Latino Adolescent Reproductive and Sexual Health Behaviors and Outcomes: Research Informed Guidance for Agency-based Practitioners

Abstract

Latinos are the largest and fastest growing minority youth group in the United States. Currently, Latino adolescents experience higher rates of teen pregnancy compared to any other racial or ethnic group and have disproportionately high levels of sexually transmitted infections and HIV. Latino teens are also affected by a number of social problems such as school dropout, poverty, depression and limited access to healthcare, which contributes to disparities in reproductive health outcomes for this population. Relatively few intervention research studies and programs have been dedicated to reducing sexual risk among Latino youth, despite their particular vulnerabilities in experiencing negative reproductive health outcomes. We provide recommendations for identifying the unique reproductive health needs of Latino youth and specific applied strategies so that agency-based social workers and other providers can develop family-based interventions that improve adolescent Latino sexual and reproductive health.

Introduction

Epidemiological Overview

The reproductive and sexual health outcomes of Latino adolescents in the United States indicate that they are disproportionately impacted by unintended pregnancies, sexually transmitted infections (STIs) and HIV (CDC 2009a). Compared to other major racial or ethnic groups, Latino teenagers have the highest rates of pregnancy in the country (81.7/1,000) (Sabatiuk and Flores 2009; Hamilton et al. 2009). In 2007, the birth rate for Latino adolescents aged 15 to 19 years was nearly three times the rate for non-Latino adolescents (Mathews et al. 2010). Among Latina teens, 52% will become pregnant at least once before they turn 20, compared with 19% of non-Latina whites (National Campaign 2010a). While the overall teen birth rate in the United States has declined each year since 1991, with the exception of a two year increase between 2005 and 2007, the rate of decline among Latina adolescents has been significantly lower than that of other races or ethnicities (Hamilton et al. 2009; Kost et al. 2010).

Although young people aged 15 to 24 years old make up only a quarter of the sexually active population, they carry a great burden of STIs and account for almost half of all new cases each year (CDC 2009b). Rates of STIs among Latinos are notably high when compared to their white counterparts. In 2008, the rate of Chlamydia among Latinos (510.4/100,000) was nearly three times that among whites (173.6/100,000), while their Gonorrhea and Syphilis rates were more than double the rates among whites (66.8/100,000, 4.7/100,000) (CDC 2009b). Rates of STIs among Latino youth were comparably high. For 2008, the rate of Chlamydia among Latino youth aged 15 to 19 (1358/100,000) was more than double that of white youth (611/100,000), while rates of Gonorrhea and Syphilis were more than double that of whites (CDC 2009c). Latinas females were also nearly seven times more likely than Latino males to be diagnosed with Chlamydia (CDC 2009a).

HIV/AIDS also greatly impacts Latino populations. While representing only 16% of the U.S. population, Latinos account for 18% of people living with HIV and an estimated 17% of new infections each year (CDC 2010). The AIDS case rate per 100,000 Latino adults and adolescents in the U.S. was the third highest among all ethnic and racial groups in 2007, approximately three times that of whites, but one-third that of blacks (CDC 2008). In particular, Latino adolescents aged 13 to 19 accounted for 19% of HIV cases in 2006, which is disproportionately high considering that they represented only 17% of the U.S. teen population that year (CDC 2006).

Many Latino teens engage in sexual behaviors that place them at increased risk for unintended pregnancies, STIs and HIV infection. For example, nearly half of Latino high school students report having had sexual intercourse and the vast majority (86%) report not using birth control pills to prevent pregnancy during last sexual intercourse (CDC 2009b). Latino youth are also less likely to use a condom during last sexual intercourse—45% of sexually active Latino students did not use a condom compared to 36.7% of white students and 37.6% of black students (CDC 2009b). Of additional concern is that Latina teens are more likely than their non-Latina peers to have a partner who is significantly older, a factor that places them at greater risk for early sexual debut and coercive sexual relationships, which in turn can facilitate greater exposure to HIV and other sexually transmitted diseases (Sabatiuk and Flores 2009).

As seen in the available sexual and reproductive health data, Latino adolescents are at a particularly high risk for unintended pregnancies, STIs, and HIV infection, and have considerable unmet health service needs. In light of this, agency-based social work practitioners should focus their efforts on targeting the reproductive and sexual health needs of Latino adolescents.

Ecological Context

Ecological perspectives to understanding social problems are a basic tenet of social work practice (Kemp et al. 1997; Meyer 1983; Ungar 2002; Sands 2001). While our focus is on Latino teen sexual and reproductive behaviors and outcomes, social work requires a contextual approach to understanding the problem of Latino teen pregnancy, STIs and HIV and it would be remiss to not consider the broader context of the health and well-being of Latino youth in the United States. Latino teen sexual behavior and reproductive health outcomes are related to a number of social problems which are areas of direct social work practice for many agency-based practitioners. These problems include issues of school dropout, poverty and depression, and are of particular concern for Latino adolescents (Umaña-Taylor 2009). In subsequent sections, we describe each of these three primary areas and relate these issues to Latino sexual and reproductive health outcomes.

School Dropout and Latino Teen Sexual Behavior

Among youth aged 16 to 24, Latinos have the highest dropout rates of any ethnic or racial group, accounting for 41% of all high school dropouts in 2008, despite the fact that they comprise only 18% of the young adult population (U.S. Census Bureau 2008). At 18.3%, the Latino youth dropout rate is markedly higher than that of whites (4.8%) or blacks (10.2%) (U.S. Census Bureau 2008). A contributing factor to these high dropout rates among Latinas is teen pregnancy. Over one-third (36%) of Latina teen mothers who drop out of high school between their sophomore and senior year cite pregnancy or motherhood as the primary reason for doing so (National Campaign 2010a).

Poverty and Latino Teen Sexual Behavior

The relationship between poverty and Latino teen sexual behavior is a complex one. Poverty has been linked with higher rates of teen pregnancy, and the poorest women in the United States are the most likely to experience unintended pregnancy (Finer and Henshaw 2006). Teen pregnancy often interrupts a teen’s educational and career trajectory, which in turn can set the stage for reduced earnings and a higher likelihood of raising a child in poverty (National Campaign 2010b). As many jobs require a high school-level education, young adults with lower levels of education are less likely to have well-paying jobs and more likely to be of lower socio-economic status (Moore et al. 2002). Young Latina mothers are particularly disadvantaged by being more likely to have a low income level and low levels of educational attainment (Dickson 2004). Latino adolescents are also more likely to grow up in a family of low socio-economic status and are more likely to become poor themselves, compared to non-Latino white adolescents (Cellini et al. 2008). Furthermore, Latino youth are placed at greater health risks because they tend to reside in geographic areas with elevated rates of HIV and STIs. Independent of their individual sexual behaviors, Latino youth are negatively impacted by the fact that their neighborhoods are geographic areas of concentrated health risks, relative to youth who do not live in such areas (Steel et al. 2007).

Depression and Latino Teen Sexual Behavior

Latino adolescents report higher levels of depression compared with youths of other ethnic and racial backgrounds (Céspedes and Huey 2008). Among teens in general, being sexually active and teen pregnancy are factors that have been associated with increased odds of depression (Hallfors et al. 2004; Woodward et al. 2001). Studies have also linked depressive symptoms in adolescence to sexual risk-taking behaviors, such as non-use of contraception (Brooks et al. 2002). A study of middle school Latino youth in New York City found that reduced levels of self esteem were associated with greater behavioral intent to engage in sexual intercourse and other risk behaviors (Guilamo-Ramos 2009). Latinos are also less likely to receive care for depression and even less likely to receive quality care for depression compared with other racial and ethnic groups (Schoenbaum et al. 2004). High rates of depression coupled with elevated rates of sexual activity among Latinos suggest that these youth face increased sexual and reproductive health risks.

Access to Health Care

Despite a considerable need, Latinos face a host of challenges in receiving both general medical and mental health care. Latinos are less likely to receive any care for depression and are more likely to receive a lower quality of care compared to whites (Lagomasino et al. 2005). Furthermore, Latinos have the lowest percentage of health insurance coverage compared to all other racial or ethnic groups, which presents a significant barrier to receiving health care services (DeNavas-Walt et al. 2010). Even if Latinos are able to access these services, they often contend with providers who are unable to communicate in Spanish or agencies unable to provide an on-site translator, which can also negatively impact the quality of received care (Dailard 2001). In order to address these barriers, agency providers should strive to recruit and retain social workers that are bilingual and bi-cultural. Schools of social work are encouraged to increase their outreach efforts with Latino students for careers in social work in addition to training non-Latino social work students to deliver health and mental health services to Latinos.

Role of Agency Providers

Despite high risk for unintended pregnancies, STIs and HIV, Latino adolescents are underrepresented in current evidence-based intervention programs. For example, in a recent call for applications to replicate 28 rigorously proven evidence-based programs to reduce teenage pregnancy by the U.S. Department of Health and Human Services, Latino adolescents were included in the studies of only about half of the proposed programs and represented less than one-fifth of all participants in the studies (Zayas and Witt 2010). In reviewing the literature, we identified only ten intervention studies from 1999 to 2010 with sexual behavior outcomes that had sizable proportions of at least 25% Latino adolescents (Harper et al. 2009; Jemmott et al. 2005; Kennedy et al. 2000; Kirby et al. 2004; Lesser et al. 2009; Mouttapa et al. 2010; Prado et al. 2007; Roye et al. 2007; Villarruel et al. 2006; Guilamo-Ramos et al. 2011). Among these studies, seven directly targeted Latinos or implemented interventions tailored for Latinos (Harper et al. 2009; Lesser et al. 2009; Jemmott et al. 2005; Prado et al. 2007; Roye et al. 2007; Villarruel et al. 2006; Guilamo-Ramos et al. 2011). Therefore, while Latino adolescents are the largest minority youth group in the United States, a disproportionately small number of research studies and programs have been dedicated to address their sexual and reproductive health needs.

In order to address the unmet sexual and reproductive health needs of Latino adolescents, they must be adequately represented in program evaluation research to ensure that programs are developed and implemented in a culturally appropriate manner, and informed by strong research in order to increase the likelihood that the intervention will produce behavioral outcomes. Direct practice social workers often strive to demonstrate that the services they provide are effective at impacting the issues they address and the populations they serve. However, evidence–based practice requires that social workers incorporate additional levels of empirical support for evaluating the impact of their efforts. Agencies currently providing sexual and reproductive health support to Latino adolescent populations can accomplish this by evaluating the results of their programs. If they are unable to do so, due to financial or other resource constraints, agency providers should consider linking with research universities in order to determine the efficacy of how the program is meeting the specific needs of Latino youth. Many schools of social work provide opportunities for agencies to link with faculty who have the research expertise and knowledge of agency practice to support agency-based evaluation efforts.

Inadequate representation of Latino youth in sexual and reproductive health intervention research presents a challenge for agency-based practitioners because few evidence-based programs exist that specifically address Latino youth. In light of this, we provide a useful example for direct practice social workers on how to use existing research for designing effective interventions for preventing negative sexual and reproductive health outcomes for Latino youth. Research with Latino families has identified three critical factors related to preventing unintended pregnancies, STIs and HIV: parent-adolescent communication, parent-adolescent relationship quality and parental monitoring and supervision. We briefly review each of these factors and provide two case studies based on Latino families to demonstrate how empirical research can inform the development of family-based interventions for social work and other direct service practitioners.

Parent-adolescent communication

The quality and effectiveness of parent-adolescent communication has been associated with a range of sexual and reproductive health outcomes and behaviors. Most research suggests that Latino parents are less likely to talk to their children about sexual topics, and when they do, discussions are often initiated after sexual activity has begun (Hutchinson 2002; Kaiser Family Foundation 2006; Zambrana et al. 2004). Other studies have shown that while Latino parents often have more difficulty talking about topics such as contraception and birth control (Raffaelli and Ontai 2001; Raffaelli and Green 2003), they do discuss certain sexual topics with their children such as abstinence and the negative consequences of sex (Guilamo-Ramos et al. 2006, 2007). However, as shown in longitudinal studies, parental communication about contraception was associated with less sexual risk taking with Latino adolescents (Hutchinson et al. 2003). A number of studies have also noted that greater levels of perceived parental openness, responsiveness, comfort and confidence in discussions about sexual topics were associated with lover levels of adolescent sexual risk behavior (Dutra et al. 1999; Guilamo-Ramos et al. 2006; Halpern-Felsher et al. 2004), suggesting that adolescents’ perceptions of the quality of communication may influence the effectiveness of parental messages about sex. Latino youth who perceive their parents as being willing to talk about how they dealt with challenging issues when they were teens reported less willingness to engage in sexual intercourse (Guilamo-Ramos and Bouris 2008). The frequency of communication between parents and children can also play an important role in reducing sexual risk. For Latino youth, studies have shown that the more often parents talk about sexuality-related topics, the more likely it is that adolescents will share similar views with their parents on those topics, suggesting that adolescents do listen to their parents and that greater frequency of communication impacts their sexual decision making (Guilamo-Ramos et al. 2007). Practitioners can help Latino parents to reduce the barriers to communication and improve parent communication skills so that they can deliver effective messages that can help reduce their child’s risk experiencing negative sexual and reproductive health outcomes.

Case Study 1: The Role of Parent-Adolescent Communication

Anthony is a 16 year old boy who has been dating his girlfriend, Elizabeth, also 16, for the past four months. Anthony describes his relationship with Elizabeth as “casual” and not too serious. Although Anthony is very curious about sex, he knows that there are many risks. Since Anthony started puberty, his father has made it a point to regularly talk to him about sex and encourages him to ask questions, despite his embarrassment. Although Anthony’s father fears that talking about sex will encourage sexual activity, Anthony’s father also understands that it is important for his son to know about the risks of having sex at this point in his life, such as getting a girl pregnant, STIs and HIV/AIDS. Despite these conversations, Anthony feels that having sex with Elizabeth might help him to feel more grown up or mature. Anthony envisions sex making Elizabeth and him closer and helping to advance their relationship from casual to more serious. Anthony knows that condoms are an effective option for reducing his chances of getting a girl pregnant and/or acquiring HIV or another STI. Anthony wonders if he might enjoy the sex and if will “feel good”. However, Anthony’s father regularly encourages him to focus on school and not date too seriously. In addition, his father reinforces his strong disapproval of Anthony having sex at this time because he is too young. He also addresses the social influences related to sex that are a part of Anthony’s world and lets him know that there are other ways to be grown up and mature outside of having sex. Anthony’s father makes an effort to spend time with his son whenever he can and to emphasize support and respect between the two of them. Anthony trusts his father’s advice and looks up to him and recognizes that he is too young to have sex at this time in his life.

As demonstrated in the case of Anthony, practitioners can motivate parents to talk to their teens about sex by reviewing the health consequences of adolescent sexual behavior and emphasizing that parent-adolescent communication actually decreases sexual risk behavior, as opposed to increasing it. Practitioners can also help parents overcome embarrassment, anxiety or other barriers by normalizing their feelings and role-playing conversations. Additionally, a strong parent-adolescent relationship can improve the effectiveness of parental messages. The communication between Anthony and his father is strengthened by the high levels of trust, support and respect in the relationship. Anthony is told to prioritize school and his future career aspirations, alongside the risks of being sexually active. Anthony is also aware that his father disapproves of him having sex at this time in his life and that he is expected to wait until he is older. By establishing a strong father-son relationship, his father can effectively convey his attitudes and values, which his son internalizes. Practitioners can also support parents by encouraging them to acknowledge the social reasons that teens have sex. Anthony’s father delivers a more impactful message by teaching his son that there are other ways to mature and grow up besides having sex, such as finishing school and focusing on career aspirations.

Parental monitoring and supervision

Parental monitoring and supervision are also factors that have been shown to reduce the risk of teen pregnancy and STDs (Cotton et al. 2004; Rai et al. 2003; Rodgers 1999). Parental monitoring has traditionally been defined as the acquisition of knowledge about the activities, whereabouts and companions of one’s child (Brown et al. 1993, Dishion et al. 1991; Pettit et al. 2001). In defining monitoring some researchers emphasize the parental monitoring behaviors that lead them to acquire information about their child, while others emphasize the actual knowledge levels parents have about their child’s activities, whereabouts and companions (Dishion and McMahon 1998). A more applied perspective involves conceptualizing parental monitoring as having three basic components: (a) parental communication of expectations, in which expectations about appropriate behavior are conveyed; (b) parental monitoring, in which parents determine if those expectations are being adhered; and (c) parental discipline and/or inducement, whereby parents discipline the transgression of those expectations and try to induce or gain their cooperation with those expectations. This three-process model serves as a foundation for developing interventions and enables practitioners to provide parents with the tools that reduce the likelihood of adolescent sexual risk behavior (Guilamo-Ramos, Jaccard, Bouris and Dittus 2010).

Among Latino adolescents, a number of studies have found that higher levels of parental monitoring were associated with higher rates of abstinence and delayed sexual onset (Velez-Pastrana et al. 2005) and lower levels of risky sexual behavior (Borawski et al. 2003; Kerr et al. 2003). While parental monitoring has been shown to protect against teen pregnancy and STDs, the ways in which parents acquire knowledge about their teen is also important. Romo et al. (2004) found that teens may perceive parental questions about their friends and personal experiences as intrusive and may respond in a hostile manner. Furthermore, while parental monitoring might be protective, the restrictions often placed on girls in Latino families may result in secrecy about dating and tension between parents and adolescents (Raffaelli and Ontai 2001). Practitioners can advise parents with effective strategies in the three-process model to monitor and supervise their adolescent more effectively.

Case Study 2: The Role of Parental Monitoring and Supervision

A 15 year old girl named Maria lives in a low-income urban neighborhood in New York City. She is in a serious romantic relationship with her boyfriend, Victor, who is nineteen. Her mother disapproves but does not enforce any rules to prevent them from spending time together. They spend a lot of time at Maria’s house because her mother works long hours and is hardly home. Maria’s mother does not keep track of who her daughter invites over or her afterschool activities because she believes that Maria is old enough to take care of herself. However, Maria is considering having sex with Victor because she thinks that she is ready. After she decides that she feels very close to Victor and trusts that he would never let anything bad happen to her, Maria decides to have sex with him.

As seen in the case of Maria, being involved in a romantic relationship and having an older partner are strong predictors for sexual activity in Latino youth. Practitioners should inform parents of these indicators to alert them to signs that their child is more likely to become sexually active if they are in a relationship, particularly with someone older. Practitioners should also emphasize that the risk of adolescents becoming sexually active increases if they are unsupervised, as Maria and Victor often are. A practitioner could advise Maria’s mother with the three-step model to a) convey her expectation that Maria not engage in sexual activity at this time in her life, (b) monitor compliance with that expectation by keeping track of what Maria does and who she spends time with, and (c) encourage Maria to comply with that expectation through discipline and inducement/cooperation strategies. Maria’s mother could be further guided with effective monitoring and supervision strategies such as knowing about Maria’s friends, her whereabouts and activities and learning how to ask questions in ways that are likely to elicit positive responses. In addition, a social work practitioner should highlight the importance of maintaining high levels of parental monitoring and supervision as their teen matures, since sexual behavior is likely to increase as adolescents get older.

Quality of Parent-Adolescent Relationship

Both parent-adolescent communication and parental monitoring and supervision occur within a broader context of family life. Specifically, communication and monitoring are more effective when adolescents report satisfaction with the overall quality of the parent-adolescent relationship. Evidence suggests that parent-adolescent relationships based on mutual warmth, closeness and trust, are one of the strongest factors protecting youth from early sexual activity and pregnancy (Heinrich et al. 2006; Resnick et al. 1997). Among Latinos, adolescents who reported feeling close to their parents were found to be less likely to initiate sex at an early age (Miller et al. 1998) and more likely to use contraception consistently and carefully (Velez-Pasterna et al. 2005). A number of studies have also noted high levels of warmth and connectedness between Latino parents and adolescents (Guilamo-Ramos et al. 2007a), pointing to Latino cultural values of familismo (Sue and Sue 2003; Cauce and Domenech-Rodriguez 2002) and simpatia, which speaks to the value of keeping relationships between people in the family smooth and flowing (Triandis et al. 1984). Important qualities that have been identified as characterizing a good parent adolescent relationship that are useful for practitioners include respect for one another, understanding each other’s feelings, being able to trust each other, having concern for each other’s well-being and knowing each other (e.g. what each other is like, what each other wants and what each other likes and dislikes) (Guilamo-Ramos and Bouris 2008).

Applied Research and Theory for Parent-Based Interventions

The research on Latino families for agency-based practitioners can be used toward the design and implementation of family-based interventions. Three core issues that are important for developing effective parental monitoring interventions are 1) the importance of using a strong theory; 2) the importance of developing an intervention that can be easily integrated into the lives of families; and 3) the importance of targeting specific parenting behaviors, rather than more global parenting style. We will highlight each core issue and suggest useful strategies for agency-based practitioners to develop family-based interventions that target the prevention or reduction of adolescent risk behaviors. To do this, we examine parental monitoring and draw upon our own research, the Families Talking Together (FTT) program, a brief, parent-based sexual risk reduction intervention developed for Latino and African American youth in New York City (Guilamo-Ramos et al. 2011). FTT was developed by a multidisciplinary team of researchers and practitioners and headed by an experienced social worker. The research found that transitions to sexual intercourse were significantly lowered as a result of the intervention. Specifically, sexual activity increased from 6% to 22% for young adults in the “standard of care” control condition, while it remained at 6% among young adults in the intervention condition at the nine-month follow-up.

In developing an effective parent-based monitoring intervention, the first core issue is that the intervention should be based upon strong theories of parental monitoring that reflect existing knowledge in the research literature. Theory helps to define and measure parental monitoring, to make and test hypotheses about the relationship between parental monitoring and adolescent risk behaviors, and to identify mechanisms to strengthen parental monitoring efforts. Our own intervention draws upon five major theories of human behavior that have been well established in the scientific literature. These theories include: 1) Social Learning Theory (Bandura 1975, 1986), (2) the Theory of Reasoned Action (Ajzen and Fishbein, 1981; Fishbein and Ajzen 1975), (3) Self-Regulation Theories (Kanfer 1975), (4) the Theory of Subjective Culture (Triandis 1972), and (5) various versions of the Health Belief Model (Janz and Becker 1984; Rosenstock, Strecher, and Becker 1988). These theories inform the integrated model commonly referred to as the Unified Theory of Behavior (UTB), which was developed through the National Institute of Mental Health through a consensus scientific meeting of top health behavior scholars and is well-established as a framework for predicting health behaviors predicting specific risk and problem behaviors (Guilamo-Ramos et. al 2008a). Additionally, the design of our intervention’s communication enhancing techniques relied on extensive research to determine specific problem areas in parent-adolescent communication about sexual intercourse (Guilamo-Ramos et al. 2008b). Based on current research, practitioners need to view parental monitoring as a dynamic and multifaceted parenting strategy that has cultural dimensions, is embedded in a dynamic parent-adolescent relationship and extends beyond parental knowledge to encompass other parental behaviors and adolescent behaviors that lead them to acquire information about their child.

The second core issue is that the intervention should be feasible and acceptable for the everyday lives of families. Many parent-based interventions require parents to attend multiple sessions over an extended period of time. From a research perspective, there are advantages to this approach because multiple sessions provide the opportunity to reinforce content with parents and provide them with opportunities to practice the skills. However, given the busy schedule of most parents, they often do not have time to attend multiple sessions. Limited research has investigated parents’ preferences regarding intervention design and delivery, which suggests that many parent-based interventions have been designed in ways that do not encourage parent participation. Parents therefore need interventions designed in ways that respond to the behaviors and opportunities that are part of a parent’s everyday life, are feasible for them to attend and encourage high levels of participation and retention. From a design standpoint, this can be done by limiting the number of sessions that parents are required to attend and using alternative mechanisms for delivering intervention content, such as the use of written and visual materials that parents can reference at home. Another strategy is to consider delivering interventions in settings and times when parents accompany their child to required appointments, such as at health clinics during physical exams that are required for the school registration process. More generally, practitioners need to think critically about the context (e.g. peer context, school context, family context, neighborhood context) as potential sources of outreach to parents for purposes of administering an intervention in order to identify effective strategies for reaching parents.

The third core issue is that the intervention should target specific parental monitoring behaviors connected with adolescent risk behavior, rather than more global parenting style. Parenting style refers to different parenting behaviors that reflect the values, beliefs and cultural norms of parents. In contrast, parenting behaviors are discrete strategies that a parent invokes to influence their child. In designing interventions, this distinction is important as parenting behaviors are likely to be easier to change than more broad parenting styles. Furthermore, changing parenting style requires more intensive efforts that are outside the real world context of many agency based social workers. Increasingly, social work agencies are asked to demonstrate effectiveness with intervention strategies that are brief in nature.

In developing a parent-based monitoring intervention, it is important to integrate these core issues in order to ensure the program’s efficiency and effectiveness. We present an adaptation of an intervention, Families Talking Together (FTT), to demonstrate how to design a parent-based intervention, with a focus on parental monitoring, a small component of the larger intervention.

Structure of the program

An important consideration for designing an intervention is that it is structured in a way that is both practical and sustainable. With FTT, our intent was to design an a cost-effective intervention that would reach a large number of families in our targeted population, Latino and African American middle school-aged adolescents and their mothers residing in inner city, resource-poor communities in New York City. The first step we took was to conduct research with a representative sample of the target population to determine parent preferences for the delivery of the program. Based on this research, we determined that parents would have difficulties attending multiple, face-to-face sessions. Consequently, the FTT intervention was designed to have only one face-to-face session, which provided parents with an opportunity to review the intervention materials and practice the skills and activities they were being asked to implement with their adolescent child. After the face-to-face session, booster calls were used to keep the intervention materials relevant to parents. Our research also suggested that it was important to recruit families from well-known institutions. Consequently, we developed a novel outreach approach, compared with existing parent-based interventions, by having a trained social worker deliver the intervention in a primary healthcare clinic to parents when adolescents visited their physician for a routine physical exam. This helped ensure that families could access the program at a convenient time and location.

Maximizing parental participation

Many parent-based interventions consist of multiple sessions and tend to be plagued with dropouts and failure to complete all sessions. In developing the FTT program, we sought to have only one session. When designing interventions, it is important to consider ways to maximize participation in the initial sessions and address ways to encourage return to future sessions. Parent participation can be viewed as a hierarchy of strategies involving three components: 1) the recruitment component, 2) the participation component, and 3) the application component. The first component focuses on initial recruitment into the program and overcoming potential barriers to participation such as the use of limited or inflexible recruitment strategies, parent’s schedule conflicts, and the use of overly general and decontextualized protocols. To address these barriers, a recruitment protocol should be developed that is flexible for the needs of diverse families, contextualized for the target population, designed to address common barriers and is low-cost and easy to implement with minimal resources. To address the participation component, the intervention needs to be flexible and meet the needs of families. This can be accomplished through flexible scheduling of sessions and the provision of child care services. The third component focuses on parents applying what was learned during the intervention to their family after completing the intervention. Application of the intervention materials is reflective of how useful parents found the material covered in the sessions. This component can include structuring interactions between program staff and parents to determine how useful parents found the intervention materials. This is also an opportunity for project staff to ascertain any obstacles implementing and applying the learned material.

Structure and content of the sessions

The content development for intervention materials and face-to-face sessions needs to be directly informed by research and have a strong theoretical framework. The parental monitoring framework was designed to ensure parents clearly convey their behavioral expectations to their children, to teach parents strategies to monitor their children and ensure children adhere to those expectations, and to teach parents effective disciple strategies when their child transgresses so as to minimize future transgressions. With FTT, facilitators were trained on key theoretical points and explained the importance of parental monitoring to parents in an evidence-based, straightforward manner. During the face-to-face session, facilitators would discuss the importance of setting clear behavioral expectations, explaining the purpose of behavioral rules and the importance of using appropriate consequences with adolescents when they transgressed parent rules. These messages were then highlighted in the written materials provided to parents and adolescents (see Figure 1 in the Appendix). Written materials consisted of a “manual” that taught parents effective communication and parenting strategies for reducing adolescent sexual risk behavior, and addressed topics such as adolescent development and self-esteem, parental self-efficacy to communicate, general parenting strategies associated with reduced sexual risk-taking, ways to improve the parent-adolescent relationship and communication, adolescent assertiveness skills and techniques for dealing with peer pressure, adolescent sexual behavior, the health consequences associated with adolescent sexual risk taking, and birth control and protection. Parents were given two communication aids that they could use to engage their adolescents. The first aid was a short booklet that the parent gave to the adolescent and used it as a basis for discussion. The booklet addressed key issues identified in our previous research as relevant for preventing sexual intercourse in adolescents (Guilamo-Ramos et al. 2008a; Guilamo-Ramos et al. 2007b). The second communication aid was a short story that parents could ask their adolescent to read to start a conversation. The story describes four adolescents who make different decisions about having sex and the consequences of those decisions. The 30-minute intervention was primarily devoted to how to effectively use these materials and how to structure conversations so as to affect factors that parents rarely address but have been found to be important by our research (Guilamo-Ramos et al. 2008a; Guilamo-Ramos et al. 2007b).

Fig. 1.

Reference materials given to parents in the Families Talking Together (FTT) intervention.

Boosters

In designing interventions, booster sessions can be an important way to monitor progress, address problems associated with the implementation of program principles and activities and can serve as a call to action to keep the intervention messages relevant to parents. In FTT, boosters consisted of a brief phone call to parents designed to reinforce the intervention content, support the likelihood that families would complete activities and offer support to parents as they sought to monitor their adolescent. During the booster calls, mothers were asked whether they had completed their homework assignments given to them during the intervention phase and whether there were any parts of the intervention materials that they needed clarification on or help with. The booster calls were short and simple and primarily encouraged the mothers to complete the assigned activities and kept the intervention salient. While such an approach may not be feasible in many agency-based settings, it is important to consider strategies to support parents in monitoring their children in ways that are likely to minimize risk behaviors.

Applied Recommendations and Resources

In order to provide social work practitioners with specific strategies, Table 1 (see Appendix) outlines familial processes and specific recommendations to reduce adolescent sexual risk behavior. Table 1 relies on empirical research related to each of the three dimensions of family life and specific strategies for enhancing social work practitioner efficacy are identified in the final column. In addition, the National Campaign to Prevent Teen and Unplanned Pregnancy provides access to current research and evidence-based resources for agencies that specifically work with Latino families. For example, the Campaign developed a guide for practitioners working with Latino families to help facilitate parent-adolescent communication about sex. This guide is available free of charge and can be accessed at (http://www.thenationalcampaign.org/resources/pdf/pubs/ParentAdolFINAL.pdf) (Guilamo-Ramos and Bouris, 2008). In addition, the Campaign also hosts the Latino Initiative (http://www.thenationalcampaign.org/espanol/default_eng.aspx) which addresses the sexual and reproductive health needs of Latino youth nationally and can be applied to agency-based social work programs and service delivery. Social workers interested in applied resources for facilitating parental monitoring strategies can refer to the recently edited volume, Parental Monitoring of Adolescents Current Perspectives for Researchers and Practitioners (Guilamo-Ramos et al. 2010), which evaluates the nature and approach of monitoring within the parent-adolescent relationship. The Center for Disease and Prevention Control (CDC) provides a useful and informative fact sheet based on the previously mentioned edited volume on parental monitoring (http://www.cdc.gov/HealthyYouth/adolescenthealth/pdf/parental_monitoring_factsheet.pdf ) and outlines applied parental strategies for improving monitoring of their teen’s activities.

Table 1.

Practitioner strategies for the prevention of adolescent sexual risk behavior.

Familial Process	Clinical Issue	Applied Recommendation
Parent-adolescent communication about sex	Latino parents fear that parent-adolescent communication about sex will encourage sexual behavior. Latino parents report lower levels of communication with their adolescent children about sex. Latino families often initiate conversations about sex and adolescent reproductive health after sexual activity has begun. Latino parents tend to focus exclusively on negative outcomes of adolescent sexual behavior versus teen social reasons for having sex. Latino families report singular, episodic discussions about adolescent sex vs. frequent, ongoing conversations. Clarity regarding Latino parental values and beliefs decreases adolescent sexual risk behavior. Context and style of parental communication matters. Latino parents can feel unprepared or anxious discussing sex with their adolescent children.	Practitioners should emphasize that parent-adolescent communication decreases sexual risk behavior, as opposed to increasing it. Practitioners can motivate Latino parents to talk about sex by reviewing the health consequences of Latino adolescent sexual behavior. Practitioners should let Latino parents know that sexual behavior tends to begin in early adolescence for many Latino teens and therefore talking early is necessary. Practitioners can remind parents to address the social influences and expectations associated with sex and not just the health consequences. Practitioners can highlight that greater frequency of communication impacts their teen’s sexual decision making and helps to convey important parental messages to teens. Practitioners should convey the importance of Latino parents actively transmitting strong messages of disapproval of sexual behavior during early adolescence. Practitioners can help Latino parents identify teachable moments/ideal opportunities and help parents to remain calm and interested in their teen’s life. Practitioners can help parents prepare by role-playing, emphasizing clear messages and acknowledging that embarrassment is normal for both parents and teens.
Monitoring & Supervision	Latino parents need adequate levels of knowledge regarding their teen’s actions, whereabouts and companions. Latino parents must convey clear expectations of developmentally appropriate behaviors. Effective monitoring requires that Latino parents convey clear guidelines of expectations and consequences to their teen children. Latino parents should foster teen independence without reducing monitoring and supervision when it is developmentally most needed and risk behaviors are most likely to initiate. Many Latino teens are in age discrepant relationships, where one of the adolescents is two or more years older than the other. The likelihood of sexual risk behavior increases if adolescent teens spend unsupervised time with older teens while no adult is in the home. Once sexual behavior has clearly begun, Latino teens need help using correct and consistent contraception.	Practitioners can convey the importance of parents eliciting information about their teen’s friends, whereabouts and activities in ways that foster open communication and allow parents to better supervise their adolescent child. Practitioners can support parents in expressing clear approval/disapproval messages to their teen child about unacceptable behavior. Practitioners can support parents in setting guidelines and delivering the consequences resulting from their teen’s noncompliance to agreed upon behavioral expectations. Practitioners should emphasize the importance of Latino parents monitoring and supervising their teen as they get older, since the likelihood of sexual activity increases and parents tend to lower monitoring efforts during adolescence. Practitioners should discourage Latino parents from permitting serious romantic relationships in early adolescence, particularly when one of the partners is two or more years older. Practitioners should emphasize the importance of Latino parents discouraging unsupervised time with no adults and to foster open communication about their teen’s whereabouts and activities. Practitioners should convey the importance of Latino parents endorsing correct and consistent contraceptive use if their teen is clearly engaging in sexual behavior.
Relationship Quality	Latino parents can strengthen the effect of communication and monitoring through a strong parent-adolescent relationship. Having high levels of parent-adolescent relationship satisfaction improves Latino teen outcomes.	Practitioners should encourage Latino parents to spend time with their teens, to not avoid conflict and to emphasize mutual goals of importance to both teens and their parents. Practitioners can highlight the characteristics of a good parent-adolescent relationship, which include mutual respect, recognition of the other’s feelings and commitment to genuinely knowing one another.

Conclusion

In summary, Latino adolescents living in the United States are disproportionately affected by a number of social and economic disadvantages which contribute to disparities in sexual and reproductive health outcomes for this population. Specifically, Latino adolescents experience higher rates of teen pregnancy compared to any other racial or ethnic group and experience high rates of STIs and HIV. In light of these negative health outcomes and limited evidence-based interventions, it is important that social workers draw upon current epidemiological data and research to develop targeted services and develop intervention content that addresses the needs of Latino adolescents. In designing family-based interventions, social workers need to think critically about ways to maximize opportunities to intervene with Latino parents by tailoring interventions around the real world contexts of their daily lives and deliver interventions in ways that do not make unrealistic demands on the family. Furthermore, Latino adolescents need to be better represented in program evaluation research to ensure that programs are developed in a meaningful and culturally appropriate manner that takes into account factors such as the central role of the family for Latino populations. To assist with program evaluation, agency-based social workers should consider partnering with research universities and schools of social work to determine program efficacy in meeting the needs of Latino youth and to provide feedback regarding the skills and core competencies that are most needed for training future generations of social workers. In conclusion, agency-based social work practitioners best serve the sexual and reproductive health needs of Latino youths and increase the likelihood of reducing negative sexual risk behavior outcomes through the use of applied intervention strategies that rely on strong empirical research.

Biography

Vincent Guilamo-Ramos is a professor at NYU’s Silver School of Social Work. He has expertise in the role of families in promoting adolescent health, with a special focus on preventing HIV/AIDS, STIs, and unintended pregnancies. Additional research interests include parent-adolescent communication, intervention research, HIV prevention, and alcohol and drug use.