure). Response-
efficacy and self-efficacy are addressed through providing information on
condom efficacy and the health utility and enjoyability of various sexual
practices. If one knows that condoms reduce the risk of contracting HIV and
that there are ways that they can be used during sexual activity to make sex fun,
one may be more likely to use condoms. Participants' self- efficacy is increased
if they are knowledgeable about where and how to obtain condoms and how to
use them correctly. The cost/benefits factor is addressed through providing the
opportunity for social/peer reinforcement and positive reinforcement for reporting
a desire and plan to engage in HIV low-risk activities. Additionally, group
discussions would be used as a means of assisting participants in realizing that
benefits outweigh the barriers or negative consequences of the high-risk
behavior. Questions such as, "who will have your girl/boyfriend" if you contract

68
and/or die from HIV disease would be asked. Although some research indicate
that youth can be motivated by fear (Job, 1988; Rhodes, MacDonald, & Elder-
Tarizy, 1990), the use of fear/scare tactics will be avoided based on evidence
that they have the potential to be counterproductive field (Hein, 1993:
Airhihenbuwa, DiClemente, Wingood, & Lowe, 1992; & Rotheram-Borus, et al.,
1995). Regarding stage three, enactment, participants are provided appropriate
information and the opportunity to develop behavioral skills through decision
making activities, group discussions, and a culturally sensitive video that
focuses on decision making and communication skills, including partner
negotiation. Community resources such as the local county public health unit,
HIV testing sites, self help groups and drug treatment programs are identified.
In consideration of social influences, mainly reference group norms, participants
who engage in or support low risk activities are encouraged to share their
feelings, thoughts and experiences with the group.
A variety of methods are utilized including group discussion, role play,
games, videos, question/answer session, HIV/AIDS risk assessment (completed
anonymously) to assist with recognition and labeling of one’s behaviors as high
risk, and skill-based activities including decision making/problem solving and
communication/partner negotiation. These methods have proven successful in
similar HIV prevention programs, particularly programs targeting African-
Americans, as well as other high-risk adolescents (Boyer, et al., 1997; Dixon,
1994; Jemmott, et al., 1998; Jemmott, et al., 1992; Kipke, et al., 1993; St.
Lawrence, Brasfield, et al., 1995; & St. Lawrence, Jefferson, et. al., 1994).

69
Cognitive-behavioral skills, derived from the Social Learning Theory (Bandura,
1977) are essential to make healthy choices and to put choices into action.
Skills-building interventions have been shown to be effective in changing
adolescents’ HIV high-risk sexual behaviors (Boyer, et al., 1997; Jemmott, et al.,
1998; Kipke, etal. 1993); Rotheram-Borus, et al, 1995; St. Lawrence, Brasfield
et al., 1995; St. Lawrence, Jefferson, et al., 1995; St. Lawrence, Jefferson, et al.,
1994; & Schinke, Botvin, Orlandi, Schilling, & Gordon, 1990). There were two
key skills that were involved, decision making and partner negotiation.
Decision making, as defined by decision theorists is “the process of
making choices among competing courses of action “ (Beyth-Maron, Fischoff, &
Jacobs Quadrel and Furby, 1991, p. 20). The “normative” theory of decision
making, in principle, considers whether a proposed solution to a problem is
sufficient to that particular problem. Additionally, it considers the goal of the
decision-maker and whether fortune/misfortune has a role in what takes place
with the decision-maker. Thus, the normative theory of decision making “is
couched in terms of the processes that people follow in order to have the best
chance of reaching their goal” (Beyth-Maron, et al., 1991, p. 21). According to
most of these general models, a person faced with a decision should first identify
relevant alternatives. Second, the person should identify possible
consequences of each action. Third, the person should evaluate the likelihood
of each consequence occurring for each action. Next, the person should
determine the relative significance of each consequence. Finally, the person

70
facing a decision should integrate the information from each step to identify the
most appealing course of action.
DiClemente (1993) states, “communication and negotiation skills that
promote safer sexual interactions and the use of condoms could provide
adolescents with a repertoire of responses that could be employed to avoid high-
risk situations” (p. 163). Communication/partner negotiation skill development
focuses on assertive behavior. This program utilized a widely used formula
developed by Bower and Boser (1976) and referred to as DESC (Describe,
Express, Specify, and Choose). The DESC formula involves the following:
Describing the other person’s behavior or the situation objectively; Expressing
your feelings about the other person’s behavior or the situation that you just
described; Specifying changes you would like to see made; and Choosing the
consequence you are prepared to carry out. Decision- making and partner
negotiation skills are incorporated in this education program. Both are
addressed in video and through role-play.
Although engagement in same sex behavior was reported by a small
percentage of juveniles in this study, the high-risk nature of this type of sexual
behavior accompanied by the failure of many African-American communities to
discuss this behavior, indicate a need for its inclusion in this educational
intervention. According to Stevenson and Davis (1994), “Many African-
Americans do not wish to discuss their sexuality with others for fear that they will
be negatively perceived as promiscuous, dirty, and responsible for current
sexual disease epidemics” (p. 42). Additionally, 33% of the total number of

71
AIDS cases among males between the ages of 13-19 are reported in the “men
who have sex with men” CDC exposure category (CDC, 1996).

TABLE 4-1: Socio-demographic Characteristics
Escambia County. Florida Jail
12
Age
11-12
Number
0
Group %
0
13-14
3
6.7
15-16
18
40.0
17-18
24
53.3
Gender
Male
42
93.3
Female
3
6.7
Race/Ethnicity
White
9
20.5
Afr.-Am.
31
70.5
Hispanic
1
2.3
Asian
2
4.5
Other
1
2.2
Length of Stay
1 -30 days
7
15.6
31-60 days
12
26.7
61-90 days
13
28.9
> 91 days
13
28.9
Villaoe Detention Facilitv
Age
11-12
8
10.3
13-14
25
32.1
15-16
33
42.3
17-18
12
15.4
Gender
Male
65
83.3
Female
13
16.7
Race/Ethnicity
White
26
33.3
Afr. Am.
43
55.1
Hispanic
2
2.6
Asian
2
2.6
Other
5
6.4
Length of Stay
1 -30 days
16
20.8
31-60 days
15
19.5
61-90 days
13
16.9
> 91 days
33
42.9

73
Table 4-2 Significant Difference Between Jail Group and Detention Group
Demographic Variable: UCF AIDS/HIV Questionnaire, Question # 58, What
is your age?
Age
Detention Group
Jail Group
13-14
35.7%
6.7%
15-16
47.1%
40.0%
17-18
17.1%
53.3%
Chi-square
Value D.F.
Significance
Pearson
21.268 2
.000
N = 70 Detention Group N = 45 Jail Group
‘Significant at level 0.05

74
Table 4-3: UCF AIDS/HIV Questionnaire - Escambia County Jail Group
HIV/AIDS Risk Behavior Questions
Freauentlv
Sometimes
Never
In the future, 1 will use a condom if
unsure of my partners sexual history.
82.2%
15.6%
2.2%
1 would have sex with an attractive
partner if no condom was available.
13.3%
37.8%
45.9%
In the future 1 plan to inject drugs.
2.3%
0%
97.8%
1 would trust a sex partner if she/
he said they are free from disease.
4.4%
24.4%
71.1%
1 would have sex without a condom
if 1 had a negative AIDS test.
6.8%
20.5%
72.7%
In the future, 1 will demand the use
of a condom (rubber) for my own
protection.
77.8%
20.0%
2.2%
In the future, 1 will demand the use
of a condom (rubber) for my
partner's protection.
73.3%
17.8%
8.9%
1 take special precautions to
prevent catching AIDS.
71.7%
24.4%
4.4%
1 ask sex partners about their sexual
history.
40.9%
43.2%
15.9%
1 share I.V. drug needles.
0%
2.2%
97.8%
In the future 1 will share I.V. drug
needles.
4.4%
0%
95.6%

75
Table 4-3: Continued
In order to body pierce, I would s
a needle.
I have had a blood test for AIDS.
I have tested positive for HIV.
I have been sexually abused.
I have been physically abused
Have you ever used marijuana?
Have you ever "shot up" drugs?
Have you injected drugs in the la
3 months?
In the last 5 times you had sex, how many times did you use a condom?
0 1 2 3 4 5
11.1% 4.4% 6.7% 15.6% 22.2% 40.0%
With how many partners have you had sexual intercourse?
none 1 2-5 6-10 Over 10
2.2% 6.7% 24.4% 15.6% 51.1%
How many sexual partners have you had in the last 3 months?
none 1 2-5 6-10 Over 10
50.0% 20.5% 22.7% 6.8% 0%
With how many partners have you had a same sex relationship?
None 1 2-5 6-10 Over 10
97.7% 0% 0% 0% 2.3%
share
Yes
No Unsure/Don't
2.2%
93.3%
4.4%
51.1%
42.2%
6.7%
0%
88.9%
11.1%
4.4%
95.6%
0%
11.1%
84.4%
4.4%
82.2%
17.8%
0%
0%
100.0%
0%
0%
100.0%
0%

Table 4-4: UCF AIDS/HIV Questionnaire - DISC Village Detention Facility
HIV/AIDS Risk Behavior Questions
Frequentlv
Sometimes
Never
In the future, 1 will use a condom if
unsure of my partners sexual history.
72.2%
27.8%
0%
1 would have sex with an attractive
partner if no condom was available.
10.1%
44.3%
45.6%
In the future 1 plan to inject drugs.
5.1%
1.3%
93.7%
1 would trust a sex partner if she/
he said they are free from disease.
5.1%
30.4%
64.6%
1 would have sex without a condom
if 1 had a negative AIDS test.
12.7%
29.1%
58.2%
In the future, 1 will demand the use
of a condom (rubber) for my own
protection.
74.7%
16.5%
8.9%
In the future, 1 will demand the use
of a condom (rubber) for my
partner's protection.
78.2%
12.8%
9.0%
1 take special precautions to
prevent catching AIDS.
70.9%
22.8%
6.3%
1 ask sex partners about their sexual
history.
34.2%
36.7%
29.1%
1 share I.V. drug needles.
0%
0%
100.0%
In the future 1 will share I.V. drug
needles.
0%
0%
100.0%

77
Table 4-4: Continued
Yes
No
Unsure/Don't Know
In order to body pierce, ¡ would share
a needle.
3.9%
92.2%
3.9%
I have had a blood test for AIDS.
70.5%
26.9%
2.6%
I have tested positive for HIV.
5.2%
79.2%
15.6%
I have been sexually abused.
18.4%
78.9%
2.6%
I have been physically abused
26.0%
70.0%
3.9%
Have you ever used marijuana?
87.2%
12.8%
0%
Have you ever "shot up" drugs?
6.5%
93.5%
0%
Have you injected drugs in the last
3 months?
3.9%
96.1%
0%
In the last 5 times you had sex, how many times did you use a condom?
0 1 2 3 4 5
17.6% 5.4% 18.9% 10.8% 5.4% 41.9%
With how many partners have you had sexual intercourse?
None 1 2-5 6-10 Over 10
7.7% 7.7% 30.8% 15.4% 38.5%
How many sexual partners have you had in the last 3 months?
None 1 2-5 6-10 Over 10
73.1 11.5% 7.7% 1.3% 6.4%
With how many partners have you had a same sex relationship?
None 1 2-5 6-10 Over 10
74.4% 6.4% 14.1% 2.6% 2.6%

78
Table 4- 5 Significant Difference Between Jail Group and Detention Group
HIV/AIDS Risk Behavior Variable: UCF AIDS/HIV Questionnaire, Question #
15-1 have been sexually abused.
No
Yes
Chi-square
Pearson
Detention Group
Jail Group
81.1% 95.6%
18.9% 4.4%
Value DF. Significance
5.038 1 .025*
N = 74 Detention Group N = 45 Jail Group
‘Significant at level 0.05
Table 4- 6 Significant Difference Between Jail Group and Detention Group
HIV/AIDS Risk Behavior Variable: UCF AIDS/HIV Questionnaire, Question #
65 - How many sexual partners have you had in the last 3 months?
Detention Group
Jail Group
None
73.1%
50.0%
1
11.5%
20.5%
2-5
7.7%
22.7%
6 or More
7.7%
6.8%
Chi-sauare
Value D.F.
Significance
Pearson
8.707 3
.033*
N = 78 Detention Group N = 44 Jail Group
‘Significant at level 0.05

79
Table 4- 7 Significant Difference Between Jail Group and Detention Group
HIV/AIDS Risk Behavior Variable: UCF AIDS/HIV Questionnaire, Question #
66 - With how many partners have you had a same sex relationship?
None
At least 1
Detention Group Jail Group
74.4% 97.7%
25.6% 2.3%
Chi-square
Pearson
Value D.F. Siqnificance
10.780 1 .001*
N = 78 Detention Group
N = 44 Jail Group
‘Significant at level 0.05

80
Table 4- 8: UCF AIDS/HIV Questionnaire
HIV/AIDS Knowledge Questions
% Correct
Significance
Jail Detention
Pearson
AIDS can be caught from sharing a
glass of water with an infected person.
75.6%
73.1%
.95120
AIDS can be caught from toilet seats.
77.8%
66.7%
.33610
AIDS can be caught from kissing on
the cheek.
88.9%
89.9%
.50371
AIDS can be caught from heavy
(tongue) kissing.
37.8%
39.2%
.58488
AIDS can be caught from sharing
marijuana pipes or cigarettes.
84.4%
70.5%
.11669
AIDS can be caught from sharing
drug needles.
100%
97.4%
.27880
AIDS can be caught from donating
blood.
33.3%
17.9%
.13481
AIDS can be caught from sharing
tattoo needles.
95.6%
92.2%
.471
AIDS can be caught from sharing
cigarettes.
88.9%
76.9%
.22697
AIDS can be caught if a person
with AIDS sneezes on you.
80.0%
67.9%
.27892
AIDS can be caught if a hospital
has to give you blood.
60.0%
66.7%
.46167
AIDS is harder to catch if you are
young and healthy.
73.3%
75.6%
.64028
Using a condom (rubber) will help
prevent catching AIDS.
84.4%
66.7%
.09245

81
Table 4- 8: Continued
You can catch AIDS by shaking hands
with a person who has AIDS.
AIDS can be caught from sharing
razor blades.
If a restaurant cook has AIDS, you
will catch AIDS if you eat food the
cook prepared.
All gay men (homosexuals) have AIDS.
Babies can be born with AIDS.
AIDS is caused by a virus.
% Correct
Significance
Jail
Detention
Pearson
88.9%
87.2%
.74416
90.9%
75.6%
.07497
77.8%
71.8%
.41384
75.6%
54.4%
.06543
97.9%
96.2%
.75144
91.1%
87.3%
.77504
Significant at level 0.05

82
Table 4- 9: UCF AIDS/HIV Questionnaire
HIV/AIDS Attitude Questions - Jail Group
Aaree
Disaaree
Don’t
Know
My chances of catching AIDS are great.
22.3%
53.3%
24.4%
My friends have a high chance of
catching AIDS.
26.6%
17.8%
55.6%
White people have less of a chance of
catching AIDS.
6.6%
75.5%
17.8%
There is a cure for AIDS but it is too
expensive for most people.
24.4%
44.5%
31.1%
If 1 caught AIDS, 1 would tell any
sex partners.
54.5%
18.2%
27.3%
If 1 caught AID'S, 1 would not tell
anyone.
22.2%
48.8%
28.9%
If 1 caught AIDS, 1 would tell close
friends.
48.9%
28.8%
22.2%
If 1 caught AIDS, 1 would not have
sex again.
44.4%
22.2%
33.3%
AIDS is a big problem in America.
95.6%
4.4%
0%
1 worry a lot about catching AIDS.
71.1%
22.3%
6.7%
1 worry a lot about my friends
catching AIDS.
53.4%
24.4%
22.2%
Only homosexuals catch AIDS.
6.7%
86.7%
6.7%
If you catch AIDS, it's your own fault.
56.8%
43.2%
0%
There is nothing you can do to prevent
catching AIDS.
9.3%
83.8%
7.0%

83
Table 4- 9: Continued
Don't
Agree
Disagree
Know
AIDS is a made up problem by the
government to decrease drug use
and sexual activity.
13.7%
72.8%
13.6%
You can have AIDS and not know it.
93.2%
2.3%
4.5%
If you catch AIDS, you will die
within ten years.
22.7%
40.9%
36.4%
It is possible for someone to have AIDS,
not know it and infect others.
88.6%
6.8%
4.5%
Compared to most people 1 feel that
1 know a lot about AIDS.
65.9%
13.7%
20.5%
Did the AIDS training you got here
influence your intentions?
79.1%
21.0%
0%
Yes
No
Don't
Know
1 would like to be blood tested for AIDS.
13.3%
75.6%
11.1%
1 would like my friends to be blood tested
for AIDS.
6.8%
65.9%
27.3%
How many
of your friends do you think have had a homosexual relationship?
None
1 2-5
6-10
Over 10
90.9%
0% 9.1%
0%
0%
How many
sex partners do you think most of your friends have had?
None
1 2-5
Over 6
Don’t Know
11.1%
2.2% 8.9%
20.0%
55.6%
Where did
you learn the most about AIDS?
relatives, friends
17.9%
books, magazines
10.3%
television, radio
10.3%
public school
43.6%
youth services
17.9%

Table 4- 9: Continued
Where have you heard the most talk about AIDS?
parents, guardians
29.3
friends
4.9
public school
31.7
youth services
12.2
television or radio
22.0

Table 4-10: UCF AIDS/HIV Questionnaire
HIV/AIDS Attitude Questions - Detention Group
85
Aqree
Disaqree
Don’t
Know
My chances of catching AIDS are great.
29.1%
36.5%
34.2%
My friends have a high chance of
catching AIDS.
40.5%.
15.2%
44.3%
White people have less of a chance of
catching AIDS.
8.9%
62.9%
28.2%
There is a cure for AIDS but it is too
expensive for most people.
27.9%
43.0%
29.1%
If I caught AIDS, l would tell any
sex partners.
51.9%
26.9%
21.5%
If I caught AIDS, I would not tell
anyone.
18.0%
60.3%
21.8%
If I caught AIDS, I would tell close
friends.
41.8%
24.1%
34.2%
If I caught AIDS, I would not have
sex again.
30.4%
35.5%
34.2%
AIDS is a big problem in America.
92.4%
3.8%
3.8%
I worry a lot about catching AIDS.
71.5%
24.7%
3.9%
I worry a lot about my friends
catching AIDS.
59.8%
28.6%
11.7%
Only homosexuals catch AIDS.
7.8%
83.1%
9.1%
If you catch AIDS, it's your own fault.
37.7%
45.5%
16.9%
There is nothing you can do to prevent
catching AIDS.
14.3%
72.7%
13.0%

86
Table 4-10: Continued
Don’t
Agree
Disaaree
Know
AIDS is a made up problem by the
government to decrease drug use
and sexual activity.
22.1%
54.6%
23.4%
You can have AIDS and not know it.
85.7%
9.1%
5.2%
If you catch AIDS, you will die
within ten years.
27.6%
47.4%
25.0%
It is possible for someone to have AIDS,
not know it and infect others.
80.5%
7.8%
11.7%
Compared to most people I feel that
I know a lot about AIDS.
66.3%
18.2%
15.6%
Did the AIDS training you got here
influence your intentions?
68.4%
31.6%
Yes
No
Don’t
Know
I would like to be blood tested for AIDS.
56.4%
26.9%
16.7%
I would like my friends to be blood tested
for AIDS.
72.2%
12.7%
15.2%
How many of your friends do you think have had a homosexual relationship?
None 1 2-5 6-10 Over 10
89.5% 5.3% 2.6% 0% 2.6%
How many sex partners do you think most of your friends have had?
None 1 2-5 Over 6 Don't Know
9.0% 2.6% 11.5% 34.6% 42.3%
Where did you learn the most about AIDS?
Relatives, friends 21.4%
Books, magazines 12.9%
Television, radio 8.6%
Public school 27.1%
Youth services 30.0%

87
Table 4-10: Continued
Where have you heard the most talk about AIDS?
Parents, guardians 16.4%
Friends 16.4%
Public school 24.7%
Youth services 32.9%
Television or radio 9.6%

CHAPTER 5
DISCUSSION, CONCLUSIONS AND IMPLICATIONS
The study was undertaken to assess the education needs of juveniles
incarcerated in an adult facility and develop an appropriate educational
intervention for these juveniles. The UCF AIDS/HIV Questionnaire and the UCF
AIDS/HIV Assessment Interview assessed the knowledge, attitudes, and
behaviors of juveniles incarcerated in the Escambia County, Florida jail.
Responses from juveniles incarcerated in the adult facility were compared with
those of youth detained in a juvenile detention facility to determine if their needs
were comparable. Escambia County, Florida jail (survey) participants consisted
of 45 adolescents detained in the juvenile section and the infirmary of the
Escambia County jail. Detention group (survey) participants were comprised of
79 adolescents incarcerated in two facilities in Northwest Florida. The jail group
participants and detention group participants were significantly different on four
variables, age, sexual abuse, number of sexual partners in the last three
months, and number of same sex relationship.
The results of Escambia County jail survey data led to the development of
an HIV/AIDS educational program designed specifically for juveniles
incarcerated in an adult facility. The educational intervention is based upon the
AIDS Risk Reduction Model (ARRM) (Catania, Kegeles, & Coates, 1990) and
emphasizes cognitive-behavioral skills.
88

89
This chapter discusses the results and implications of the results. It is
divided into four sections, Socio-demographics, HIV Risk behaviors, knowledge
and attitudes about HIV/AIDS, and HIV/AIDS prevention programs. There have
been few studies of incarcerated youth conducted previously.
Socio-demographics
Research studies reveal that youth incarcerated in detention facilities are
predominantly male (more than 85%), of racial or ethnic minority (42% African-
American), between the ages of 14 and 17 (average age 15.7) and are generally
detained for an average of eight months (Council on Scientific Affairs, 1990).
Socio-demographic characteristics of Juveniles incarcerated in the Escambia
County, Florida jail were comparable to incarcerated juveniles, nationally
regarding ethnicity and gender. The majority (83.3%) of Escambia County,
Florida jail participants were male. African-Americans comprised almost three-
fourths of the jail sample. Escambia County, Florida jail participants were
between the ages of 13 and 17. However, over half were age 17, somewhat
older than the national average of 15.7 years. Over a fourth of the jail juveniles
had been detained over 3 months compared to a national average of 8 months.
HIV/AIDS Risk Behaviors
Incarcerated youth have been identified as a subgroup of adolescents
who are at increased risk for infection due to a higher prevalence of HIV high-
risk behaviors (Council on Scientific Affairs, 1990). Results of this study
duplicated results of other studies. Morrison et al. (1994), in a study of 119
juveniles in a detention facility found these adolescents to be at high risk relative

90
to the general population. These youth had high rates of sexual activity, a high
number of sexual partners and a low rate of condom use. For example, one-
third of these juveniles had used condoms the last time they engaged in sexual
intercourse with their primary or steady partner, while about half had used
condoms with their casual partners. Additionally, in a study involving
incarcerated adolescents and public high school students, 99% of detained
youth reported being sexually active and 73% reported two or more sexual
partners during the past year (DiClemente, et al., 1990). Regarding drug use, a
nationwide survey of detained juveniles revealed that 63% of respondents used
drugs regularly (Council on Scientific Affairs, 1990). The vast majority (98%) of
Escambia County, Florida jail participants were sexually experienced. Over half
reported 10 lifetime sexual partners and two-fifths reported consistent condom
use. Over four-fifths had used marihuana. Additionally, the majority of these
youth did not perceive themselves or their friends to be at high risk for
contracting HIV. Lanier and McCarthy (1989), in a study assessing HIV
awareness of juveniles detained in a detention center had similar results. Over
three fourths of these juveniles reported that they did not feel they were at high
risk for HIV infection and almost as many believed the same about their friends’
risk for becoming infected.
Knowledge and Attitudes about HIV/AIDS
Research studies reveal that, although incarcerated adolescents tend to
be less knowledgeable than the general adolescent population, they
demonstrate high levels of AIDS knowledge (DiClemente, et al., 1991).

91
Similarly, Escambia County, Florida jail participants reported high levels of
HIV/AIDS knowledge regarding modes of transmission, high-risk
group/behaviors, and risk- reduction activities. Some studies show that
incarcerated youth are in lower agreement with AIDS health guidelines, have
lower perceived personal threat of acquiring AIDS, and have lower personal self-
efficacy compared to youth who were not incarcerated (Nader, Wexler,
Patterson, McKusick, & Coates, 1989). These results were duplicated in this
study. A little over one-fifth of Escambia County, Florida jail participants
perceived themselves to be at risk for HIV infection and about half agreed that
individuals are responsible for preventing their infection with HIV.
HIV Prevention Programs and Incarcerated Adolescents
The results of the UCFAIDS/HIV Questionnaire and the AIDS/HIV Risk
Assessment Interview were used to plan and develop an educational
intervention for juveniles incarcerated in the Escambia County, Florida jail. This
intervention is based on the AIDS Risk Reduction Model (ARRM) and is
designed to be presented in four 2-hour modules. It is skill-based and
incorporates cognitive and behavioral aspects. The overall goals of the program
are to: 1) decrease number of sexual partners with whom they engage in unsafe
sexual practices; 2) increase participants’ perceived susceptibility of their own
risk for contracting HIV; 3) increase the consistent and correct use of latex
condoms and other barrier methods during sexual intercourse; 4) eliminate or
decrease frequency of drug use in situations that may lead to sexual activity;
and 5) increase/reinforce HIV/AIDS knowledge. By the end of this educational

92
intervention, participants will be able to: 1) identify and discuss HIV high-risk
behaviors; 2) identify major modes of HIV transmission; 3) identify ways in which
HIV is not transmitted; 4) personalize own risk for contracting HIV; 5) describe
methods of HIV prevention; 6) describe and utilize appropriate
communication/partner negotiation skills; 7) describe and utilize appropriate
decision making/problem solving skills; 8) describe correct condom use; 9)
identify where/howto obtain latex condoms; and 10) identify community
resources, including drug treatment facilities, mental health facilities, local public
health unit, HIV test sites, and self-help groups such as Alcoholics Anonymous
(AA) Cocaine Anonymous (CA) and Narcotics Anonymous (NA).
Research suggest that the most successful risk-reduction programs are
those programs that are theory-based, include both cognitive and behavioral
aspects, and are skilled-based (Allensworth & Symons, 1989; Longshore, 1990;
Boyer & Kegeles, 1991; fisher & Fisher, 1992; Jemmott, Jemmott, & Fong ,
1992; & Jemmott, Jemmott, & Fong, 1998). This education program is similar to
other prevention programs that have proven efficacious in reducing adolescents’
risk for contracting HIV in several ways. It is based upon the AIDS Risk
Reduction Model (ARRM) and incorporates two key skills included in most
successful prevention programs, decision-making and communication/partner
negotiation. Additionally, this education intervention is sensitive to cultural
values, taking into account the ethnicity of participants. A major difference in
this educational program and other risk-reduction programs is that it was

developed utilizing information obtained from the results of a survey and
interview administered to this same population.
Implications and Conclusions
Survey results revealed that juveniles incarcerated in the Escambia
County, Florida jail and the DISC Village detention center are at high risk for
exposure to and infection with HIV, the primary causal factor of AIDS. One of
the main educational implications of these findings is that while adolescents are
knowledgeable about HIV, they are also engaging in high-risk behaviors.
These findings are similar to finding in other studies involving adolescent among
the general population (DiClemente, et al., 1986; DiClemente, et a!., 1993) as
well as among incarcerated adolescents (Morrison, Baker, & Gillmore,1994;
Lanier, et al., 1991; DiClemente, et al., 1991; & Lanier, & McCarthy, 1989b).
Additionally, these juveniles do not perceive themselves to be at high risk for
infection. These results compare to the results of other studies among
incarcerated adolescents (Katz, et al., 1995; Nader, et al., 1989; & Lanier, &
McCarthy, 1989b).
A second implication of the findings of this study is the need for more
HIV/AIDS research that evaluates the specific education needs of the targeted
population. In order for HIV programs to be successful, they must address the
particular high-risk behaviors of that particular population. This educational
program focused on perceived susceptibility; communication skills, especially
regarding partner’s sexual history and negotiation regarding condom and

94
drug/alcohol use; reinforcement of transmission knowledge; self efficacy; correct
condom use; and community resources.
A third implication is the need for school-based HIV prevention programs
to target students in the early preadolescent years. Over forty percent of jail
group participants reported that the majority of their HIV/AIDS education was
learned from public school. Given the deficits they demonstrate, it is important
that these juveniles who are at high risk for dropping out of school learn as much
as possible and as early as feasible. Additionally, Abraham and Sheeran
(1994) report that many heterosexuals become sexually active at age 16 or
earlier. Also school-based HIV prevention programs need to be theory- and
skills-based with cognitive and behavioral aspect. Results of this study
revealed that, although these juveniles reported high levels of HIV/AIDS
knowledge, they were at high-risk for becoming exposed to and infected with HIV
and the majority did not perceive themselves to be at high risk for HIV infection.
As of 1989, approximately 94,000 10-17 year olds were detained in
juvenile facilities and during 1990 and estimated 6,000 juveniles were
incarcerated in local jails or in State or Federal Prisons aspects (DiClemente,
Lanier, Horan, and Lodico, 1991). Incarcerated juveniles are primarily male and
of ethnic or racial minority. Research suggests that the most successful HIV
prevention programs are those programs that are theory- and skills-based,
include both cognitive and behavioral aspects and are sensitive to cultural
values (Allensworth & Symons, 1989; Longshore, 1990; Boyer & Kegeles, 1991;
Fisher & Fisher, 1992; Jemmott, Jemmott, & Fong, 1992; DiClemente, 1993;

95
National Commission on AIDS, 1994; and Jemmott, Jemmott, & Fong, 1998).
Thus, a conclusion is the critical and urgent need to develop, implement and
evaluate appropriate educational interventions for a growing number of
incarcerated youth.
Second, this study was an exploratory study of youths in two settings, the
Escambia county jail, an adult facility and DISC Village detention facility.
Survey and interview data results revealed that the two groups are very similar.
Therefore, while the educational intervention was developed for juveniles
incarcerated in the Escambia jail, with minor modifications regarding the
approach and not content, it is believed to be applicable to juveniles
incarcerated in the detention facility. This study represents a major contribution
to the literature in two ways. First, there are few studies that have been
conducted previously that identify the needs of either population, and second,
only a few, if any, programs have been developed for these youths based on
their needs.
In conclusion, health educators and other health care professionals
involved with HIV prevention among high-risk adolescents generally
acknowledge that knowledge alone does not translate into positive behavior
change. Prevention programs must provide adequate and correct information.
In addition, they must also provide the opportunity and resources for
adolescents to develop the behavioral skills required to decrease their
participation in high-risk behaviors and increase participation in risk-reduction
activities.

96
Recommendations for Future Research
Survey findings reveal a group of adolescents at high risk for exposure to
and infection with HIV, the primary causal factor of AIDS. Socio-
demographically, Escambia County, Florida jail juveniles are majority male
(93.3%), over half are age 17, almost three-fourths are African-American and
more than a fourth had been detained over three months. Juveniles in the
Escambia County, Florida jail were statistically significantly different from
juveniles detained in DISC Village detention facility on one socio-demographic
variable, age. Over half of the Juveniles detained in jail were age 17 while
almost three-fourth of detention center juveniles were between the ages of 13
and 16. When comparing Escambia County, Florida jail juveniles to
incarcerated juveniles on a national level, the two populations appear to be
somewhat comparable. According to the Council on Scientific Affairs (1990),
youth incarcerated in detention facilities are predominantly male (more than
85%), and of racial or ethnic minority (45% African-American). They appear to
be clinically different on two variables, age and length of incarceration.
Juveniles detained in detention centers have an average age of 15.7. The
average length of incarceration is 12 days for short-term facilities and eight
months for long-term facilities.
Escambia County, Florida jail juveniles reported a number of high-risk
behaviors. Almost all are sexually experienced, over half have had 10 lifetime
sexual partners, 40% use condoms consistently, and 82% have used marihuana.
Although these juveniles reported moderate to high levels of HIV/AIDS

97
knowledge, only 23.3% perceived themselves to be a high risk for becoming
infecting with HIV. Juveniles in the Escambia County, Florida jail were
comparable to juveniles detained in DISC Village detention facility on the
majority of behavior, knowledge and attitude variables. However, they were
statistically significantly different on three important behavior variables, sexual
abuse, number of sexual partners in the last three months and the number of
same sex partners.
These study findings indicate a need for future HIV/AIDS research to
accurately and effectively assess the education needs of juveniles incarcerated
in juveniles and adult facilities, plan and develop appropriate HIV/AIDS
educational programs for incarcerated adolescents utilizing survey data results,
implement HIV/AIDS educational programs in detention and jail settings, and
evaluate the effectiveness of these educational programs.
Instruments must effectively assess juveniles1 education needs, including
alcohol use, due to the association of alcohol use and lowered inhibitions and
impaired judgement. Recommended changes in the UCF HIV/AIDS
Questionnaire include assessment of juveniles1 use of alcohol and other mind-
altering drugs; juveniles’ living conditions regarding homeless or runaway status
prior to incarceration; and, juveniles1 participation in high-risk behaviors as
related to length of time incarcerated. Additionally, the terms “HIV” and “AIDS”
need to be used more accurately and appropriately to adequately reflect
juveniles’ actual HIV/AIDS knowledge. For example, the term “AIDS” in question
#20, “AIDS can be caught from toilet seats?” should be replaced with “HIV.”

It is important to note that incarcerated adolescents who participate in
HIV/AIDS educational programs t have little, if any an opportunity to practice
98
risk-reduction recommendations. Therefore, follow-up sessions must be
provided to these adolescents upon their release.
In order for HIV/AIDS educational programs to be successfully
implemented in jails and other correctional settings, it is important to have the
approval of and cooperation from the appropriate authorities (Dolan, Wodak, &
Penny, 1995; & Stevens, 1993). Future research needs to address policies and
procedures regarding implementation of jail-based educational programs. A
number of major intervention issues are encountered in attempting to implement
a similar educational program in a county jail and detention center. First,
obtaining parents/legal guardians’ consent can be difficult and time consuming
due to the lack telephone service, incorrect addresses, and fear and skepticism
regarding the educational program.
Second, gaining access to inmates and having a convenient time and an
appropriate setting to conduct HIV/AIDS education can prove challenging.
Security for the community, jail personnel as well as for other inmates is a
primary concern of jail personnel. Inmates are not provided the freedom to move
about at will. Inmates’ movement from one location to another requires the
direct supervision of jail personnel. The availability of rooms in which
educational program can be conducted is limited. Thus, scheduling an
educational program at the most effective time or place in jail is not easily
facilitated. Additionally, due to security concerns as well as the lack of large

99
available rooms in the jail, educational programs are restricted to serving a small
number of inmates at one time. Juveniles in long-term detention centers are not
subject to these limitations. The availability of spacious rooms and easy access
to juveniles in long-term detention centers allows for HIV/AIDS educational
programs to be provided to large numbers of juveniles at one time.
Third, the content of the educational intervention is of concern to jail and
detention center personnel. For example, condoms and hypodermic needles are
contraband. Therefore, demonstrations regarding correct condom use and
correct cleaning of drug injecting equipment are not permitted. Additionally
correctional personnel may desire to review and approve all educational
materials, including videos.
Finally, there is a need for further research on juveniles in adult and
detention setting for youth in other parts of the country to determine whether
there are differences base on geographical location, state and county laws and
local correctional facility policies.

APPENDIX A
UCF AIDS/HIV QUESTIONNAIRE
You have been selected to participate in a study of AIDS and HIV. Your
thoughts concerning AIDS and how it is spread are important to us. We are
trying to slow the spread of AIDS among young people. You are free to
withdraw from this study at any time. There are no harmful effects and in no way
can your responses hurt you. We strongly encourage you to take 15 minutes
and fill out this questionnaire. By completing this questionnaire you voluntarily
indicate your willingness to participate in the study. NO ONE WILL KNOW
WHO YOU ARE OR HOW YOU ANSWERED. ALL SUBJECTS HAVE
COMPLETE ANONYMITY AND CONFIDENTIALITY. Read each question, and
after you decide which answer is best, fill in the correct space with a No. 2
pencil.
A. BEHAVIOR
These questions deal with precautions
1. In the future, I will use
a condom if unsure of my
partners sexual history.
a. Frequently
b. Sometimes
c. Never
2. I would have sex with an
attractive partner if no
condom was available.
a. Frequently
b. Sometimes
c. Never
3. In the future I plan to
inject drugs.
a. Frequently
b. Sometimes
c. Never
you may take as a result of AIDS.
4. I would trust a sex partner
if she/he said they are free
from disease.
a. Frequently
b. Sometimes
c. Never
5. I would have sex without
a condom if I had a negative
AIDS test.
a. Frequently
b. Sometimes
c. Never
6. In the future, I will demand the
use of a condom (rubber) for
my protection.
a. Frequently
b. Sometimes
c. Never
100

101
7.
In the future, I will demand
13.
I have had a blood test for
the use of a condom (rubber)
for my partner’s protection.
AIDS.
a. Yes
a. Frequently
b. No
b. Sometimes
c. Don’t know
c. Never
14.
I have tested positive for
8.
I take special precautions to
prevent catching AIDS.
HIV.
a. Yes
a. Frequently
b. No
b. Sometimes
c. Don’t know
c. Never
15.
I have been sexually abused.
9.
I ask sex partners about their
sexual history.
a. Yes
b. No
a. Frequently
b. Sometimes
c. Unsure
c. Never
16.
I have been physically abused.
10.
I share I.V. drug needles.
a. Yes
b. No
a. Frequently
b. Sometimes
c. Unsure
c. Never
17.
In the future I will share
I.V. needles.
11.
I would like to be blood tested
for AIDS.
a. Frequently
b. Sometimes
a. Yes
b. No
c. Never
c. Don’t Know
18.
In order to body pierce, I would
Share a needle.
12.
I would like my friends to be
blood tested for AIDS.
a. Yes
b. No
a. Yes
b. No
c. Don’t know
c. Unsure

102
B. KNOWLEDGE
These questions ask you how you think people with catch AIDS.
19. AIDS can be caught from
sharing a glass of water of
water wit h an infected person
a. Yes
b. No
c. Don’t know
20. AIDS can be caught from
toilet seats.
a. Yes
b. No
c. Don’t know
21. AIDS can be caught from
kissing on the cheek.
a. Yes
b. No
c. Don’t know
22. AIDS can be caught from
heavy (tongue) kissing.
a. Yes
b. No
c. Don’t know
23. AIDS can be caught from
sharing marijuana pipes
or cigarettes.
24. AIDS can be caught from
sharing drug needles.
a. Yes
b. No
c. Don’t’ know
25. ADIS can be caught from
donating blood.
a. Yes
b. No
c. Don’t know
26. AIDS can be caught from
sharing tattoo needles.
a. Yes
b. No
c. Don’t know
27. ADIS can be caught from
sharing cigarettes.
a. Yes
b. No
c. Don’t know
28. AIDS can be caught if a
person who has AIDS
sneezes on you.
a. Yes
a. Yes b. No
b. No c. Don’t know
c. Don’t know

103
29. A!DS can be caught if a
hospital has to give you blood.
a. Yes
b. No
d. Don’t know
30. AIDS is harder to catch if you
are young and healthy
a. Yes
b. No
c. Don’t know
31. Using a condom (rubber) will
help prevent catching AIDS.
a. Yes
b. No
c. Don’t know
32. In the last 5 times you had sex,
how many times did you use
a condom?
a. 0
b. 1
c. 2
d. 3
e. 4
f. 5
33. You can catch AIDS by shaking
hands with a person who has AIDS.
a. Yes
b. No
c. Don’t know
34. AIDS can be caught from
sharing razor blades.
35. If a restaurant cook has AIDS,
you will catch AIDS if you eat
food the cook prepared.
a. Yes
b. No
c. Don’t know
36. All gay men (homosexuals)
have AIDS.
a. Yes
b. No
c. Don’t know
37. Babies can be born with AIDS.
a. Yes
b. No
c. Don’t know
38. AIDS is caused by a virus.
a. Yes
b. No
c. Don’t know
These questions ask you how you feel
about AIDS.
39. My chances of catching AIDS
are great.
Strongly agree
Agree
Disagree
Strongly disagree
Don’t know
a.
b.
c.
d.
e.
a. Yes
b. No
c. Don’t know

104
40. My friends have a high
chance of catching AIDS.
a. Strongly agree
b. Agree
c. Disagree
d. Strongly disagree
e. Don’t know
41. White people have less of a
chance of catching AIDS.
a. Strongly agree
b. Agree
c. Disagree
d. Strongly disagree
e. Don’t know
42. There is a cure for AIDS but
it is too expensive for most
people.
a. Strongly agree
b. Agree
c. Disagree
d. Strongly disagree
e. Don’t know
43. If ¡ caught AIDS, I would tell
any sex partners.
a. Strongly agree
b. Agree
c. Disagree
d. Strongly disagree
e. Don’t know
44. If I caught AIDS, I would not
tell anyone.
a. Strongly agree
b. Agree
c. Disagree
d.Strongly disagree
e.Don’t know
45. If I caught AIDS, I would tell
close friends.
a. Strongly agree
b. Agree
c. Disagree
d. Strongly Disagree
e. Don’t know
46. If! caught AIDS, I would not
have sex again.
a. Strongly agree
b. Agree
c. Disagree
d. Strongly disagree
e. Don’t know
47. AIDS is a big problem in
America.
a. Strongly agree
b. Agree
c. Disagree
d. Strongly disagree
e. Don’t know

105
48. I worry a lot about catching
AIDS.
a. Strongly Agree
b. Agree
c. Disagree
d. Strongly disagree
e. Don’t know
49. I worry a lot about my friends
catching AIDS.
a. Strongly agree
b. Agree
c. Disagree
d. Strongly disagree
e. Don’t know
50. Only homosexuals catch AIDS.
a. Strongly agree
b. Agree
c. Disagree
d. Strongly disagree
e. Don’t know
51. If you catch AIDS, it’s your
own fault.
a. Strongly agree
b. Agree
c. Disagree
d. Strongly disagree
e. Don’t know
52. There is nothing you can
Do to prevent catching AIDS.
a. Strongly agree
b. Agree
c. Disagree
d. Strongly disagree
e. Don’t know
53. AIDS is a made up
problem by the
government to decrease
sexual activity and
drug use.
a. Strongly agree
b. Agree
c. Disagree
d. Strongly agree
e. Don’t know
54. You can have AIDS and
not know it.
a. Strongly agree
b. Agree
c. Disagree
d. Strongly disagree
e. Don’t know
55. If you catch AIDS, you will
die within ten years.
a. Strongly agree
b. Agree
c. Disagree
d. Strongly disagree
e. Don’t know
56. It is possible for someone
to have AIDS, not know it
and infect others.
a. Strongly agree
b. Agree
c. Disagree
d. Strongly agree
e. Don’t know

106
57. Compared to most people 63. Have you injected drugs in
I feel that I know a lot the last 3 months?
about AIDS.
a. Yes
a. Strongly agree
b. Agree
b. No
c. Disagree
64.
With how many partner
d. Strongly disagree
have you had sexual
e. Don’t know
intercourse?
The purpose of this last section is
a. None
for you to tell us something about
b. 1
yourself. No one will ever know
c. 2-5
who you are; all replies are
d. 6-10
anonymous.
e. Over 10
58. What is your age?
65.
How many sexual partners
have you had in the last
a. 11-12
b. 13-14
3 months?
c. 15-16
a. None
d. 17-18
b. 1
c. 2-5
59. What is your gender?
a. Male
d. 6-10
e. Over 10
b. Female
66.
With how many partners
have you had a same sex
60. What is your race?
relationship?
a. White
a. None
b. African American
b. 1
c. Hispanic
c. 2-5
d. Oriental
d. 6-10
e. Other
e. Over 10
61. Have you ever used marijuana?
67.
How many of your friends
do you think have had a
a. Yes
b. No
homosexual relationship?
a. None
62. Have you ever “shot up” drugs?
b. 1
a. Yes
c. 2-5
b. No
d. 6-10
e. Over 10

107
How long have you been
here?
a. 1 -30 days
b. 31-60 days
c. 61-90 days
d. over 91 days
69. Where did you learn the most
about AIDS?
a. Relatives, friends
b. Books, magazines, or newspapers
c. Television, radio
d. Public school
e. Youth Services
70. Did the AIDS training you got here
influence your intentions?
a. Strongly agree
b. Agree
c. Disagree
d. Strongly disagree
71. Where have you heard the
most talk about AIDS?
a. Parents, guardians
b. Friends
c. Public school
d. Youth Services
e. Television or radio
72. Where are you located?
68. How many sex partners do 73.
you think most of your
friends have had?
a. None
b. 1
c. 2-5
d. Over 6
e. Don’t know
a. Orlando
b. Tallahassee

APPENDIX B
AIDS/HIV RISK ASSESSMENT INTERVIEW
Interviewer Name
Date
Location
What are your future plans (school, work, party, etc.)? (List in order of
importance).
How much formal education have you had?
What type of educational ambitions do you have? (e.g., get a GED, HS Diploma,
BS, MS or Ph.D.).
What type of work ambitions do you have? (e.g., to work construction, become a
doctor, etc).
How long have you been in custody?
Are you satisfied with how you are treated?
What is the most important thing you have learned
What offenses were you charged with?
What type of pressure or stresses have you faced while incarcerated? (Specific
examples)
108

109
How do you handle potential violent situations? Give specific examples.
Are there strong clique groups while you are detained?
Describe them.
Which clique group do you best fit with?
How much do you know about HIV/AIDS?
Where did you learn the most about HIV/AIDS? (List in order)
Many juveniles have HIV. What could be done to keep this number from
increasing?
Have you had an HIV test?
If yes, what was the result?
If no, would you like to be tested
Should people in prison be tested for HIV?
Why or why not?

110
Have you ever shared needles:
for tattooing?
drugs?
body piercing?
for any other reason?
Would you ever share needles? Why or Why not?
Who is at-risk for HIV?
Are you at-risk for HIV?
Are your friends?
What would you do if you had AIDS?
These next questions are somewhat personal, remember that no one will know
how you answered.
How many sexual partners have you had?
Do you discuss your partners’ sexual history with them?
For sex, would you prefer a male partner of a female?

Ill
Would you ever have sex with someone of the same gender?
Why or why not?
Have you ever engaged in deviant sex acts? (ex. use or work as prostitute,
multiple partners, etc.). Give examples.
In your group (cottage, dorm), how many juveniles would you say have had
alternative sexual preferences? (Bisexual or lesbian, give %%%%).
In other groups you know of?
Should condoms be available in:
Prison?
School?
Is it hard to get condoms (when you are not in custody)?
Why or why not?
If you could do things over, what would you do different?
Why or why not?
How big of a problem do you think AIDS is?
Is there a cure?

112
What should be done about the AIDS problem in America?
Which topic that we discussed caused you the most discomfort?
Why?
Are there any other issues or problems that we have not discussed?
Thank you for your help. Your information will help us a lot
COMPLETE AFTER INTERVIEW.
Interviewer impressions (openness of subject, degree of discomfort, etc.)
Description of subject. Approximate age, ethnicity, gender, soma-type,
etc.

APPENDIX C
INSTITUTIONAL REVIEW BOARD APPROVAL LETTER

istitutional Review Board
114 Psychology Bldg.
PO Box 112250
Gainesville, FL 32611-2250
February 15, 1996
Phone: (904) 392-0433
Fax: (904) 392-0433
TO:
Ms. Sadie B. Sanders
117 FLG/PO Box 118210
FROM: C. Michael Levy, Ch
University of Florida Institutional
Review Board
SUBJECT: Approval of Project #96.057
Development of an educational intervention regarding HIV/AIDS for
incarcerated adolescents detained in a county jail
I am pleased to advise you that at today’s convened meeting of the University
of Florida Institutional Review Board this project was approved. The Board
concluded that participants will not be placed at risk in this research.
Although it is not essential that you obtain signed, witnessed parental informed
consent for participants incarcerated at Disc Village, Tallahassee, Florida,
it is essential that you obtain legally effective informed consent from each
participant’s parent or legal guardian for participants detained in the Escambia
County jail. When it is teasible, you should obtain signatures from both
parents. Enclosed is the dated, IRB-approved informed consent to be used when
recruiting participants for this research.
If you wish to make any changes in this protocol, you must disclose your
plans before you implement them so that the Board can assess their impact
on your project. In addition, you must report to the Board any unexpected
complications arising from the project which affect your participants.
Approval of this project runs for a period of one year from the date of this
meeting, the maximum duration permitted by the Federal Office for Protection
Research Risks. If this project will not be completed by February 15, 1997,
please contact this office at least six weeks prior to that time so that we may
advise you how to apply for a renewal.
By a copy of this memorandum, your Chair is reminded of the importance
of being fully informed about the status of all projects involving human
participants in your department, and for reviewing these projects as often
as necessary to insure that each project is being conducted in the manner
approved by this memorandum.
CML/h2
cc: Vice President for Research
College Dean
HRS
Alta Douglas
Dr. Barbara A. Rienzo
114
Equal Opportunity/Affirmative Action Institution

APPENDIX D
Assent Form
Researchers from the University of Florida are doing a study to learn what young
people think about AIDS/HIV. The study is being paid for by the principal
researcher. Your thoughts about AIDS, how it is spread, and howt protect
yourself are important to us. We would like to ask you to help us with the study.
We will ask you to complete a short survey which takes approximately 20
minutes. You will also be asked some questions that will require about 45-60
minutes of your time. Several weeks after you complete the survey and answer
the questions, you will be asked to participate in an HIV/AIDS educational
program designed to assist you in reducing your risk for becoming exposed and
infected with HIV. The educational program will take approximately 10 hours to
complete. Your participation is voluntary and you can withdraw anytime you like.
You do not have to answer any questions you do not wish to answer nor
participate in any activity you do not wish to participate in. You will have
complete anonymity and confidentiality. NO ONE WILL KNOW WHO YOU ARE
OR HOW YOU ANSWERED. To maintain your privacy you will be asked to not
give nor write your name (other than on this Assent Form). Nothing to do with
the study can hurt you, your health or your well being. What we learn may help
you since the HIV/AIDS educational program may help slow the spread of HIV
and AIDS. You will not be compensated in any way. If you have any questions
or want to learn more about the study you can call or write Ms. Sadie B. Sanders
at the University of Florida, Department of Health Science Education, Room 5
FLG, PO Box 11822210, Gainesville, FL 32611-8210; ph. (352) 392-0583. You
can also contact Dr. S. K. Zoss or Ms. J. J. Crater at the Escambia County jail,
(904) 436-9693 if you have any questions or problems. Questions or concerns
about research participants’ rights may be directed to the University of Florida
Institutional Review Board office, Box 112250, Gainesville, FL 32611-2250; ph.
(352) 33920433.
I have read the procedure described above. I voluntarily agree to participate in
the study and I have received a copy of this description.
Participant’s Name
Date
115

APPENDIX E
Consent Form
Researchers from the University of Florida are doing a study to learn what young
people think about AIDS/HIV. The study is being paid for by the principal
researcher. Your child’s thoughts about AIDS, how it is spread, and how she/he
can protect him/herself are important to us. We would like to ask your child to
help us with the study. We will ask your child to complete a short survey which
takes approximately 20 minutes. He/she will also be asked some questions that
will require about 45-60 minutes of his/her time. Several weeks after your child
completes the survey and answers the questions, he/she will be asked to
participate in an HIV/AIDS educational program designed to assist him/her in
reducing his/her risk for becoming exposed to and infected with HIV. The
educational program will take approximately 10 hours to complete. Your child
does not have to answer any questions he/she does not wish to answer nor
participate in any activity he/she does not wish to participate in. Your child will
have complete anonymity and confidentiality. NO ONE WILL KNOW WHO
HE/SHE IS OR HOW HE/SHE ANSWERED. To maintain your child’s privacy,
he/she will be asked to not give nor write his/her name (other than on the Assent
Form). Nothing to do with the study can hurt your child, your child’s health, or
your child’s well-being. What we learn may help your child since the HIV/AIDS
educational program may help slow the spread of HIV and AIDS. Your child will
not be compensated in any way. If you or your child have any questions or want
to learn more about the study you can call or write Ms. Sadie B. Sanders at the
University of Florida, Department of Health Science Education, Room 5 FLG, PO
Box 118210, Gainesville, FL 32611-8210, (352) 392-0583. You can also
contact Dr. S. K. Zoss or Ms. J. J. Crater at the Escambia County jail, (904) 436-
9693 if you have any questions or problems. Questions or concerns about
research participants’ rights may be directed to the University of Florida
Institutional Review Board office, Box 112250, Gainesville, FL 32611-2250; ph.
(352) 2392-0433
I have read the procedure described above. I voluntarily agree to have my child
participate in the study and I have received a copy of this description.
Parent/Legal Guardian’s Name Date
Participant’s Name
116

APPENDIX F
HIV/AIDS Educational Program for Juveniles Incarcerated in a county jail
Based on the AIDS Risk Reduction Model (ARRM)
Each educational program session is two hours in length. The first
session covers basic HIV/AIDS information including definitions of HIV and
AIDS, transmission of the virus and HIV high risk behaviors, and videos, "Don't
Forget Sherrie" and "Letter From Brian". The second session includes HIV
prevention and a game, HIV Basketball, that focuses on providing accurate HIV
information, and an opportunity for participants to personalize their own risk
(anonymously). The third session focuses on decision making/problem solving
and communication/partner negotiation skills and a video. The fourth and final
session addresses correct condom use, HIV antibody testing, community
resources, and participants' reactions to the educational intervention.
The first session begins with an introduction to and explanation of the
purpose and content of the prevention program. Basic ground rules,
emphasizing the responsibility of the facilitator and each participant to maintain
confidentiaOlity and respect the rights, feelings, and ideas of each other are
addressed. Participants are asked for any additional ground rules. They are
encouraged to speak one at a time and discouraged from interrupting when the
facilitator or another participant is speaking. It is emphasized that participation
in any activities and/or discussions is strictly voluntary and will be encouraged
but not forced. The facilitator will observe participants closely during and after
each session for signs of discomfort or anxiety. Participants are informed of the
117

118
availability of an information box during each session for anonymous questions,
comments, and suggestions.
Sessions two, three and four each begin with a review of the previous
session. Each session ends with a review of the day’s session and a preview of
the session to follow.
Program Goals:
The overall goals of this program are to:
1. Decrease number of sexual partners.
2. Decrease the frequency of sexual intercourse with partners of unknown
HIV serostatus.
3. Increase the consistent and correct use of condoms and other barrier
methods during sexual intercourse.
4. Eliminate or decrease frequency of drug use in situations that may lead to
engagement in sexual activity.
Program Objectives:
By the end of this educational intervention, participants will be able to:
1. Identify and discuss HIV high-risk behaviors.
2. Identify major modes of HIV transmission.
3. Identify ways in which HIV is not transmitted.
4. Personalize own risk for contracting HIV.
5. Describe methods of HIV prevention.
6. Describe and utilize appropriate partner negotiation skills.
Describe and utilize appropriate communication, problem solving and
decision making skills.
7.

119
8. Describe correct condom use
9. Identify where/how to obtain condoms
10. Identify community resources, including drug treatment facilities, mental
health facilities, local public health department, HIV testing sites, self-help
groups including Alcohol Anonymous (AA), and Narcotics Anonymous
(NA),
Methods:
Group discussion/lecture
Game (HIV Basketball)
Videos ("Don't Forget Sherrie", "Letter From Brian", "Are You With Me")
Question/Answer Sessions
HIV Risk Assessment (completed anonymously), to assist with recognition and
labeling of one's behaviors as high-risk
Skilled-based activities
SESSION ONE (two hours)
Objectives
By the end of the session, participants will be able to:
1. Define HIV and AIDS.
2. Identify and discuss three HIV high-risk behaviors.
3. Identify behaviors by which HIV is not transmitted.
4. Identify four body fluids through which HIV is transmitted.
Session One Contents
1.
2.
Definition HIV & AIDS
History/origin of HIV/AIDS

120
3. Transmission of HIV
4. The Disease Spectrum
4. Cumulative Reported AIDS Cases and Estimated HIV Cases
5. Video - "Don't Forget Sherrie"
Materials and Resources Needed
1. Flip chart, markers for writing on chart and keeping game score
2. Question/comment box
3. Pencils and note paper
4. VCR Player
SESSION TWO (two hours)
Objectives
By the end of the session, participants will be able to:
1. Personalize own risk for contracting HIV.
2. Describe methods of HIV prevention.
Session Two Contents
1. Prevention
2. Personal HIV Risk Assessment
3. HIV Testing
4. Video - "Letter from Brian"
Materials and Resources Needed
1. Flip Chart, markers
2 HIV Risk Assessment
3.
Question/Comment Box

121
4. Pencils and note paper
5. Basketball game score board
6. VCR player
SESSION THREE (two hours)
Objectives
By the end of the session, participants will be able to:
1. Describe and utilize appropriate communication skills, including partner
negotiation.
2. Describe and utilize appropriate problem solving
and decision making skills.
3. Describe and role play condom negotiation skills sexual
partner.
Session Three Contents
1. Communication, Decision Making, and Partner Negotiation Skills
2. Video, "Are You with Me"
Materials and Resources Needed
1. Flip chart, markers
2. VCR Player
SESSION FOUR (two hours)
1. Describe how to use a condom correctly.
2. Describe and utilize appropriate communication skills, including partner
negotiation.

122
3. Identify where/how to obtain condoms.
4. Identify community resources, including drug treatment facilities, HIV
antibody testing sites, self-help groups including Alcohol Anonymous
(AA), Cocaine Anonymous (CA) and Narcotics Anonymous (NA).
Session Four Contents
1. Correct Condom Use
2. Communication, Decision Making, and Partner Negotiation Skills
3. Community Resources
4. Participants’ comments regarding the educational program
Materials and Resources Needed
1. Hand out - Correct condom use
2. Hand out - Community Resources
VIDEOS
Hoffman, J. (Producer), & Neema Barrett, N. (Director). (1991). Are you with
me? (Film). AIDS Films (Select Media), New York.
Modern Talking Pictures SVS, Inc., (1988). Don’t forget Sherrie. St. Petersburg,
FL
DECISION MAKING and PATNER NEGOTIATION ACTIVITY
You and your girl/boy friend are alone and the two of you are engaging in some
heavy foreplay. What do you do next?

123
HIV BASKETBALL GAME
Participants are divided into two teams, each with a team captain. The team
captain is selects the question and provides an answer upon conferring with the
other team members. Questions are selected from 1, 2, or 3 point categories.
Questions worth 1 point have the least degree of difficulty and those worth 3
points are the most difficult. The team responding to a question will have 20
seconds to confer with each other and provide a response. Failure of a team
captain to respond, respond within the designated time period, or respond with a
correct answer will result in loss of turn and the other team will have the
opportunity to respond to the question. The team that reaches 10 points first,
wins the game.
ONE POINT QUESTIONS
What is AIDS?
What is the name of the virus that causes AIDS?
What is HIV?
What is the name of the virus that causes AIDS?
TWO POINT QUESTIONS
What are 2 ways an HIV positive mother can transmit HIV to her unborn or
newborn child?
How can a person tell if they have HIV?
What are 4 ways HIV is not transmitted from one person to another?
What are 2 ways in which HIV is transmitted from one person to another?

124
THREE POINT QUESTIONS
What are 4 body fluids through which HIV can be transmitted?
What are 4 ways in which HIV transmission can be prevented?
How can using non-injecting drugs, including alcohol place a person at risk for
contracting HIV?
FLIP CHART TOPICS
"HOW HSV IS TRANSMITTED"
1. Sexual Contact with person with HIV
Anal
Vaginal
Oral
2. Blood-to-Blood
Sharing same needle (injecting drug, tattoo) as person with HIV
Sharing same items as person with HIV that can be contaminated
(i.e., razor, toothbrush)
3. HIV+ mother to unborn or newborn child
"HOW HIV IS NOT TRANSMITTED"
1 Casual Contact (i.e., shaking hands with HIV+ person)
2. Insects/Animals
3. Inanimate objects
4. Donating blood

125
"BODY FLUIDS THAT TRANSMIT HIV"
1. Blood
2. Semen
3. Vaginal Secretions
4. Breast Milk
"BODY FLUIDS THAT DO NOT TRANSMIT HIV"
1. Tears
2. Sweat
3. Saliva
4. Urine
5. Nasal Fluid
"HIV HIGH RISK BEHAVIORS"
1. Sexual contact with HIV positive person
2. Sexual contact without a condom or other barrier method
6. Sharing same items that can be contaminated with blood or sexual fluids
as person with HIV (i.e., razors, needles, and sex toys)
"HIV PREVENTION"
1. Sexual abstinence
2. Drug abstinence
3. Latex condoms and other barrier methods (i.e. dental dam, saran wrap)
4. Clean injecting drug needles and other injecting equipment with bleach

126
5. No sharing of tattoo/body piercing needles and personal hygiene items
7. Universal Precautions (avoid direct contact with fluids through which HIV
can be transmitted
"HIV DISEASE SPECTRUM"
1. Person becomes infected
2. 2 weeks to 6 months to a positive antibody test
3. Average of 10 years to an AIDS Diagnosis
4. Average of 2-5 years from first opportunistic disease until death
"HIV ANTIBODY TESTING"
1. Anonymous and confidential testing
2. Benefits and risks of testing
"DECISION MAKING STEPS" (Normative Theory of decision making)
1. List relevant action alternatives
2. Identify possible consequences of those actions
3. Evaluate the probability of each consequence occurring
4. Determine the relative significance of each consequence
5. Integrate information to identify most appealing course of action

127
H1V/A1DS RISK ASSESSMENT (To be completed anonymously)
1.
YES
NO
Have you ever had sexual intercourse (anal, oral, or vaginal)
with anyone without the use of a condom?
2.
YES
NO
Have you ever had sexual intercourse (anal, oral, or vaginal)
with anyone with HIV or AIDS?
3.
YES
NO
Have you ever had sexual intercourse (anal, oral, or vaginal)
with an IV drug user?
4.
YES
NO
Have you ever had sexual intercourse (anal, oral, or vaginal)
with the sexual partner of anyone with HIV or AIDS?
5
YES
NO
Have you ever had sexual intercourse (anal, oral, or vaginal)
with the sexual partner of an IV drug user?
6.
YES
NO
Have you ever shared drug injection equipment, including a
needle with another person?
7.
YES
NO
Have you ever shared tattoo needles with another person?
8.
YES
NO
Have you ever shared body piercing needles with another
person?
9.
YES
NO
If you answered yes to any of the above questions, have you
been tested for HIV within 6 months of participation the last
behavior(s) to which you answered yes?

128
COMMUNITY RESOURCES LIST
HIV Antibodv Testina
(Anonymous)
Escambia AIDS Services and
Education (EASE)
3624 W. Fairfield Drive
Pensacola, Florida 32501
(850) 456-7079
Mental Health Services
Lakeview Center, Inc.
1221 W. Lakeview Avenue
Pensacola, Florida 32501-1857
(850) 469-3500
Baptist Hospital Behavioral
Medicine Center
Condoms
(850) 434-4011
EASE
Crisis Line (HelpLine)
Escambia County Public Health Dept.
(850) 595-1300
Lakeview Center, Inc. Bldg. H
Primary Health Care Services
Druq and Alcohol Counselina
Escambia Community Clinics
2200 Palafox Street
Lakeview Center, Inc.
1221 W. Lakeview Avenue
Pensacola, Florida 32501-1857
(850) 469-3730
Pensacola, Florida 32501
(850) 436-8880
Escambia County Public Health
Department
Support Groups
1295 W. Fairfield Drive
Pensacola, Florida 32501-1857
Alcoholics Anonymous (AA)
(850) 433-4191
(850) 595-6500
Narcotics Anonymous (NA)
(850) 444-4298
Cocaine Anonymous (CA)
(850) 444-0999

REFERENCES
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BIOGRAPHICAL SKETCH
I received a Bachelor of Science degree in Physical Education with a
minor in Health Education from Tuskegee University and a Master of Science
degree in Health Education from the University of West Florida. My professional
experience includes serving as clinical intake specialist/utilization manager and
health education specialist for a drug and alcohol treatment program; director of
a Florida Department of Juvenile Justice detention facility; therapist/case
manager for a community mental heath agency; and as a drug and alcohol
counselor for an adolescent residential substance abuse treatment program. I
also taught at the junior high school, high school, and adult high school levels. I
will be granted a Doctor of Philosophy in health and human performance with an
emphasis in health behavior and a minor in medical sociology through the
College of Health and Human Performance, Department of Health Science
Education in August 1998. I will begin as visiting assistant professor at the
University of Florida in the Department of Health Science Education in August
1998.
140

I certify that I have read this study and that in my opinion it conforms to
acceptable standards of scholarly presentation and is fully adequate, in scope
and quality, as a dissertation for the degree of Doctor of Philosophy.
Barbara A. Rierizo/Uhair
Professor of Health Science
Education
I certify that I have read this study and that in my opinion it conforms to
acceptable standards of scholarly presentation and is fully adequate, in scope
and quality, as a dissertation for the degree of Doctor of Philosophy.
'¿Ik
William Chen
Professor of Health Science
Education
I certify that I have read this study and that in my opinion it conforms to
acceptable standards of scholarly presentation anqis fulty'adequate yin scope
and quality, as a dissertation for the degree oTDoctprpf Philpsqphy/
R. Paul Duncan
Professor of Health Services
Administration
I certify that I have read this study and that in my opinion it conforms to
acceptable standards of scholarly presentation and is fully adequate, in scope
and quality, as a dissertation for the degree of Doctor of Philosophy.
M. David Miller
Professor of Foundations of
Education
This dissertation was submitted to the Graduate Faculty of the College of
Health and Human Performance and to the Graduate School and was accepted
as partial fulfillment of the requirements for the degree of J2$>p1^r of^hilgsop^y.
August 1998
Dean, Collége of Health and
Human Performance
Dean, Graduate School



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