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Compendium of Evidence-Based Interventions and
Best Practices for HIV Prevention

Street Smart

GOOD-EVIDENCE

Intervention Description

Target Population
Runaway youth

Goals of Intervention

  • Eliminate or reduce sex risk behaviors
  • Eliminate or reduce substance use

Brief Description

Street Smart is a 10-session intensive small-group skills-based intervention for runaway youth. The intervention focuses on providing access to health resources, making condoms available, training youth on personal skills, and training staff to help support the youth in changing their behavior. In small groups of 5-6, the youth discussed the following topics: basics about HIV/STD risk, assessing personal risk and avoiding sexual risk, the correct use male and female condoms, how substance use affects sexual control and judgment, identifying and managing triggers for unsafe sex, and problem solving. Each session, youth use a “Feeling Thermometer” to help the youth recognize and discuss their feelings. Youth are taught to cope with their feelings by practicing coping skills and relaxation skills to control feelings of anxiety, depression, anger, and desire. The intervention focuses on positive self-talk to build self esteem, help with difficult situations, and increase self-efficacy for safer sex. Tokens of appreciation and compliments are exchanged among the youth to provide positive support for appropriate behavior and meeting HIV-related goals. Activities to promote positive attitudes, increase self-efficacy, and build effective communication, personal, and technical skills include games, exercises, practicing, role-playing. In addition, youth attended video and art workshops to develop media messages through soap opera dramas, public service announcements commercials, or raps to reinforce safer sex. An individual counseling session is provided to discuss attitudes, identify triggers and barriers, and develop a plan for coping and overcoming barriers to practice safer sex. Finally, youth visit a local community-based agency providing health and mental health care to learn about other available resources in the community.

Theoretic Basis

  • Social Learning Theory

Intervention Duration
10 sessions (9 small-group and 1 individual) delivered over a 3 week period

Intervention Settings
Four runaway youth shelters

Deliverer
Co-led by a trained researcher and a shelter staff

Delivery Methods

  • Counseling
  • Developing video and art media
  • Exercises/Games
  • Goal Setting
  • Group Discuss
  • Homework
  • Practice
  • Role Play
  • Video

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Intervention Package Information

An intervention package was developed with funding from CDC’s Replicating Effective Programs (REP) Project. The intervention package and training are available through CDC’s Diffusion of Effective Behavioral Interventions (DEBI) project.

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Evaluation Study and Results

The original evaluation was conducted in New York and New Jersey between 1988 and 1991.

Key Intervention Effects

  • Reduced unprotected sex

Study Sample
The propensity-matched baseline study sample of 187 runaway youths is characterized by:

  • 53% African American, 29% Hispanic, 17% White or other
  • 51% Male, 49% Female
  • Mean age of 16 years, range: 11-18 years
  • 45% dropped out of school

Recruitment Settings
Runaway youth shelters

Eligibility Criteria
All runaway youth at the four shelters

Assignment Method
Four shelters were assigned to 1 of 2 groups: Street Smart (n = 2 shelters; 167 participants) or comparison (n = 2 shelters; 144 participants). Baseline propensity scoring was used to identify comparable intervention and control sub-groups of youth for analyses (n = 187 overall; n = 101 Intervention, n = 88 comparison).

Comparison Group
Participants in the control shelters received routine shelter services. Staff received HIV education training and could have provided individual HIV-related risk reduction counseling to the youth. They were given local referrals for health concerns and condoms were made available at the shelters.

Relevant Outcomes Measured and Follow-up Time

  • Sex behaviors measured in the previous 3 months were: the number of sex partners, number of insertive or receptive vaginal, anal, or oral sex acts, number of unprotected sex acts of each type, and abstinent from vaginal or anal sexual acts.
  • Substance use behaviors measured in the previous 3 months were: prevalence and frequency of the use of alcohol, marijuana, crack, cocaine, hallucinogens, barbiturates, sedative, amphetamines, over the counter drugs, prescription drugs, and heroin.
  • Outcomes were measured at 3, 6, 12, 18, and 24 months after baseline which translates to approximately 0, 3, 9, 15, and 21 months after the intervention.

Participant Retention

  • Intervention (propensity-matched sub-sample):
    55% retained at immediate post-intervention
    60% retained at 3 months after the intervention
    40% retained at 9 months after the intervention
    41% retained at 15 months after the intervention
    65% retained at 21 months after the intervention
  • Control (propensity-matched sub-sample):
    59% retained at immediate post-intervention
    65% retained at 3 months after the intervention
    63% retained at 9 months after the intervention
    58% retained at 15 months after the intervention
    76% retained at 21 months after the intervention

Significant Findings
Among female youth, intervention participants reported significantly fewer unprotected sex acts than control participants at 21 months after the intervention (p = .018).

Considerations

  • This intervention fails to meet the best-evidence criteria due to low retention rates and assigning groups of individuals to study conditions while analyzing at the individual level.
  • The intervention was available at the intervention shelters throughout the 3 month period after assignment, so it is unclear if youth received more than the intended 10 sessions. This also means that the follow-up assessments translate to approximately 0, 3, 9, 15, 21 months after the intervention.
  • Among female youth, intervention participants were more likely to report abstinence from vaginal and anal sex than control participants at 15 months after the intervention (p = .088), although this finding was not statistically significant and was at a follow-up with low retention rates.
  • After identifying a propensity-matched sub-sample, baseline differences still existed. Those in the control group were more likely to report recent alcohol and marijuana use at baseline than those in the intervention group (p’s < .05).
  • There were no significant intervention effects among male youth for any of the intended outcomes except for a lower proportion of male youth reporting marijuana use immediately following the intervention, compared to control youth (p < .05). This finding does not meet GOOD-EVIDENCE criteria due to the type of outcome, no follow-up time, and low retention rates.
  • At 9 months after the intervention, female youth in the intervention were less likely to report using alcohol (p = .053) or marijuana (p = .005) and reported fewer numbers of drugs used (p = .019) than female youth in the control group. Similar findings were found for marijuana use and number of drugs used at 3 months after the intervention. These findings do not meet GOOD-EVIDENCE criteria due to the type of outcome and low retention rates at 9 months.
  • There were baseline differences in the original study sample. A propensity score matching that identified similar baseline sub-groups of intervention and control youth was conducted to protect the findings from confounding bias.
  • This intervention could be considered a community-level intervention as the intervention was available on an ongoing basis in the shelters for 3 months. Since the evaluation, utilizing a cohort design, can be reviewed using these criteria, this intervention is included within this review and will be updated later in the community-level intervention section of the website.

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References and Contact Information

  • Rotheram-Borus, M., Song, J., Gwadz, M., Lee, M., Van Rossem, R., & Koopman, C. (2003). Reductions in HIV risk among runaway youth. Prevention Science, 4, 173-187.
  • Rotheram-Borus, M., Koopman, S., Haignere, C., & Davies, M. (1991). Reducing HIV sexual risk behaviors among runaway adolescents. JAMA, 266, 1237-1241.

Researcher: Dr. Mary Jane Rotheram-Borus
Department of Psychiatry, University of California Los Angeles
10920 Wilshire Blvd, Suite 350
Los Angeles, CA 90024-6521
email: rotheram@ucla.edu 

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