Recruitment
Parents and caregivers of youth 11–14 years of age were recruited from 22 after-school programs (e.g. Boys and Girls Clubs) and 19 charter schools in medically underserved communities between 2015 and 2018. Written informed consent was received from the parent participants and written assent was received from the youth. All study procedures were approved from the Committee for the Protection of Human Subjects at the University of Texas Health Science Center at Houston (HSC-SN-15-0091) prior to recruitment and enrollment of study participants. Student research assistants enrolled youth as dyads with their parent and randomly assigned dyads using a computerized random number generator to either the intervention or control group using a 1:1 group allocation. At follow-up, the study team research assistants were blinded to group assignment. Parents and youth received $20 for each completed survey.
First, we used community-based participatory methods to adapt
Families Talking Together (FTT) to include a module on adolescent vaccinations and HPV specifically. FTT + HPV has three main components: a brief face-to-face session, a take-home manual, and booster calls. FTT has been successful in delaying sexual debut in minority youth at nine months post-intervention when implemented in clinics and schools [
13,
14]. Importantly, it is available in English and Spanish.
Nurses are the largest frontline healthcare provider workforce and well-positioned to deliver health promoting interventions in community settings. To build on this expertise, we wanted to assess the delivery of FTT + HPV by student nurses [
29]. Therefore, we recruited undergraduate senior level student nurses from a public health nursing clinical course who received approximately 32 h of extensive training on the implementation of the FTT + HPV program and community-based research to serve as the interventionists. Training included Protection of Human Subjects certification, parent-based adolescent sexual health, STIs and HPV, HPV vaccination, and health education communication methods and strategies.
Intervention description
In the face-to-face session, the parent and student nurse met for approximately 45 min to review the FTT + HPV materials, motivate parents to talk with their children, and address specific components of the program. Student nurses helped parents designate a time to talk with their children and reviewed information about the context of the present-day teen’s world (e.g., physical changes, teen thinking, peers, emotions, and teen moral development) and how a parent can help a teen through positive parenting (e.g., parenting styles, child discipline, parental monitoring, communication, relationship building, forming healthy relationships, self-esteem, refusal and negotiation skills, and risk reduction strategies). The student nurse reviewed information about adolescent vaccinations including the importance of the HPV vaccine, presented local resource materials detailing where and when the child can get vaccinated, and helped the parent make an appointment for vaccination when on-site vaccination clinics were available. Each parent received a manual that reiterated the above-mentioned information as well as three handouts to supplement the face-to-face session. The handouts discussed adolescent vaccinations, contraceptives, and healthy relationships. Parents were encouraged to work through the activities in the manual with their child over the following weeks.
The manual was divided into sections covering health and social consequences of premature sexual behaviors, positive parental influences on adolescent sexual behaviors, saying ‘no’ to sex, common teen beliefs about sex, monitoring and supervision strategies, parent-child relationship building, and communication tips. Two follow-up telephone-based booster calls were delivered at one- and three-months post-intervention. During the booster session call, the student nurse discussed the parent’s progress with communication and vaccination and discussed barriers they were facing while progressing through the manual with their child. Bilingual nursing students were assigned to participants who preferred to receive the intervention discussion or materials in Spanish. When possible, we coordinated with a local pediatric mobile vaccination clinic to offer all childhood vaccinations free of charge through the Vaccines for Children program during the recruitment events. A total of seven vaccination events were coordinated.
The attention control group parents received information from the student nurse on promoting healthy nutrition and exercise among adolescents in a 45-min session. During the session, the student nurse and the parent set a goal related to nutrition and physical activity for their child. Parents also received a brochure of healthy lifestyles and booster calls and 1- and 3-months post-intervention. Similarly, all materials and sessions were available in English and Spanish.
Parent measures
Baseline surveys collected data about parents’ demographic characteristics including gender, race/ethnicity, level of education, parental role, annual household income, religiosity, and insurance status. In addition, a battery of psychosocial measures were collected at baseline, one, and six months. The primary behavioral outcomes of interest for parents were parent-child sexual health communication, parental intention to vaccinate their children for HPV, and vaccination uptake and completion rates. Psychosocial determinants known to influence parental practice, sexual health communication, and parental monitoring were secondary outcomes examined in this study, as well as factors associated with HPV vaccine uptake and completion such as vaccine beliefs. Parent communication expectancies associated with parent-youth discussions about sex was assessed using a 15-item scale developed by DiIorio et al. [
5]. Each item begins with the stem, “
If you talk with your child about sex topics...” and is followed by an expected outcome for parents such as, “
you will feel that you did the right thing” or “
it would be unpleasant” [
5] with options from strongly disagree to strongly agree on a 5-point Likert scale. Parent communication self-efficacy was assessed using a 16-item scale. Sample items from the scale include, “
You can always explain to your child what you think about adolescents their age having sex” [
6]. Response options ranged from “not sure at all” to “completely sure” on a 7-point Likert scale. Frequency of communication about sex was assessed using an 8-item scale [
6]. A sample item is: “
In the past month, how often have you talked to your child about how to handle sexual pressure by friends or potential partners?” with a 10-point scale ranging from never to 10 times or more. Communication ability was assessed using a single item: “
How would you rate your ability to communicate with your child about sexual topics?” [
6] on a 7-point scale. Communication openness was defined as the extent to which parents feel comfortable talking to their child about sex and was assessed using an 8-item scale [
14] with response options ranged from strongly agree to strongly disagree on a 4-point scale.
Secondary parental outcomes included parental connectedness which was defined as the degree of closeness between a parent and child using a 4-item scale [
14]. Parents were asked to respond to the following statement: “
Most of the time, your child is warm and loving toward you.” Response options ranged from not at all to very much on a 1–5 scale. Parental involvement, actively participating in a child’s life, was assessed using a 10-item scale [
14]. A sample item is, “
During the past month, how many times did you and your child do fun things together?” Response options were on a 5-point scale that ranged from “not at all” to “7 or more times.” Parental monitoring was assessed using a 7-item scale [
14]. A sample item is: “
Do you currently have clear rules or expectations about where your child can go after school?”
Parental vaccine beliefs were assessed using a 22-item scale. Sample items include “Vaccinations protect children from getting diseases from unvaccinated children” and “I am more likely to trust vaccinations that have been around awhile.” Response options ranged from disagree to agree on a 5-point scale. Intention to vaccinate was assessed using a single item: “Are you planning to give your child all 3 doses of the HPV series?” This item was scored on a dichotomous scale (0 = no, 1 = yes).
Participant scores for the parent measures were calculated as the mean of the answered items multiplied by the total number of items in the scale. This method addresses missing data by using the scale items that were answered by a participant to calculate their scale score (Newman, 2014). Cronbach’s alpha for the parent measures ranged from .74 to .93.
Youth measures
At baseline, gender, age, and race/ethnicity were among the sociodemographic variables collected for youth. In addition, a host of behavioral and psychosocial measures were administered at baseline, one- and six-months.
The primary outcomes of interest for youth were sexual activity and HPV vaccine uptake. Youth self-reported whether they had ever engaged in oral, vaginal, or anal sex at baseline, one, and six months. These items were scored on a dichotomous scale (0 = no, 1 = yes). Youth also reported frequency of sexual behavior in the past month which was scored on a 6-point Likert scale ranging from never to more than 10 times. To assess HPV vaccine initiation and completion, vaccination records were obtained from IMMTRAC, a state-wide vaccination registry. Records were available for most youth in the study (85%); parental report was used for the 15% of youth whose vaccination records were not listed in the registry.
Secondary outcomes known to influence adolescent sexual behavior we also assessed.
Beliefs about sex were assessed using a 4-item scale [
34]. A sample item is: “
I believe people my age should wait until they are older to have sex.” Beliefs about abstinence were examined with a 6-item scale [
34]. For example, youth were asked to respond to the following statement: “
The best way for young people to avoid an unwanted pregnancy is to wait until they are married before they have sex.” Perceived parents beliefs about sex were assessed with a 4-item scale [
34]. A sample item from the scale is “
My caregiver believes people my age should wait until they are older before they have sex.” Response options for these 3 scales ranged from strongly agree to strongly disagree on a 1–4 scale.
Self-efficacy for refusing sex was examined using a 7-item scale [
6]. Each item begins with the stem “
Could you stop the person that you like from…” which is followed by intimate behaviors such as “
kissing you on the lips, if you did not want them to do that” or “
touching your private parts below the waist, if you did not want them to do that.” Response options were on a 4-point scale and ranged from definitely could not to definitely could. Condom knowledge was assessed with a 6-item scale [
32]. Sample items include: “
Do condoms help keep a person from getting pregnant?” with response options of “Yes,” “No” or “Not sure.” Condom self-efficacy was assessed using a 4-item scale [
34]. A sample is: “
How sure are you that you could tell your partner you want to use condoms?” Youth responded on a 1–3 scale ranging from “not at all sure” to “definitely sure.”
Exposure to risky situations was assessed using a 6-item scale [
6]. Each item begins with the stem “
In the past month, how often have you….” and is followed by a scenario which might make a youth vulnerable such as “gone to, or stayed at, a party where alcohol was being used”. Response options ranged from “never” to “daily” on a 7-point scale.
HIV/STI knowledge was assessed with a 5-item scale [
6]. A sample is: “
You can tell if a person has HIV or AIDS just by looking at them.” Response options for youth were true, false, or not sure. Intentions towards sex were examined using a 5-item scale [
6]. Each item begins with the stem “
How likely is it that you will….” and is followed by statements such as “
have oral sex in the next year” or “
remain sexually abstinent from now until the marriage” on a 1–5 scale. Expectancies for youth were assessed using a 21-item scale that inquired about how the youth would feel if he/she had sexual intercourse at this point in life and included “
it would be embarrassing for me if I got pregnant or got a girl pregnant” or “
I would feel more attractive” using a 5-point scale from agree to disagree [
6].
Communication self-efficacy can be defined as a youth’s level of comfort with talking to their parent about sex and was assessed using a 16-item scale [
14]. Each item begins with the stem “
How sure are you that you can talk to your caregiver about…” followed by topics like “
where to buy or get condoms” or “
how to tell a boy/girl no if you do not want to have sex” on a 1–4 scale. Communication about sex outcome expectancy was assessed using a 15 item-scale [
6]. A sample item was “
If you talk with your caregiver about sex topics you will feel responsible” using a 5-point scale from strongly disagree to strongly agree. Communication about sex was assessed with 8-items examining the content of parent-youth sexual health discussions [
17]. Youth were asked questions like “Ha
ve you ever talked to your caregiver about when to start having sex” with response options of yes and no. Communication ability was examined using a single item from Schuster et al. [
32]:
How would you rate your ability to communicate with your caregiver about sexual topics [
32]
? Youth responded on a 7-point scale ranging from excellent to terrible. Communication content and frequency was assessed by 21-items examining parent-youth sexual health communication [
6]. Each item begins with the stem “
How many times has your caregiver ever talked to you about…” followed by topics such as “
how you will make decisions about whether to have sex” on a 1–5 scale ranging from never to 10 times or more.
Parent-youth connectedness was assessed using a 5-item scale [
14]. Sample items include: “
How close do you feel to your caregiver?” with response options from 1 to 5. Parental monitoring was examined using 5-items that measured youths’ perception of parents’ knowledge about what the youth is doing, who they are with, and where they are in their free time [
14]. A sample item is: “
How much does your caregiver know about who your friends really are?” with responses on a 4-point scale. Intentions and beliefs about child disclosure about sex was assessed using a 4-item scale. A sample is: “
I plan to talk to my caregiver about sexual health issues in the future” with response options on a 5-point scale.
Participant scores for the youth measures were also calculated as the mean of the answered items multiplied by the total number of items in the scale. Cronbach’s alpha for the youth measures ranged from .71 to .95, except for the intentions towards sex scale, which had a reliability measure of .63.