In this post, Dr Alexandra Morales, Assistant Professor at Miguel Hernández University (Spain), shares details of an exciting new project to promote positive sexual health behaviours in adolescents who are living in children’s shelters in Spain. The project is being conducted in collaboration with Dr. Espada, Full Professor at Miguel Hernández University; Dr Orgilés, Full Professor at Miguel Hernández University; and Dr Lightfoot, Professor at University of California San Francisco. Alexandra explains this new line of research, why this work is so important, and what the next steps are for the project.

How the project started

In 2015, I defended my PhD dissertation on the efficacy of Competencias para adolescentes con una sexualidad saludable (COMPAS for its acronym in Spanish) (In English: Competencies for adolescents with a healthy sexuality), a sexual health promotion intervention targeted at Spanish adolescents attending school. The efficacy of this intervention was evaluated through two projects funded by the Foundation for AIDS Research and Prevention in Spain (FIPSE in Spanish) that consisted of multi-center studies involving six provinces of Spain. Results indicated that COMPAS promoted healthy sexual behaviours in more than 2,000 adolescents from the north, center, south, and east of Spain. Behaviours, such as unprotected sex and early sexual onset, associated with sexual risk were significantly reduced in the long-term. Results of these studies are now published in scientific journals^1-7. These promising results from COMPAS encouraged me to keep working on the program and to adapt it for use with a specific population known to have a high-risk to sexually transmitted infections (STIs) and unplanned pregnancies.

While I was an undergraduate student I trained as a psychologist in a shelter located in Alicante. I implemented an intervention I had designed for a health promotion course to reduce sexual risk behaviors in the adolescents staying at the shelter. False beliefs on sexuality, need for love, affection and belonging were easily identified in this group. The early onset of sexual practices and their risky sexual behaviors indicated to me how vulnerable this population were to STIs and unplanned pregnancies. After 10 years and the experience gained during my PhD on school-based interventions to promote positive sexual health, I was encouraged to move forward from schools to shelters. To get me started in this direction I applied for a postdoctoral grant and got it! At the start of my PhD, together with my supervisors, Dr Espada and Dr Orgilés, I undertook a literature review to find out what was already known in this field and what was needed in terms of intervention. On our way, Dr Lightfoot, Professor at University of California San Francisco (United States), an expert on sexual health promotion and HIV prevention for homeless youth, joined us on the project.

COMPAS project team

What do we already know about children and adolescents living in shelters in Spain?

It is estimated that 30% of children and adolescents under 18 years old in Spain are at risk of social exclusión⁸. Since 2007, unemployment in households with children has increased by 290%, which has contributed to greater poverty and inequality in the general population in Spain⁹. When the situation of lack of protection is serious enough to make it advisable to separate the child from the family, a situation of helplessness is declared, and the child is move to a shelter. In addition to the lack of parental resources for upbringing, other minors are protected by social services after situations of sexual abuse, physical and/or psychological abuse. Spain is one of the countries in the European Union with highest rates of children and adolescents living in shelters¹⁰. It is estimated that more than 30,000 children were separated from their families and were supervised by public administrations in 2011¹¹.

What makes adolescents living in shelters more vulnerable to sexually risky behaviors?

Adolescents living in shelters are especially vulnerable to STIs and unplanned pregnancies. The scientific literature indicates that, compared to the general population, youth who live in shelters are more likely to initiate sexual contact at an early age (before the age of 13), identify multiple sexual partners, report less consistent use of condoms, and are more likely to have a history of STIs and/or unplanned pregnancies ^12-14. A longitudinal study of 536 adolescents living in shelters in Illinois and Wisconsin (Midwest Study) concluded that they were more likely to have an STI compared to their peers who did not live in shelters. Chlamydia was the most commonly reported STI amongst this group¹⁵. Furthermore, when participants in the study were 21 years old, 80% were already parents¹⁶. In this same study, 50% of the men who had lived in shelters reported having a couple who were pregnant, compared to the 19% of the group that grew up in a “normalized” environment. These findings are consistent with the few Spanish studies that explored sexual risk in adolescents living in shelters. A study conducted by Zárate¹⁷ analyzed differences in sexual risk between groups of females aged between 15 and 19 years who were living in shelters and those who were not. Compared to women who did not live in shelters, those that did reported that they experienced their first sexual experience at a younger age, were sexually active in a greater proportion (84% vs. 28%), and were less likely to use contraceptive methods to protect themselves from pregnancies (14% vs. 100%). Qualitative data from this study indicated that emotional disorders (highly prevalent in children living in shelters) makes them especially vulnerable to pregnancies and STIs because they are less skilled at rejecting unsafe sex, especially when their partner provides them security and protection¹⁷.

 Introducing our project

According to our recent meta-analysis on the efficacy of sexual health promotion interventions designed for adolescents¹⁸, there are no programs aimed specifically at addressing the sexual risk of adolescents who are living in shelters. Based on this gap in the literature and the need to provide protection resources to this population, our new project was conceptualized as a pilot study. The main aims are to adapt and evaluate the COMPAS program to promote healthy sexual behaviours in adolescents who are living in shelters. We aim to recruit 130 adolescents at risk of social exclusion, living in shelters located in the Valencian Community (Spain) to take part in this pilot study.

Inclusion criteria are as follows:

• Adolescents must be aged between 12 and 17 years
• Must be at risk of social exclusion due to family factors (parents who use drugs, lack of parental skills, caregiver illness, families that are homeless and/or orphaned) and/or have economic problems (risk of poverty in the family context, parental unemployment)
• Must be living in shelters in the Valencian Community, and
• Have not participated in specific activities for the promotion of positive sexual health during the last year.

The pilot evaluation will include a pre-, a post-, and a 3- month follow-up. Measures will include sociodemographic variables, and other theoretical constructs related to sexual behaviors, such as knowledge on STIs, attitudes toward sex, perceived norms, condom use intention, sexual risk perception, self-efficacy, as well as sexual behaviors, including sexual practices, number of sexual partners, methods of protection, among others.

The next steps

We are now working on the adaptation of COMPAS program (originally designed and evaluated in schools) to shelters in Spain. As part of this process, I have had the opportunity to work personally on this with Dr Lightfoot during a research stay at University of California San Francisco during 2017.  We hope findings from a series of focus groups will be available over the next year to complete the adaptation process of this school-based intervention to shelters. We hope that the results from this pilot study indicate reductions in sexual risk amongst adolescents who are living in shelters in Spain. Psychologists, social workers, health agencies and researchers worldwide may directly benefit from the results of the current project. The adaptation of evidence-based interventions (designed initially for general population) to high-risk populations must be a priority for those to work on health promotion. Sexual risk in adolescents who are living in shelters is not only specific to those living in Spain. Subsequently, we encourage the adaptation, implementation and evaluation of preventative interventions that address high-risk populations across Europe. To ensure that we can all benefit from our learning we would like to hear from colleagues who would be interested in collaborating on future projects on sexual health promotion in adolescents.

About the author:

Alexandra Morales is an Assistant Professor and researcher in the Aitana Research Group at the Miguel Hernández University (Spain). Alexandra completed her doctorate in Health Psychology at Miguel Hernández University, focusing on sexual risk factors and the evaluation and efficacy of HIV and STI prevention interventions for adolescents. She has worked on the development, cultural adaptation, implementation, and evaluation of school-based prevention interventions. Some of her main interests include sexual risk factors, cultural adaptation of prevention interventions, and methodology in prevention research. You can read more about her work by following her on ResearchGate.

References

1. Espada JP, Orgilés M, Morales A, Ballester R, Huedo-Medina TB. Effectiveness of a school HIV/AIDS prevention program for Spanish adolescents.  AIDS Educ Prev 2012; 6: 500-513.
2. Espada JP, Morales A, Orgilés M, Jemmott JB, Jemmott LS. Short-term evaluation of a sexual education program based on skills development compared to a well-established program. J Adoles Health 2015, 56: 30-37.
3. Escribano S, Espada JP, Morales A., Orgilés M. A Two Years’ Follow-Up Evaluation Of A Sexual-Health Education Program For Spanish Adolescents Compared To A Well-Established Program. Evaluation & The Health Professions 2016. doi: 10.1177/0163278716652217
4. Escribano S, Espada JP, Morales A, Orgilés M. Mediation Analysis of an Effective Sexual Health Promotion Intervention for Spanish Adolescents.  AIDS Behav 2015, 19(10): 1850-1859.
5. Morales A, Espada JP, Orgilés, M. A one-year follow-up evaluation of a sexual-health education program for Spanish adolescents compared to a well-established program. Eur J Public Health 2015. Available at: http://eurpub.oxfordjournals.org/content/early/2015/05/09/eurpub.ckv074
6. Morales A, Carratalá E, Orgilés M, Espada JP. Un estudio preliminar de la eficacia de un programa de promoción de la salud sexual en adolescentes con padres divorciados [A preliminary study of the efficacy of a program to promote sexual health in adolescents with divorced parents]. Health and Addictions 2017, 17(1): 37-44.
7. Morales A, Espada JP, Orgilés M, Secades-Villa R, Remor E. The short-term impact of peers as co-facilitators of an HIV prevention programme for adolescents: A cluster randomised controlled trial. Eur J Contracept Reprod Health Care 2014. Advance online publication. doi: doi:10.3109/13625187.2014.919445
8. Evolución (2004-2013) de la tasa de riesgo de pobreza o exclusión social (estrategia Europa 2020) por edad y sexo [Evolution (2004-2013) of the risk rate of poverty or social exclusion (Europe 2020 Strategy) by age and sex]. 2013. Retrieved from http://www.ine.es/jaxi/tabla.do
9. La infancia en España. El valor social de los niños: Hacia un pacto de estado por la infancia [The childhood in Spain. The social value of children: Towards a state pact for childhood]. Madrid: UNICEF Comité Español. 2014.
10. Cabrera EM. Niños, niñas y adolescentes en acogimiento residencial: Un análisis en función del género [Children and adolescents in residential care: An analysis based on gender]. Qurriculum: Revista de Teoría, Investigación y Práctica Educativa 2015(28):88-102.
11. Observatorio de la Infancia. Estadística básica de medidas de protección a la infancia [Basic statistics of child care interventions] (vol. 14). Madrid: Ministerio de Sanidad, Políticas Sociales e Igualdad; 2012.
12. Biglan A, Mrazek PJ, Carnine D, Flay BR. The integration of research and practice in the prevention of youth problem behaviors. Am Psychol 2003; 58(6-7):433.
13. Putnam-Hornstein E, Cederbaum J, King B, & Needell B. California’s most vulnerable parents: A cross-sectional study of birth rate trends among girls in foster care. Los Angeles, CA: Children’s Data Network, University of Southern California; 2013.
14. S. Department of Health and Human Services. Adoption and foster care analysis and reporting system: The AFCARS report: Preliminary FY2013 estimates as of July 2014. www.acf.hhs.gov/sites/default/files/cb/afcarsreport21.pdf. Updated 2014.
15. Courtney M, Dworsky A, Ruth G, Tom Keller, Havlicek J, & Bost N, eds. Midwest evaluation of the adult functioning of former foster youth: Outcomes at age 19. Chicago, IL: Chapin Hall Center for Children at the University of Chicago. 2005.
16. Courtney ME, Dworsky AL, Cusick GR, Havlicek J, Perez A, Keller TE. Midwest evaluation of the adult functioning of former foster youth: Outcomes at age 21. 2007. Retrieved from http://www.chapinhall.org/sites/default/files/ChapinHallDocument_2.pdf
17. Zárate NE. Maternidad adolescente de las jóvenes tuteladas en Cataluña [Teenage motherhood of the young people supervised in Catalonia]. Universitat Autònoma de Barcelona; 2013.
18. Morales A, Espada JP, Orgilés M, Escribano S, Johnson BT, Lightfoot M. Interventions to Reduce Risk for Sexually Transmitted Infections in Adolescents: A Meta-Analysis of Trials, 2008-2016. Plos One (under review).