Educating Bahamian teenagers about HIV

drs bonita stanton & sonja lunn Educating Bahamian
teenagers about HIV

Drs Bonita Stanton and Sonja Lunn discuss a unique risk reduction and decision-making HIV
intervention project underway in the Bahamas, and talk about integrating this into education programmes

What led to the creation of the Focus on an alarming increase in persons with genital who were in the control group. We also found
Youth in the Caribbean (FOYC) programme? ulcers. A fourfold increase in HIV infections that the knowledge and skills impact endured
SL: It began when a team of vaccine was an indication that three epidemics (crack over 36 months. Indeed, we have now followed
researchers from Robert Gallo’s laboratory cocaine, genital ulcer diseases and HIV) a subset of these youths into high school and
came to the Bahamas to explore the possibility together caused the Bahamas’ numbers to we see that there is a continuing effect of FOYC.
of conducting a vaccine trial for HIV. Although increase disproportionately. We don’t have a large enough sample to be
the timing did not work out for the vaccine Testing for HIV in teenagers is, by and large, able to look at actual condom use among the
trial, the University of Maryland team carried out on girls who attend antenatal sexually active, but in terms of their condom
happened to mention the Focus on Kids (FOK) clinic. Random testing for young people use skills and knowledge, we are still seeing an
programme, a risk reduction behavioural under the age of 17 cannot be conducted effect when these kids are in grade 10.
intervention targeting adolescents. without parental consent, so there is no mass To what extent will the results of this
Investigators at the University, including testing of adolescents. As far as teenage boys programme be of benefit to Caribbean
Dr Bonita Stanton, had developed this and are concerned, they are hardly tested. HIV prevention research and the public
were evaluating it through a longitudinal, How important is it to include intensive in- health community?
randomised and controlled trial in Baltimore. service training along with a detailed script SL: As far as the public health community
Stanton’s research seemed to provide an ideal or lesson plan for teachers? is concerned, training parents as a means of
opportunity to conduct some concrete studies BS: I think that this is tremendously critical. making for healthier children and healthier
in prevention. We were fortunate to secure We found that teachers who are implementing communities is totally unique. Training
a grant for FOK researchers to come to the the programme, and doing so in the manner students in the concept of decision making
Bahamas and train a team in 1998, and that described in the teacher’s training manual, is also a very good public health concept and
was the first pilot study of FOYC. have had longer and more complete training in neither of these have been fully addressed in
Could you provide a synopsis of HIV FOYC. We also found that they are supported the Caribbean community. This programme
development in the Bahamas? To what by their school administrators and the parents is probably the first time that the comfort
extent do young people have access to in the community, as well as have a resource level, when talking about matters of a sexual
testing facilities? person that they feel they can contact if they nature, has really been raised effectively. That
SL: In the 1980s there was a crack cocaine have a problem or question. Teachers who is a very important component of teacher
epidemic and due to the position of the 700 were not adequately trained, and do not have efficiency and parental monitoring going
islands of the Bahamas in between South and perceived or real access to resources are much forward. The ongoing national implementation
North America, it was treated as trade route. less likely to continue, or are more likely to drop of a programme demonstrated to be effective
The growth in cocaine use led to an increase in some of the difficult activities that are often through a randomised controlled, longitudinal
sex for drugs and sex with drugs. Following the really critical. trial is unique. The fact that the national
crack cocaine epidemic, STI clinics documented What results did you see from the implementation effort is being studied to
longitudinal study involving schools in advise future efforts is even more unusual.
the Bahamas?
BS: The study lasted 36 months and included
15 elementary schools. We found that FOYC,
both with or without the Caribbean Informed
Parents and Children Together (CImPACT)
initiative, increased knowledge and condom
use skills and intention over the study period.
At 36 months we had enough sexually active
youths to be able to see that FOYC+CImPACT
decreased unprotected sex compared to those

74 International innovation

drs bonita stanton & sonja lunn

Engaging parents
in prevention

A US-Bahamian team is collaborating to deliver a novel HIV
education programme through schools called FOYC+CImPact.
The researchers found the programme to be effective and now
are evaluating national implementation efforts

Globally, 34 million people were living with A decade of collaboration, culminating
HIV in 2011. The World Health Organization in an effectiveness trial conducted in 15
has five key goals for addressing this government primary (elementary) schools
significant public health concern, one of with three years follow-up, demonstrated
which is to reduce sexual transmission of HIV the programme to be effective in improving
by 50 per cent by 2015. They are also working knowledge, protective behaviours, intentions
towards a substantial reduction in maternal and among those sexually active, increased
deaths from HIV. engagement in protected sex. Accordingly,
A unique programme underway in the both Ministries of Health and Education have
Bahamas is focusing on this issue by combining collaborated to implement the programme in
HIV education with youth pregnancy teaching. grade six classes throughout the Bahamas and,
Known as Focus on Youth in the Caribbean together with the researchers, are conducting
(FOYC), it delivers what is believed to be implementation research to determine
the first inclusive HIV and teen pregnancy factors associated with greater fidelity of
prevention programme. The FOYC team, led implementation.
by Dr Bonita Stanton, Schotanus Professor of
Pediatrics and Vice Dean of Research at Wayne A range of intervention tools
State University School of Medicine, has been The team has used a number of different
working on this project for more than a decade. approaches and methods to engage with
Their latest initiative has been the national young people, including interactive games,
implementation and evaluation of FOYC in storytelling, videos and a decision-making
combination with another programme called model known as SODA (Stop, Options,
Caribbean Informed Parents and Children Decision, Action). One storyline they have
Together (CImPact), a teaching video for found appealing to students is ‘The Family
parents to strengthen and promote effective Tree’, where learning decision making is
parental communication and monitoring skills. contextualised in a story about a relatable
family. The students are involved in developing
FOYC+CImPact the family, with respect to their characters and
FOYC+CImPact was adapted from ‘Focus on relationships, as the programme evolves. This
Kids’, a US programme set up in the 1990s kind of approach has proven to be particularly
which developed and evaluated an HIV effective at engaging them in the outcomes.
prevention scheme targeting teenagers in “The active involvement in the storyline which
public housing developments. Its success we promote through The Family Tree helps
prompted the Bahamian Ministries of Health the students to understand that they also
and Education to request assistance so they have choices, and the decisions they make will
could develop a similar programme for youth impact what happens to these characters,”
and this has been established for grade six observes Stanton. Dr Sonja Lunn,
children. They wanted an education scheme who is working alongside Stanton,
with its foundations firmly rooted in robust describes how the SODA model is
parent-child communication and forward also developed as the project
planning. The Principal Investigator of the progresses using different
project is the former director of the National activities, such as role play:
AIDS Program and presently sits within the “In our culture role play
Ministry of Health. Implementation has largely is one of the most
been through the Ministry of Education. effective ways for
children to really

www.researchmedia.e75 u

Intelligence The results from the national implementation of Focus
on Youth in the Caribbean and the Caribbean Informed
Fidelity and Outco mes of National Parents and Children Together programmes will be very
Implementation of FOYC+CImPact in important to the HIV prevention research and public
the Bahamas
OBJECTIVES health community in the Caribbean
The Bahamian Ministry of Health and
the Ministry of Education, Science and externalise how they have to think through Grade 6 Bahamian school girl
Technology have collaborated to implement hypothetical situations,” notes Lunn. This is
a nationwide Focus on Youth in the Caribbean supported by working closely with the parents, The researchers have also been observing
and Caribbean Informed Parents and Children including videos simulating real-life experiences teachers and recording any changes in behaviour
Together (FOYC+CImPACT) programme to where families exchange roles to look at a and teaching following involvement in the
children in grade six to improve knowledge, problem, explore the consequences of different initiative. This includes identifying how much
protective behaviours and intentions. options and then act out a chosen pathway. support they feel they are receiving and the
Recognising the importance and significance All of the different tools and approaches comfort level with teaching on these subjects.
of a national implementation effort, the FOY used by the FOYC+CImPact educators are An anonymous student survey, as part of the
research team was utilised to learn from founded on Protection Motivation Theory, a Health and Family Life Education curriculum,
and inform the implementation efforts. This behavioural model based on social cognitive allows education curriculum officers to monitor
implementation research is being conducted theory. Its underlying philosophy is to how the implementation of FOYC+CImPACT is
in three cohorts, each with two to three years understand the ways that risky behaviour progressing and to evaluate how it is making a
follow-up over five years. (unprotected sex) can negatively impact a difference to their students.
KEY COLLABORATORS teenager and then to assess protective paths
Bonita Stanton, MD, is Vice Dean for Research to mitigate this. In order for such a model to Global influence
and Professor of Pediatrics, Wayne State be successful the teenager needs to have the The results from FOYC+CImPACT will be very
University School of Medicine (WSU-M). correct information available to them, as it is important to the HIV prevention research and
Stanton has been collaborating with the essentially a benefit versus risk approach. Lunn public health community in the Caribbean.
Ministries of Health and Education in The elucidates that they need to tread carefully The group has prepared many different
Bahamas on HIV prevention for well over because there are many cultural myths to publications, including papers in peer-
a decade • M Perry Gomez, MBBS, FACP consider: “We have to constantly, carefully reviewed international scientific journals such
is Minister of Health of The Bahamas, the and gently counter these when we are as AIDS Behaviour and the International Journal
Standing Chair of the Executive Council of the pointing out different options to parents and of STD & AIDS. They have also presented at
Caribbean HIV and AIDS Regional Training children”. By the end of the intervention the conferences, including those of the American
Initiative, and a member of the Executive Board goal is that the young participants have been Public Health Association and the Pediatric
of Pan Caribbean Partnership Against HIV and presented with a full picture regarding each of Academic Societies, and met with teachers
AIDS (PANCAP). He has collaborated with the decision-making components of the model and school administrators throughout the
Stanton on adolescent risk reduction and HIV and enabled to make informed decisions on Caribbean. In addition, information about the
prevention since 2004 • Lynette Deveaux, BA their own behaviour. The researchers have programme has been included in a weekly
is the coordinator of the Focus on Youth HIV found these approaches particularly useful for radio talk show. Stanton points out that
Prevention/Research Program, Office of HIV/ communicating the key messages across to the project has global reach. For example,
AIDS in the Bahamian Ministry of Health and pre-adolescents and older adolescents. medical schools in the US are interested in
a member of the executive management team FOYC’s work with medical students in the
of the National HIV & AIDS Programme. She Parental engagement Caribbean: “In our own programme here, with
has conducted HIV prevention intervention The intention of linking the two initiatives is to both our resident and our medical students,
and implementation research in school and incorporate existing modules and trials, and to we talk about the importance of behavioural
community-based-settings for over 10 years in significantly increase parental involvement in interventions”. They are now looking forward
the Bahamas. the programme. “The current implementation to seeing how the programme evolves in
WSU-M: Xinguang Chen, MD, PhD, Professor of FOYC+CImPACT is consistent with our the coming years and continuing to support
of Pediatrics; Xiaoming Li, PhD, Professor of earlier effectiveness trial. The only exception is families to educate their children about HIV
Pediatrics and Director, Pediatric Prevention there is some variation in the way we deliver and teenage pregnancies.
Research Center; Bo Wang, PhD, Assistant parent engagement,” explains Stanton. This
Professor, Department of Pediatrics; Veronica part of the scheme has been integrated
Koci-Dinaj, MA, a doctoral student, Department through the Parent Teacher Association (PTA)
of Psychology, WSU which has assisted in increasing attendance
The Bahamas: Sonja Lunn, MBBS, a physician at the evening sessions where small groups
trained at the University of Edinburgh, is of parents have completed randomised
Associate Coordinator, FOYC, Ministry of effectiveness trials have been completed. Lunn
Health, Commonwealth of The Bahamas. believes that the value of this is in the way it
Glenda Hyacinth Rolle, MA, Senior Education promotes the important role of parents in
Officer, Ministry of Education, Science and monitoring boys: “The essential thing about
Technology, Commonwealth of The Bahamas FOYC is the concept that all children need
FUNDING monitoring, and we are successfully teaching
National Institutes of Health parents how to do this”.
CONTACT
Bonita Stanton, MD
Professor of Pediatrics and Vice Dean
of Research
Wayne State University School of Medicine
540 East Canfield Detroit, Michigan 482011241
Scott Hall, USA
T +1 313 577 9553
E [email protected]

76 International innovation