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Service Delivery Innovation Profile

Culturally Appropriate, School-Based Education and Support Reduces Likelihood That Latino Teens Will Engage in Risky Sexual Behaviors


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Snapshot

Summary

A program known as Cuidate ("Take Care of Yourself") focuses on reducing the risk of sexually transmitted diseases, including HIV/AIDS, and pregnancy among Latino teenagers. The program, which was tested during after-school hours at three schools in Philadelphia as part of a research project and implemented during regular school hours at one high school in Denver, centers on a series of facilitator-led classes at which students learn accurate information about sexually transmitted diseases and pregnancy, and discuss attitudes about sex. The program incorporates commonly held cultural beliefs in the Latino community, using them to frame abstinence and condom use as acceptable and effective health strategies. At the Denver school, the program also included the school-based clinic, which served as a source of support once the classes ended for students with follow up questions or needs. Two randomized controlled trials found that the program reduced the likelihood of engaging in risky sexual behaviors, including sexual intercourse, unprotected sex, and having multiple partners. 

Evidence Rating (What is this?)

Strong: The evidence consists of data on self-reported sexual behavior from two randomized controlled trials in Latino adolescents aged 13 to 18 years (conducted in the United States and in Mexico; comparisons of self-reported sexual activity via periodically administered questionnaires) between students who participated in the program and students who participated in a general health information program and anecdotal reports from students to facilitators and from facilitators to school administrators.
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Developing Organizations

University of Michigan, School of Nursing
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Date First Implemented

2000
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Patient Population

Age > Adolescent (13-18 years); Race and Ethnicity > Hispanic/latino-latinaend pp

Problem Addressed

Latino youths have significantly higher rates of pregnancy and sexually transmitted diseases (STDs), including HIV/AIDS, than do non-Latino White youths.
  • Higher pregnancy rates: In 2004, the pregnancy rate among Latinas aged 15 to 19 years averaged 132.8 per 1,000 individuals, well above the 45.2 per 1,000 rate among White females.1 Teenage Latinas in Colorado have especially high pregnancy rates—whereas they represent only 22 percent of the total population aged 15 to 19 years, they account for more than 55 percent of all teen births in the state.2 A national youth risk behavior survey found that Latino youth in Colorado were more likely than Whites to have sex before the age of 13 years and to have four or more sexual partners and less likely to report receiving education in school on HIV or AIDS.3
  • Higher risk of STDs, including HIV/AIDS: In 2006, Latinos accounted for the second highest proportion of HIV/AIDS cases among youth aged 13 to 19 years (as compared to other racial and ethnic groups).4 Latino youth were also two to three times more likely than White youth to suffer from gonorrhea and chlamydia.5

What They Did

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Description of the Innovative Activity

A program known as Cuidate ("Take Care of Yourself") focuses on reducing the risk of STDs, including HIV/AIDS, and pregnancy among Latino teenagers. The program, which was tested during after-school hours at three schools in Philadelphia as part of a research project and implemented during regular school hours at one high school in Denver, centers on a series of facilitator-led classes at which students learn accurate information about STDs and pregnancy and discuss attitudes about sex. It incorporates commonly held cultural beliefs among Latinos, using them to frame abstinence and condom use as acceptable and effective health strategies. At the Denver high school, the program also incorporated the school clinic as a source of additional support once the classes ended. Key program components include the following:
  • Course structure: The program consists of six modules (described in detail below) delivered to mixed gender groups of 8 to 10 students. At the Philadelphia high schools, these modules were taught in six 50-minute sessions held over two consecutive Saturdays. At the Denver high school, the modules were spread out over fifteen 45-minute sessions to fit into the school's regular 45-minute class periods, which also allowed more time for discussion and other activities.
  • Focus on reframing of cultural values: The program incorporates commonly held cultural beliefs related to gender roles and family, using them to promote safer sexual behaviors. For example, after discussing the traditional definition of "machismo" (which includes many stereotypes, such as that a strong man can do what he wants with whomever he wants, and can make decisions for others), facilitators present an alternative view that incorporates the values of caring for and protecting others, including keeping the family safe. In this way, condom use can be presented as consistent with the value of machismo, because a strong man takes responsibility for himself and cares for his partner and family. Similarly, after discussing an image of Latina women that incorporates typical stereotypes and beliefs (e.g., that a woman should care for the family first; be faithful to her partner; and leave decisionmaking, especially related to sex, to the man), facilitators introduce an alternative image emphasizing fidelity and abstinence as positive behaviors, and framing condom use as a way to take responsibility for one's family. This reframing makes it acceptable for women to carry condoms for the purpose of initiating discussion about their use and to refuse sex if necessary.
  • Multiple formats for teaching six-part curriculum: To make the classes as engaging as possible, facilitators lead group discussions; conduct role playing exercises; and use videos, music, interactive games, and skill-building activities to teach a six-part curriculum, outlined below:
    • Introduction and overview: Facilitators present information about HIV and safer sex and lead a discussion intended to help students increase their knowledge of HIV and identify attitudes and beliefs about HIV and safer sex. Part of this discussion focuses on Latino cultural values, such as machismo, respect, and the importance of family.
    • Building HIV knowledge: Students watch a video about HIV and then discuss myths and facts about it.
    • Understanding vulnerability to HIV infection: Students discuss cultural attitudes about HIV, role play a young couple's conversation about safe sex, and play a bingo game with points for correct answers about HIV.
    • Attitudes and beliefs about HIV/AIDS and safer sex: Students listen to several songs and discuss various sexual situations. Discussion topics include ¿Quíen es Más Macho? (Who is More Macho?), adolescent vulnerability and forced choice, and La Zona Peligrosa (The Danger Zone).
    • Building condom-use skills: After a discussion of condom use and barriers to it, the facilitator demonstrates correct condom application on a plastic model. Students then have an opportunity to practice condom application on the model.
    • Building negotiation and refusal skills: Students engage in a series of role playing exercises intended to help them become comfortable with saying they do not want to have sex. They also play a version of Jeopardy that centers on HIV.
  • Incentives to encourage participation: In Philadelphia schools, participating students received a T-shirt with the study logo, along with financial compensation of up to $110—$40 after completion of the educational sessions, $20 for completing 3- and 6-month follow up questionnaires, and $30 for completing a 12-month follow up questionnaire. In Denver, participating students received a gift card for a local store if they enrolled and completed the program. This gift card helped to overcome several major challenges to getting the Denver students to participate, including feeling embarrassed or fearful of being judged by peers, believing they already knew enough about sex and hence did not need this type of information, and forgetting to secure permission from parents (and/or turn in the signed permission slip).
  • Support and followup from school nurse/clinic: At the Denver school, the school nurse spoke at one of the classes, and students also visited the school-based clinic to meet the staff. Once the classes ended, students were encouraged to visit the clinic if they had follow up questions or needed specific services, such as birth control, pregnancy testing, or HIV/STD testing. 

Context of the Innovation

The University of Michigan School of Nursing, in Ann Arbor, MI, offers bachelor's degree, master's degree, and PhD programs in nursing. The HIV prevention program developed over a period of several years beginning in the late 1990s, after a researcher at the school became concerned about the high rates of HIV and pregnancy among Latino adolescents and the lack of educational material targeted at this population. To address these issues, she sought to apply elements of Latino culture in support of HIV and pregnancy prevention, building on the success of a similar program (known as Be Proud! Be Responsible!) for African-American adolescents based on social cognitive theory and the theories of reasoned action and planned behavior. Once the researcher had developed the curriculum and tested it in several high schools (including those in Philadelphia), it was accepted by the Center for Disease Control and Prevention (CDC) for its Replicating Effective Programs project, which identifies HIV/AIDS prevention interventions with demonstrated evidence of effectiveness. The CDC subsequently chose Cuidate for its Diffusion of Effective Behavioral Interventions project, which works to disseminate effective HIV interventions into practice and make them more accessible. (To become a Diffusion of Effective Behavioral Interventions intervention, programs must be science-based behavioral interventions with demonstrated evidence of effectiveness in reducing risky behaviors.) The school in Denver implemented the program after being approached by representatives of the CDC program. Additional details surrounding the program's implementation in both Philadelphia and Denver are described below.

Did It Work?

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Results

The program reduced the likelihood of engaging in risky sexual behaviors, including sexual intercourse, unprotected sex, and having multiple partners.
  • Less likely to engage in sexual intercourse: Participating students reported engaging in less sexual intercourse at 3, 6, and 12 months after program participation than did a group of similar students participating in a general health information program.
  • More consistent condom use: Participating students reported more consistent condom use and fewer days of unprotected intercourse at 3, 6, and 12 months after program participation than did students taking the general health information program; in addition, adolescents receiving an HIV risk-reduction intervention who were sexually inexperienced at the start of the program reported fewer days of unprotected sex than the students receiving general education.
  • Fewer sex partners: Participating students were less likely to have had multiple partners than were students in the general program.
  • Positive reception from students: Students in both Philadelphia and Denver reported benefiting from the program, as outlined below:
    • Philadelphia: On a scale of 1 (strongly disagree) to 5 (strongly agree), participants in Philadelphia indicated they liked the curriculum (mean 4.5) and their facilitator (mean 4.3), that they learned from the program (mean 4.1), and that they would recommend it to their friends (mean 4.2).
    • Denver: Students in Denver reported enjoying the program and learning new information about HIV, STDs, and pregnancy prevention from it. They expressed particular interest in discussions focused on Latino cultural values and identity. Facilitators reported that students engaged in open and frank conversations, particularly on sensitive topics.

Evidence Rating (What is this?)

Strong: The evidence consists of data on self-reported sexual behavior from two randomized controlled trials in Latino adolescents aged 13 to 18 years (conducted in the United States and in Mexico; comparisons of self-reported sexual activity via periodically administered questionnaires) between students who participated in the program and students who participated in a general health information program and anecdotal reports from students to facilitators and from facilitators to school administrators.

How They Did It

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Planning and Development Process

Key elements of the planning and development process used in Philadelphia included the following:
  • Contacting and recruiting participating schools: The researcher identified a number of schools with significant Latino populations and contacted their school boards about arranging to test Cuidate at their high schools on Saturdays.
  • Recruiting facilitators: Program developers recruited 41 adults from schools and community-based organizations to serve as facilitators. Facilitators generally were Hispanic or Latino (with 93 percent self-identifying as being a part of these groups) and bilingual in English and Spanish. They typically had at least a high school or general equivalency diploma, along with experience with adolescents in health education, AIDS education, or skill-building. During the initial trial, these facilitators were randomly assigned to implement either the Cuidate program or the general health promotion curriculum described earlier. 
  • Training facilitators: The researcher who developed Cuidate provided 2.5 days of training to all facilitators, with a focus on teaching the information and skills needed, encouraging and ensuring implementation fidelity, and generating enthusiasm and high levels of motivation for the program.
Key elements of the planning and development process used in Denver included the following:
  • Identifying and recruiting partners: Representatives of the CDC's Replicating Effective Programs project contacted two Colorado organizations about implementing the program—The Colorado Organization on Adolescent Pregnancy and Prevention and Denver Area Youth Services (more commonly known as DAYS). These organizations approached administrators of a high school in Denver about participating; the school seemed to be an attractive partner due to its large Latino population, established need for HIV and teen pregnancy prevention, and existing relationship with DAYS staff. School officials felt that the Cuidate program represented a culturally appropriate complement to three other programs offered at the school—an after-school group for girls, a parental engagement program, and a school-based health center.
  • Building parental support: To obtain support from parents, DAYS staff introduced and explained the program at several parent education meetings and gave parents the opportunity to review the curriculum at back-to-school nights.
  • Adapting program to school schedule: DAYS staff modified program delivery to fit the school's schedule. To accommodate the school's 45-minute class periods, the curriculum was changed to fifteen 45-minute sessions delivered over a 3-week period. The new format not only allowed for implementation of the full curriculum at the school, but also provided additional time to address questions from students and facilitate classroom discussion. To minimize disruption to core subjects (e.g., math, science, language arts), program leaders decided to hold the sessions during physical education classes.
  • Training facilitators: The researcher who developed Cuidate provided training and technical assistance to DAYS staff to prepare them to deliver the program.
  • Enrolling students: Physical education teachers recruited 9th grade students, referring those interested to onsite DAYS staff to learn more about the program and to obtain a permission slip. Overall, 69 youth in mixed-gender 9th grade physical education classes participated, along with 24 youths in 11th and 12th grade who were referred by a teacher. All students had to have signed parental permission before they could enroll.

Resources Used and Skills Needed

  • Staffing: As described above, the program requires trained facilitators to direct the classes. Typically, one or two facilitators present in each class. The researcher developed the program as part of her job as a professor at the University of Michigan School of Nursing.
  • Costs: Program costs consist primarily of course materials (e.g., videos, songs, handouts, game pieces). Schools and agencies interested in implementing the program can purchase the curriculum, supplementary materials (posters, a music CD, a DVD, and a CD containing electronic copies of materials for reproduction, such as handouts, game boards, forms, and worksheets), and training material from Select Media (see link below).
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Funding Sources

National Institute of Nursing Research; Centers for Disease Control Replicating Effective Programs
A grant from the National Institute of Nursing Research funded the research project in Philadelphia, and the CDC's Replicating Effective Programs project supported the initial costs of developing the training and course materials used in Denver.end fs

Tools and Other Resources

The CDC's summary of the Cuidate program is available at http://www.cdc.gov/hiv/topics/research/prs/resources/factsheets/cuidate.htm.

Additional information on the Cuidate curriculum can be found on the Select Media Web site at http://www.selectmedia.org/programs/cuidate.html.

Adoption Considerations

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Getting Started with This Innovation

  • Include parents as early as possible: To encourage broad participation and avoid problems later, reach out to parents several months before program kickoff by hosting informational sessions where they can learn about the program's content and have their questions answered. These sessions also help parents talk about the classes with their children once they begin, and offer an ideal opportunity to obtain signed parental consent.
  • Make enrollment easy: If school policy allows, consider use of an "opt-out" enrollment process in which eligible students can be automatically enrolled unless their parents fill out a form requesting that their children not participate.
  • Set aside time for remedial education: Facilitators often find that many students lack formal education in basic human development and reproductive anatomy and have basic questions about topics such as puberty and pregnancy. If possible, assess students' knowledge on these topics before implementation, and conduct a separate remedial session for relevant students or build this information into the first module.
  • Set up structures to engage students: To the extent possible, facilitators should avoid standard lecturing and instead foster as much group interaction as possible. Role playing, group discussions, and use of multiple media (e.g., videos, music, games) can encourage students to take an active role in learning.
  • Keep classes small: Small classes (10 students or less) help create a relaxed, safe atmosphere in which students get to know each other and feel comfortable asking questions and discussing thoughts and feelings.

Sustaining This Innovation

  • Be flexible: Because conditions at schools often change, school administrators may need to be flexible to continue offering the program. For example, depending on the time available, the program can be offered as two long sessions or as six or more shorter sessions, and can be taught during school hours or on weekends. Facilitators can come from in-house staff or from outside the school. The program can also be offered as a standalone course or incorporated into an existing health class.
  • Keep content up to date: Class materials may need to be updated occasionally to reflect current events (e.g., newly available birth control methods and vaccines).
  • Provide additional support outside classroom: School administrators should look for opportunities to create partnerships that can enhance students' learning and offer them additional support outside the classroom. For example, as noted earlier, the Denver high school incorporated the school-based health clinic into the program. Physicians, nurses, and/or social workers from outside the school might also be brought in to provide education and support, such as by serving as a guest speaker.

Spreading This Innovation

Information provided in March 2013 indicates that high schools, community-based agencies and public health organizations in Arizona, Puerto Rico, Nevada, California, Utah, Florida, New Mexico, Texas, Virginia, West Virginia, Illinois, Washington, Massachusetts and Washington D.C. have implemented the Cuidate program.

More Information

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Contact the Innovator

Antonia M. Villarruel, PhD
Professor, Nola J. Pender Collegiate Chair
Associate Dean for Research and Global Affairs
University of Michigan School of Nursing
400 North Ingalls Building, Rm 4320
Ann Arbor, MI 48109-5482
(734) 615-9696
E-mail: avillarr@umich.edu

Innovator Disclosures

Dr. Villarruel has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.

References/Related Articles

Mueller TE, Castaneda CA, Sainer S, et al. The implementation of a culturally based HIV sexual risk reduction program for Latino youth in a Denver area high school. AIDS Educ Prev. 2009 Oct;21(5 Suppl):164-70. [PubMed]

Villarruel AM, Jemmott JB, Jemmott LS. A randomized controlled trial testing an HIV prevention intervention for Latino youth. Arch Pediatr Adolesc Med. 2006 Aug;160(8):772-7. [PubMed]

Villarruel AM, Jemmott LS, Jemmott JB. Designing a culturally based intervention to reduce HIV sexual risk for Latino adolescents. J Assoc Nurses AIDS Care. 2005 Mar-Apr;16(2):23-31. [PubMed]

Villarruel AM, Zhou Y, Gallegos EC, Ronis DL. Examining long-term effects of Cuidate -- a sexual risk reduction program in Mexican youth. Rev Panam Salud Publica. 2010;27(5):345-51.

Centers for Disease Control and Prevention. Best-Evidence- ¡CUÍDATE! (Take Care of Yourself). Available at:
http://www.cdc.gov/hiv/topics/research/prs/resources/factsheets/cuidate.htm

Select Media. ¡Cuidate! Available at: http://www.selectmedia.org/programs/cuidate.html

Footnotes

1 Ventura SJ, et al. Estimated Pregnancy Rates by Outcome for the United States, 1990-2004. 2008:56:15. Hyattsville, MD: National Center for Health Statistics. Available at: http://www.cdc.gov/nchs/data/nvsr/nvsr56/nvsr56_15.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.)
2 Colorado Organization on Adolescent Pregnancy, Parenting, and Prevention. The state of adolescent sexual Health in Colorado 2008. 2008.
3 Centers for Disease Control and Prevention. Youth online: comprehensive results. U.S. Department of Health and Human Services. Available at: http://apps.nccd.cdc.gov/youthonline/App/QuestionsOrLocations.aspx?CategoryId=4
4 Centers for Disease Control and Prevention. Cases of HIV infection and AIDS in the United States and dependent areas, 2006. 2008. U.S. Department of Health and Human Services. Available at: http://www.cdc.gov/hiv/surveillance/resources/reports/2006report/
5 Centers for Disease Control and Prevention. Trends in reportable sexually transmitted diseases in the United States, 2006. Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention. 2007. Available at: http://www.cdc.gov/std/stats06/pdf/Surv2006.pdf
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Original publication: January 19, 2011.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: March 26, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: March 17, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.