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. Author manuscript; available in PMC: 2023 Feb 1.
Published in final edited form as: Psychol Serv. 2021 Jan 7;19(1):167–175. doi: 10.1037/ser0000498

Motivational interviewing to reduce risky sexual behaviors among at-risk male youth: A randomized controlled pilot study

Shayna S Bassett e, Daniel J Delaney a, Amy M Moore b, Mary Clair-Michaud c, Jennifer G Clarke d, LAR Stein a,c,d
PMCID: PMC9069535  NIHMSID: NIHMS1738292  PMID: 33411550

Abstract

Background:

Despite male youth taking more sexual risks that lead to unwanted partner pregnancy and/or sexually transmitted infections, research evaluating interventions for risky sex has focused almost exclusively on adolescent and adult females. With sexually transmitted infections among male youth on the rise, behavioral interventions that target risky sex among male youth are needed.

Purpose:

A randomized controlled pilot study was conducted to examine the feasibility and acceptability of two manualized behavioral interventions for sexually active male youth.

Methods:

Sexually active at-risk male youth (N = 27) were recruited and randomized to receive one session of motivational interviewing (MI) or didactic educational counseling (DEC). Assessment interviews were conducted prior to and 3-months following the intervention session.

Results:

Support for the feasibility and acceptability of delivering behavioral interventions to reduce risky sexual behaviors among at-risk male youth was found. Compared to participants in DEC at follow-up, participants in MI reported having significantly fewer sexual encounters with casual partners, used substances at the time of sex significantly less often with all partners and casual partners, and reported fewer incidents of using substances at the time of sex without a condom with all partners. Conversely, participants who received MI used substances at the time of sex with main partners and used substances at the time of sex without a condom more often with main partners at follow-up compared to participants who received DEC.

Conclusions:

Results of the pilot study support conducting a larger randomized controlled trial to examine treatment effects.

Keywords: Youth, risky sex, risky behaviors, motivational interviewing, sexual health

Introduction

Risky sexual behavior (e.g., casual sexual encounters, having multiple sexual partners, sex without a condom, combining substance use and sex; Ashenhurst, Wilhite, Harden, & Fromme, 2017) among male youth is a growing public health concern. Youth 15–24 years old account for approximately 50% of all new sexually transmitted infections (STIs; Centers for Disease Control and Prevention [CDC], 2017). Although the rates of STIs among female youth decreased slightly from 2012–2016, the prevalence of STIs among male youth increased by as much as 14–30% within the same time period (CDC, 2017). Not only are STIs unwanted, but they are also a sign that youth may putting themselves at risk for unplanned pregnancy. Adolescent and young adult males that are socially disadvantaged (e.g., justice-involved, of low socioeconomic status, racial/ethnic minority) are at greater risk for STIs and unplanned partner pregnancy (Belenko, Dembo, Rollie, Childs, & Salvatore, 2009; Buffardi, Thomas, Holmes, & Manhart, 2008; CDC, 2017; Fenton, 2001; Pantin, Schwartz, Sullivan, Prado, & Szapocznik, 2004). Racial/ethnic disparities exist in teen pregnancy rates, with Black and Hispanic youth having twice the teen pregnancy rate as nonHispanic White youth (Kost, Maddow-Zimet, & Arpaia, 2017). Additionally, substance use and psychiatric disorders (e.g., posttraumatic stress disorder [PTSD], depressive disorders) are often associated with risky sexual behaviors among youth (Ramrahka, Caspi, Dickson, Moffitt, & Paul, 2000; Turner, Latkin, Sonenstein, & Tandon, 2011) with youth from socially disadvantaged backgrounds reporting higher rates of PTSD and depression (Kessler et al., 2012; SAMHSA, 2017). Disparities in social determinants of health (e.g., economic disadvantage, lack of access to reproductive health care, marginalization, racism) have been found to contribute to these inequities (Fenton, 2001; Hogben & Leichliter, 2008). Given these findings, the development and testing of behavioral interventions that target risky sexual behaviors (e.g. contraceptive use, number of sexual partners) with at-risk male youth is imperative.

Interventions for Risky Sexual Behaviors and Contraceptive Use

Even though male youth take more sexual risks than female youth (National Research Council, 2011), research evaluating interventions for risky sexual behaviors and contraceptive use has almost exclusively focused on adolescent and adult females (Cardoza, Documét, Fryer, Gold, & Butler, 2012; Lopez, Grey, Chen, Tolley, & Stockton, 2016; Scott-Sheldon, Huedo-Medina, Warren, Johnson, & Carey, 2011). To date, the majority of interventions targeting risky sex and unplanned pregnancy among youth have been education-based. Two-thirds of the programs included in the 88 studies reviewed by Goesling et al. (2014) provided sex education or abstinence-only curriculums, and only 35% percent found evidence for intervention efficacy. Moreover, only 8% of the studies looked primarily at male youth. These findings highlight the need for more efficacious interventions, particularly interventions that are tailored to reduce STIs and unplanned partner pregnancy among male youth.

Motivational Interviewing.

One promising intervention for addressing risky sexual behaviors and contraceptive use is Motivational Interviewing (MI). MI is an empathic, client-centered, collaborative approach that targets specific client behaviors by exploring the client’s natural ambivalence about change (Miller & Rollnick, 2013). The clinician elicits the client’s reasons for behavior change, rolls with any resistance to change, and builds the client’s confidence in their ability to change (Miller & Rollnick, 2013). This is done using techniques such as reflective listening, building self-efficacy, eliciting “self-motivational statements,” providing personalized feedback, and recognizing and generating solutions to barriers to behavior change. MI has been found to be effective and efficacious in targeting several health behaviors such as substance use, medication compliance, diet and exercise (Hettema, Steele, & Miller, 2005; Lundahl, Kunz, Brownell, Tollefson, & Burke, 2010; Scott-Sheldon, Carey, Elliott, Garey, & Carey, 2014), with even single-session interventions capable of producing behavior change (Eaton et al., 2016; Sagherian, Huedo-Medina, Pellowski, Eaton, & Johnson, 2016). Additionally, MI has been found to be efficacious for reducing risky behaviors among adolescent and young adult populations, as well as individuals from disadvantaged backgrounds and racial/ethnic minority groups (Clair et al., 2013; Cushing, Jensen, Miller, & Leffingwell, 2014; Hettema et al., 2005; Rosengard et al., 2008). Some research suggests MI may be as effective, if not more effective, for racial and ethnic minorities compared to Whites (Hettema et al., 2005).

A limited number of studies have specifically investigated the efficacy of MI for risky sex and contraceptive use. Lopez et al. (2016) conducted a review of interventions for female contraceptive use to reduce unplanned pregnancy. Of the ten studies included in the review, six studies tested MI or interventions with components of MI. Overall, those in the MI groups were found to use more effective forms of contraception at follow-ups (Ceperich & Ingersoll, 2011; Floyd et al., 2007; Rendall-Mkosi et al., 2013; Whitaker et al., 2016) and reduce unplanned pregnancy (Barnet et al., 2009). However, at least one study found no significant differences between the MI and the control group (Kirby et al., 2010). Although evidence suggests that MI may increase contraceptive use, these studies contained only female samples. Studies inclusive of male participants found MI produced more significant reductions in unprotected anal sex among young adult gay and bisexual men (Parsons, Lelutiu-Weinberger, Botsko, & Golub, 2014), reduced unprotected sex among homeless young adults (Tucker, D’Amico, Ewing, Miles, & Pedersen, 2017), and increased condom use among college students (Kiene & Barta, 2006). Thus, while no studies to date have investigated the use of MI for reducing risky sexual behaviors among at-risk male youth, previous research suggest it may be an efficacious option. With an emphasis on autonomy, avoidance of labeling client behaviors, and a lack of confrontational tactics, MI may be particularly well-suited for underserved male youth. Additionally, it may be more effective to approach male youth who have little or no interest in abstaining from a particular behavior (e.g., sexual activity) with a harm reductionist method that emphasizes personal choice, such as MI.

Current Study

Given existing health disparities and the dearth of research regarding reproductive health and contraception use among male youth, behavioral interventions to reduce risky sexual behavior among sexually active male youth at higher risk for STIs and unplanned partner pregnancy (e.g., justice-involved, racial/ethnic minority, low socioeconomic status) were developed, and a randomized controlled pilot study was conducted to demonstrate the feasibility and acceptability of the interventions. Due to the lack of research investigating behavioral interventions for risky sex with male youth, this study serves as a crucial and necessary step in the development of efficacious interventions focusing on this at-risk population.

Method

Participants and procedures

Male youth were eligible to participate if they were 14 to 21 years old, reported having vaginal intercourse with a female partner during the previous 4 months, and intended to have vaginal intercourse with a female partner in the next 6 months. Recruitment was conducted at five social service settings in the Northeast region of the United States. These included a juvenile justice facility, a community mental health outpatient clinic, an alternative high school, a career technical training program, and a community arts organization. Research staff visited with small groups of male youth at each setting, invited them to participate in a study looking at a variety of health behaviors including sexual health, described study procedures, and assessed interest in participation. Following these visits, interested individuals provided research staff with their contact information and were contacted by staff within a week to be screened for study eligibility. Male youth who were eligible and agreed to participate provided written assent (≤ 17 years old; parental consent was waived) or informed consent (≥ 18 years old). All procedures received Institutional Review Board approval. Baseline assessments took about 90 minutes to complete and were conducted by trained master’s-level staff blind to intervention condition. Participants were randomized to condition using a random-numbers table. The same staff member who completed the baseline assessment completed the intervention session with the participant following randomization. Three months following the intervention (see description below), participants were reassessed (60 minutes) by a different staff member who was blind to intervention condition. All staff were trained on assessments and received weekly supervision. All data were checked by senior level staff for recording errors.

Assessments and interventions were conducted in private spaces at a convenient time and location (e.g., private room at local public library) identified by participants. Participants were compensated following each study encounter; $25 for completing the baseline assessment, $30 after the treatment intervention, and $35 for completing the follow-up assessment. Additionally, participants were compensated an additional $10 for completing the treatment session and follow-up assessment within one week of the due date.

Interventions.

Following completion of baseline assessment, participants were randomly assigned to receive one manualized session of Motivational Interviewing (MI) or Didactic Educational Counseling (DEC). Both interventions were designed to be approximately 60–90 minutes in length and to occur within 1 week of the baseline assessment. Two physicians with extensive knowledge in the use of MI with underserved populations were involved in the initial development of the study interventions. The first physician works with underserved youth and initially developed the intervention for sexual behavior with C. DiClemente, a renowned investigator with expertise in MI, HIV risk and the Transtheoretical Model (TTM); the second physician works with incarcerated men and women. Two PhD-level behavioral scientists with at least 30 years of experience between them then tailored the intervention based on their prior work in MI and TTM for a randomized controlled trial investigating the use of an MI intervention to reduce risky sexual behaviors among underserved female youth (R01 HD-065942). Tailoring included getting and responding to feedback that the intervention was too long. Community members and treatment providers in the field were consulted regarding which elements were thought to be most useful. These elements were retained. The intervention was tailored further for male youth for the current study by two clinical psychologists with expertise in underserved youth and MI (the fourth and fifth authors). This involved placing less emphasis on hormonal birth control and more focus on the methods male youth have control over (e.g., condoms, withdrawal, abstinence). The language used to discuss pregnancy prevention was changed to “prevent partner pregnancy.”

All interventions were conducted by master’s-level female counselors. Counselors (n = 2) received a month of manualized training to provide both intervention types. A clinical psychologist provided weekly supervision to counselors and reviewed all study intervention files. All intervention sessions were audio-recorded. The supervisor randomly performed fidelity coding on 20% of the intervention sessions and 20% of those were randomly double-coded by trained research staff. Formal fidelity analyses, including inter-rater reliability could not be conducted due to the small sample size. Each intervention coded was found to meet criteria for fidelity.

MI Intervention.

Using information from the baseline assessment, a personalized feedback report was generated regarding partner pregnancy and STI risk, confidence to use condoms, number of casual partners, interest in and timing of having children, and so forth. Risk for partner pregnancy and STIs were calculated along a continuum according to number of sexual partners, frequency of condom use, and use of additional birth control methods (e.g., withdrawal), with more risky behaviors representing higher risk. For example, having one main partner and always using condoms was considered “very low risk” while having over 10 sexual partners and never using condoms was considered “very high risk.” Only birth control options males have complete control over were considered in the calculation of risk rates (i.e., abstinence, vasectomy, condoms, withdrawal). After reviewing the personalized report together, the counselor offered the participant an opportunity to 1) develop a plan to reduce risky sexual behaviors, and 2) discuss steps for negotiating condom use with partners. The youth were also encouraged to think about how they might talk with their partner(s) about considering or starting another birth control method (e.g., hormonal method). Further information regarding the development of the intervention and how to access it for use in research or clinical settings is available by contacting the last author.

The instrument used to determine fidelity to the MI intervention was the Motivational Interviewing Treatment Integrity (MITI) 3.1.1 (Moyers, Martin, Manuel, Miller, & Ernst, 2010). Consistent with the MITI, MI interventions were determined to have been performed with fidelity if the following benchmarks were met: Global Spirit Rating >= 3.5; % of Open Questions >= 50%; % of Complex Reflections >= 40%; Reflection-to-Question Ratio 1:1 at minimum; MI-Adherent >= 90%.

DEC Intervention.

The DEC session provided participants with an informational overview of reproductive health (e.g., methods of contraception, risky sexual behaviors, symptoms and consequences of STIs) similar to what they might receive in a sex education class in school-based settings. As with the MI intervention, more emphasis was placed on the methods male youth have control over (e.g, condoms, withdrawal, abstinence).

A fidelity form consisting of 6 items thought to capture the intervention components specific to DEC was generated based on content in the treatment manual for this intervention condition (e.g., “The counselor talked about how to use a condom and types of lubricant?”). Five items on the measure assessed the extent to which proscribed MI approaches were used (e.g., The counselor talked about the youth’s confidence in using condoms and abstinence.) to provide an estimate of treatment differentiation. Supervisors rated how skillfully the counselor addressed each component with ratings ranging from 0 (topic not introduced) to 3 (very skillfully). DEC sessions were considered to have been conducted with fidelity if the counselor performed each DEC component at least somewhat skillfully and MI topics were not introduced.

Measures

Demographics.

At baseline, participants reported demographic information such as age, race, ethnicity, family history, legal involvement, and substance use during the past 12 months.

Sexual Behavior Questionnaire (SBQ).

The SBQ was administered to assess current and past sexual behavior of participants at baseline and at follow-up. For this study, “sex” was defined for participants as voluntary vaginal or anal sexual intercourse between a male and a female or between two males. “Main or steady partner” was defined as someone who the participant was serious about and who he considered to be his primary sexual partner. “Casual partner” was defined as a sexual partner such as a friend or acquaintance who the participant did not consider to be his primary sexual partner. Participants were asked to report the number of sexual partners in the previous 12 months and number of lifetime sexual partners. This measure was developed for use with adult females (Clarke et al., 2006) and adapted for use with male youth. Modifications made were relatively minor (e.g., pronouns were changed, language used to describe partners [“other guys” vs. “other partners”] was changed).

Timeline Followback (TLFB).

A calendar-assisted TLFB approach was used at baseline and follow-up to assess the number of days participants engaged in vaginal intercourse with main and/or casual partners, method(s) of contraception used, and drug and alcohol use around the time of sex during the previous 90 days (Weinhardt et al., 1998).

Sexually Transmitted Infection (STI) Testing.

Participants provided urine sample at baseline and follow-up using laboratory specifications and procedures. All samples were tested for Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG), and Trichomonas vaginalis (TV) using nucleic acid amplification (GEN-PROBE Aptima Assay, San Diego, CA). Results were received via secure fax and participants were notified of their results within 2 to 3 business days.

Participants who tested positive were provided with a referral to a health clinic in their community. In accordance with State guidelines, positive CT and NG results were reported to the Department of Health.

Center for Epidemiologic Studies Depression Scale (CESD-10).

Depressive symptoms were measured using the 10-item CESD at baseline (Andresen, Malmgren, Carter, & Patrick, 1994). This valid and reliable measure assesses the presence and severity of depressive symptoms during the past 7 days. Items are scored on a 4-point Likert scale from 0 (rarely) to 3 (most or all of the time). Possible scores range from 0 to 30, with higher scores indicating greater depressive symptoms. A score ≥10 was used to define the presence of depressive symptoms (Andresen et al., 1994).

Posttraumatic Stress Disorder Checklist (PCL-S).

PTSD symptoms were measured using the 6-item PCL-S at baseline (Lang et al., 2012). Participants were asked to rate the degree to which they were bothered by symptoms related to a specific stressful experience in the past 30 days. Items were scored on a 5-point Likert scale from 1 (not at all) to 5 (extremely). Possible scores range from 6 to 30, with higher scores indicating greater PTSD symptoms. A score >14 was used to define the presence of PTSD symptoms (Lang et al., 2012).

Teen Fidelity Form.

Following the intervention session, participants were asked to rate how satisfied they were with their counselor (e.g., The counselor was easy to talk to; 1 = “strongly disagree” to 4 = “strongly agree”), how useful they found different intervention components (e.g., We talked about how to use a condom and types of lubricants; 0 = “topic not introduced” to 3 = “very useful”), and how interested they were in using condoms in the future (1 = “not at all” to 5 = “very much”). All questions were read aloud, responses were placed in a sealed envelope, and participants were assured that their responses would not be seen by nor impact the counselor.

Analyses

Feasibility parameters of interest included proportion of eligible youth recruited, youth compliance with study protocol, and attrition. Acceptability of treatment interventions was assessed by asking youth to rate their level of satisfaction with the treatment session and counselor at the end of their session. Small sample sizes do not allow for treatment efficacy to be evaluated or effect sizes to be meaningfully estimated. As a result, it is recommended that pilot studies focus on estimation and confidence intervals to extrapolate the size and direction of treatment effects (Lee, Whitehead, Jacques, & Julious, 2014). To estimate treatment effects and generate confidence intervals, negative binomial (NB) regression models were used to predict sexual behavior at follow-up controlling for sexual behavior at baseline. NB regression is a useful procedure for examining count data (i.e., the number of times a behavior occurred over a fixed period of time) that is highly skewed and over-dispersed, as if often then case when analyzing risk behaviors with low base rates (Coxe, West, & Aiken, 2009; Neal & Simons, 2007). Outcomes of sexual behavior included 1) number of sexual encounters, 2) number of times used a condom, 3) number of times used substances at the time of sex, and 4) number of times sex occurred with substance use and without a condom. Each outcome was examined for all partners, main partners, and casual partners. Some participants had limited access to sex over the follow-up period due to spending time in a controlled environment (e.g., incarcerated). Therefore, possible sex days (i.e., exposure) varied between participants and was included in each model as an offset variable.

Results

Feasibility and acceptability

Forty-three male youth were screened for inclusion in the study. Sixteen (37.2%) were ineligible (n = 11), declined to participate (n = 3), or could not be located/contacted to complete the baseline assessment (n = 2). Most youth (n = 6; 54.5%) were ineligible due to not having vaginal intercourse in the past four months, three (27.3%) were ineligible due to age, and two (18.2%) were ineligible due to not planning to have vaginal intercourse in the next six months. Of those who declined to participate, two were not interested, and one reported he was too busy to participate.

Twenty-seven eligible male youth completed the pilot, exceeding the recommended sample size of 12 per group for a pilot study (Julious, 2005). Most (74%) participants identified as belonging to a racial or ethnic minority group. In general, about 20% of the sample was recruited from each recruitment site. Participants’ age when first had sex ranged from eight to eighteen years old. All participants identified as heterosexual, none reported having male sexual partners, and over half reported having unprotected sex at least once during the 90 days prior to baseline assessment. Number of sexual partners in the past year ranged from one to thirteen. Number of sexual partners in lifetime ranged from one to eighty. Complete demographic information is available in Table 1.

Table 1.

Participant demographics collected at baseline (N = 27)

M (SD)
Age 17.4 (1.3)
Age first had sex 14.2 (2.0)
Number of partners in past year 3.4 (2.9)
Number of partners in lifetime 11.2 (15.1)
%
Recruitment site*
 Juvenile correctional facility 22.2
 Community mental health center 22.2
 Alternative high school 22.2
 Career technical training program 22.2
 Community arts organization 11.1
Racial/ethnic group most identify with*
 African American/Black 22.2
 American Indian/Alaskan Native 18.5
 Asian 3.7
 Hispanic/Latino 29.6
 White 25.9
Sexual partner(s)
 Had a main partner 81.5
 Had casual partner(s) 51.9
 Had both a main and casual partner(s) 40.7
Mental health
 Screened positive for depression 44.4
 Screened positive for PTSD 59.3
 Screened positive for both depression and PTSD 37.0
 Screened negative for both depression and PTSD 33.3
Substance use past 12 months
 Alcohol use 70.4
 Drug use (excluding marijuana use) 29.6
 Drug use (including marijuana use) 85.2
Had unprotected sex past 90 days 59.3
Never had STI testing 25.9
Number of times partner ever became pregnant
 0 88.9
 1 7.4
 2 3.7
Number of living children
 0 92.6
 1 7.4
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Notes. M = mean, SD = standard deviation,

*

= categories do not total 100% due to rounding, % = percent, PTSD = posttraumatic stress disorder.

Overall, participants in both treatment conditions reported feeling positively about their counselor (DEC: M[SD] = 3.77[.30]; MI: M[SD] = 3.84[.25]), satisfied with their session (DEC: M[SD] = 4.54[1.13]; MI: M[SD] = 4.64[.50]), and endorsed having interest in using condoms at the conclusion of their session (DEC: M[SD] = 4.16[1.34]; MI: M[SD] = 3.93[1.27]). STI testing was completed by 100% of participants at baseline and by 92.6% of participants at follow-up. Furthermore, 100% of participants completed the 3-month follow-up assessment.

Outcomes of risky sexual behavior

Confidence intervals for estimates from the negative binomial regressions found that, compared to DEC, those who received MI had fewer sexual encounters with casual partners at follow-up (Incidence Rate Ratio [IRR] = .12; 95% confidence interval [CI; .04, .39]), used substances at the time of sex less often with all partners (IRR = .22; 95% CI [.07, .67]) and with casual partners at follow-up (IRR = .04; 95% CI [.01, .26]), and used substances at the time of sex without a condom less often with all partners at follow-up (IRR = .21; 95% CI [.05, .82]). Conversely, participants who received MI used substances at the time of sex with main partners (IRR = 2.49; 95% CI [.88, 7.88]) and used substances at the time of sex without a condom more often with main partners (IRR = 1.51; 95% CI [.47, 4.88]) at follow-up compared to participants who received DEC. Omnibus tests for the models examining the relationship between treatment condition and condom use were not significant (i.e., p > .05); this precluded an examination of the coefficient estimates and confidence intervals. Coefficients and confidence intervals for regression models with significant omnibus tests are presented in Table 2.

Table 2.

Estimated regression coefficients and standard errors for negative binomial models

3-month outcomes B se p IRR 95% CI
All partners
 # times AOD use at time of sex
  MI −1.51 .56 <.01 .22 .07, .67
  BL # times AOD use at time of sex 03 .01 <.001 1.03 1.02, 1.05
 # times AOD use at time of sex, no condom
  MI −1.58 .70 .03 .21 .05, .82
  BL # times AOD use at time of sex, no condom .05 .01 <.001 1.05 1.04, 1.07
Main partner
 # times AOD use at time of sex
  MI .91 .53 .09 2.49 .88, 7.08
  # times AOD use at time of sex .08 .01 <.001 1.08 1.07, 1.10
 # times AOD use at time of sex, no condom
  MI .41 .60 .49 1.51 .47, 4.88
  BL # times AOD use at time of sex, no condom .08 .01 <.001 1.09 1.07, 1.10
Casual partner(s)
 # sexual encounters
  MI −2.12 .60 <.001 .12  .04, .39
  BL # sexual encounters .07 .01 <.001 1.07 1.05, 1.10
 # times AOD use at time of sex
  MI −3.18 .94 .001 .04 .01, .26
  BL # times AOD use at time of sex .13 .03 <.001 1.13 1.06, 1.21
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Notes. Only coefficients from negative binomial regression models with significant omnibus tests are presented. IRR = incidence rate ratio; AOD = alcohol and/or other drugs; MI = motivational interviewing; BL = baseline.

At baseline, none of the youth reported having ever had an STI. Two youth (7.4%) tested positive for chlamydia over the duration of the study; one tested positive at baseline and one tested positive at follow-up. All other STI tests were negative.

Discussion

This pilot study provides support for the feasibility and acceptability of delivering behavioral interventions to reduce risky sexual behaviors among at-risk male youth. Approximately 63% of the male youth screened met inclusion criteria and agreed to participate in the study. Feasibility was also supported by participants’ compliance with the study protocol, which included providing urine samples for STI testing, and a complete lack of study attrition. Participant demographics listed in Table 1 suggest the project was successful in recruiting male youth at greater risk for STIs and unplanned partner pregnancy. It is important to note that some youth were likely more at risk due to confronting multiple forms of social disadvantage (e.g., justice-involved, experiencing psychiatric symptoms, racial/ethnic minority status), compared to other youth who may have only experienced one form. Future research is needed to determine the impact this may have on intervention outcomes.

Surprisingly, all participants identified as heterosexual and none of the participants reported having male partners. Study inclusion criteria (i.e., having had and planning to have vaginal intercourse) and the definition of sex used in the study (i.e., vaginal or anal intercourse) may have contributed to the exclusion of reported sexual contact with other males (i.e., oral sex with male partners was not assessed). Future studies would benefit from including additional forms of sexual contact (e.g., oral sex) to assess risky sex more comprehensively.

In support of study acceptability, male youth in both treatment conditions rated their counselors highly (e.g., agreed the counselor was easy to talk to, supported his choices and decisions about sex and condoms), endorsed satisfaction with their intervention session, and on average reported they would like to use condoms “a lot” at the conclusion of their intervention session.

Confidence intervals for six (i.e., 50%) of the models tested suggested an effect of treatment greater than zero, typically in favor of MI. Compared to participants in DEC at follow-up, participants in MI reported having fewer sexual encounters with casual partners, used substances at the time of sex less often with all partners and casual partners, and reported fewer incidents of using substances at the time of sex without a condom with all partners. These findings are consistent with a recent study examining the efficacy of MI to reduce risky sexual behaviors among at-risk female youth (Moore et al., 2018). In contrast, participants in MI reported using substances at the time of sex and using substances at the time of sex without a condom with their main partner more often at follow-up than participants in DEC. Further research is needed to determine whether these findings are spurious or reflect a limitation of the MI intervention. At this time, findings seem to suggest the MI intervention could be bolstered to better address decision-making around risky sex with main partners. Contrary to other research with male participants [e.g., Parsons et al., 2014; Tucker et al., 2017; Kiene & Barta, 2006), MI was not found to increase condom use. It’s unclear if this discrepancy results from fundamental differences between the participant groups (e.g., attitudes/beliefs about condom use; access to condoms related to age or resources), or if the current pilot study was merely underpowered to detect these changes. Additional research is needed to clarify this inconsistency.

Additional limitations beyond the nature of the pilot study (i.e., small sample size) warrant mention. First, both research staff identified as White/Non-Hispanic which may have impacted minority youths’ level of trust and subsequent willingness to participate in the study. Though over half of African Americans and Latinos surveyed by Garza et al. (2017) reported it was not at all important to be invited to participate in research by staff who matched their race/ethnicity, nearly 20% of the sample stated this was very important. Future studies would benefit from a more diverse research staff to meet the needs and preferences of participants. Second, all research staff were female. Although this is consistent with what male youth are likely to encounter given that a large proportion of counselors and healthcare providers (e.g., registered nurses, physicians assistants) are female (United States Department of Labor, 2017), it may have influenced their willingness to participate in the study and/or discuss sensitive topics, particularly for individuals with religious and/or cultural beliefs that consider it inappropriate to have conversations about sexual behavior with members of the opposite sex. However, research has found many young men are more comfortable with and prefer female providers (Buzi & Smith, 2014). Therefore, the authors strongly recommend the inclusion of both male and female research staff in future studies.

To gauge whether having an all-female staff may have impacted youth reports in the current study, we reviewed participants’ responses to the Misreporting Questionnaire (Stein et al., 2002) a posteriori. This measure was administered in private at the conclusion of the study to assess how often participants purposely over- or under-reported specific behaviors (e.g., use of condoms during sex, number of sexual partners) over the course of the study using 10 items on a Likert scale ranging from 1 (yes, during the entire study) to 5 (never). Interviewers did not know how youth responded. Overall, most participants (approximately 92%) reported responding truthfully to the research questions with about 7% stating they “hardly ever” over- or under-reported. Therefore, having an all-female staff appears to have had little impact on youth reports over the course of the study, but may have impacted recruitment.

Third, the study definition of sex was limited to vaginal and anal intercourse. This allowed us to focus on sexual behaviors that place youth most at-risk for unintended partner pregnancy and STIs. However, future studies would benefit from assessing the effects of an MI intervention on a wider range of sexual behaviors that (e.g., oral sex, mutual masturbation) as these behaviors also present a level of risk for STIs (American College of Obstetricians and Gynecologists, 2013). Fourth, HIV testing could not be included in the study protocol due to the limited resources that were available for the pilot study. This would be an important outcome for future studies on sexual behavior among underserved populations to include given the heightened level of risk for HIV that has been observed within these groups (Pellowski, Kalichman, Matthews, & Adler, 2013). Fifth, the current study largely relied on self-report measures which are subject to social desirability and recall bias (Althubaiti, 2016). However, self-reports of condom use and sexual behavior have been found to be highly accurate for moderate time durations such as 3 months (Jaccard, McDonald, Wan, Dittus, & Quinlan, 2002). Sixth, some measures were modified and others have not yet been well-validated for the study population. Larger studies are needed to assess the validity and reliability of the measures used in the current study with the study population. Lastly, follow-up periods beyond three months are necessary to determine the extent to which sexual behavior changes are sustained.

Despite these limitations, findings from the pilot study support the use of motivational interviewing to reduce risky sexual behavior among at-risk male youth. Preliminary results indicate a randomized controlled trial is warranted.

Acknowledgements of support:

This work was supported by the National Institute of Child Health and Human Development under grant number R01 HD-065942 (PI: Stein). The authors gratefully thank Nicole Theroux-Kochanek, Laurel Murphy, and Suzanne Sales for their contributions to the project.

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