Video Abstract

Video Abstract

OBJECTIVES:

In this study, we evaluate the efficacy of Families Talking Together (FTT), a triadic intervention to reduce adolescent sexual risk behavior.

METHODS:

Adolescents aged 11 to 14 and their female caregivers were recruited from a pediatric clinic; 900 families were enrolled; 84 declined. Families were randomly assigned to FTT or 1 of 2 control conditions. The FTT triadic intervention consisted of a 45-minute face-to-face session for mothers, health care provider endorsement of intervention content, printed materials for families, and a booster call for mothers. The primary outcomes were ever having had vaginal intercourse, sexual debut within the past 12 months, and condom use at last sexual intercourse. Assessments occurred at baseline, 3 months post baseline, and 12 months post baseline.

RESULTS:

Of enrolled families, 73.4% identified as Hispanic, 20.4% as African American, and 6.2% as mixed race. Mean maternal age was 38.8 years, and mean adolescent grade was seventh grade. At the 12-month follow-up, 5.2% of adolescents in the experimental group reported having had sexual intercourse, compared with 18% of adolescents in the control groups (P < .05). In the experimental group, 4.7% of adolescents reported sexual debut within the past 12 months, compared with 14.7% of adolescents in the control group (P < .05). In the experimental group, 74.2% of sexually active adolescents indicated using a condom at last sexual intercourse, compared with 49.1% of adolescents in the control group (P < .05).

CONCLUSIONS:

This research suggests that the FTT triadic intervention is efficacious in delaying sexual debut and reducing sexual risk behavior among adolescents.

What’s Known on This Subject:

Health care providers (HCPs) and parents are important partners in managing adolescent sexual and reproductive health. However, limited research has tested the efficacy of triadic interventions implemented with parents and HCPs to reduce adolescent sexual risk behavior.

What This Study Adds:

We show the efficacy and feasibility of a triadic intervention designed to target both HCPs and parents in reducing rates of adolescent sexual debut and promoting higher condom use at last sexual intercourse.

Adolescents in the United States experience significant negative sexual and reproductive health (SRH) outcomes, particularly Hispanic and African American adolescents. Although overall adolescent pregnancy and birth rates in the United States have decreased by >50% since 1990,1  rates remain high, with roughly 194 000 births to mothers aged 15 to 19 annually.2  Hispanic and African American adolescent girls have significantly higher teenaged birth, repeat birth, and teenaged pregnancy rates compared with overall national rates for their counterparts of the same age.2,3  Furthermore, the annual incidence of sexually transmitted infections (STIs) in adolescents aged 15 to 19 has increased by 19% since 2014, reaching a record high in 2018, with Hispanic and African American adolescents accounting for nearly half of the ∼500 000 STIs among youth.4  Additionally, adolescents and young adults aged 13 to 24 represent ∼21% of all new HIV diagnoses, with Hispanic and African American adolescents accounting for 4 in 5 new diagnoses among adolescents and young adults in 2018.5,6  Adolescent SRH disparities represent a national public health priority.710 

Health care providers (HCPs) (eg, physicians, nurses, nurse practitioners, and physician assistants) are critical actors in efforts to reduce negative adolescent SRH outcomes.1116  HCPs support adolescent SRH and reduce risk through anticipatory guidance and preventive care services such as STI screening, access to contraception, HPV vaccination, preexposure prophylaxis, and health education.914  In addition, HCPs offer care to adolescents who do experience negative SRH outcomes, including unplanned teenaged pregnancy, STIs, and HIV. The extant scientific literature indicates that adolescents consider their HCP an important and trusted resource for addressing SRH needs.17 

Nevertheless, adolescents overwhelmingly identify parents as the most significant influence in shaping their sexual decision-making.18  Parents are influential in a range of adolescent sexual behaviors, including timing of sexual debut, use of contraception (including condoms), and HIV testing.1922  However, strategies for reducing adolescent SRH disparities have tended to be focused directly on adolescents through school-based programs, community-based interventions, and media campaigns.2325  Parent-targeted interventions are less common, which is surprising given well-established evidence supporting the important parental role of shaping adolescent SRH outcomes and behaviors.2628 

Even more striking is the limited programming that combines parent and HCP efforts to jointly support adolescent SRH.27,29  National health organizations and practice guidelines support HCP efforts to involve parents in providing SRH services to adolescent patients.1116  Parents deem providers as excellent sources of information regarding the SRH needs of their adolescent children.27,29,30  Likewise, HCPs acknowledge the benefits of parental support in health care delivery to adolescent patients.29,31  Therefore, triadic (ie, provider-parent-adolescent) interventions relying on provider-initiated incorporation of parents into adolescent SRH care represent an innovative and promising approach to promote positive SRH outcomes in adolescents. Additionally, triadic interventions have the potential to be cost-effective and low effort because they can incorporate provider extenders (medical assistants, social workers, counselors, etc) for intervention delivery.32  However, there has been limited research testing the efficacy of triadic interventions linking parents, adolescents, and HCPs in reducing negative adolescent SRH outcomes.32 

The current study was a randomized clinical trial (RCT) designed to evaluate the efficacy of a clinic-based triadic intervention designed to reduce adolescent sexual risk behavior and support adolescent SRH. Adolescents in the triadic intervention group were hypothesized to engage in fewer sexual risk behaviors compared with control adolescents, including engagement in vaginal intercourse, debut of vaginal intercourse, and condom use at last sexual intercourse, as measured 12 months post intervention.

The current investigation is a formal efficacy trial of the Families Talking Together (FTT) triadic clinic intervention. We conducted a parallel RCT in which mother-adolescent dyads were randomly assigned to a control group that received no intervention, an active control group that received a nutrition-focused intervention, or an experimental group that received the FTT intervention. Data revealing preliminary efficacy and lessons learned from a small pilot study33  informed the methodology for the current investigation.

The research took place in a community-based health clinic located in an urban context with elevated incidence of teenaged pregnancy, STIs, and HIV among adolescents.34,35  The clinic is a federally qualified health center36  that provides primary and preventive care to underserved individuals regardless of income or health insurance status.37 

Mother-adolescent dyads were recruited in a health care clinic during a non–acute care visit (eg, annual physical examination and routine follow-up). Staff members were bilingual in English and Spanish and approached dyads to determine eligibility and describe the study. Dyads were eligible if the adolescent was aged 11 to 14, was either Hispanic or African American, and identified as heterosexual or indicated sexual attraction to opposite sex partners. “Mothers” refers to both biological and nonbiological primary adult female caregivers. Once eligibility was established, dyads were informed about the opportunity to participate in a research project focused on improving parent-adolescent communication. Interested dyads signed informed consent forms for mothers and assent forms for adolescents. The research was approved by the New York University Institutional Review Board.

The FTT triadic intervention is adolescent centered, parent involved, and HCP endorsed. FTT was designed to reduce adolescent sexual risk behaviors and shape adolescent SRH through collective efforts of HCPs, provider extenders, and parents. Dyads randomly assigned to the experimental group received the standard of care plus the FTT intervention for mothers. Provider extenders (paraprofessionals trained in the FTT program) delivered the intervention for 45 to 60 minutes while the adolescent completed the wellness visit. The FTT intervention included 4 components: (1) a face-to-face session delivered by a provider extender to familiarize mothers with the intervention materials, emphasizing specific strategies for parent-adolescent communication about sex, condom use, and strategies for parental monitoring; (2) written intervention materials (a family workbook) for mothers to use with the adolescent at home designed to support parental mastery of effective communication about sex and monitoring or supervision strategies; (3) an HCP endorsement of the intervention to adolescents and mothers, conveying the importance of parent-adolescent communication regarding intervention content; and (4) 1 phone booster session 1 month after the face-to-face intervention in which provider extenders reinforced FTT messages. At no time did the intervention interfere with confidential time between the provider and adolescent patient.

The active control condition was similar to the experimental condition, except the content pertained to nutrition information instead of FTT. Mothers randomly assigned to the passive control group returned to the waiting room after completing the baseline survey. HCPs interacted with mothers and adolescents as they would with any patient not enrolled in the study.

Adolescents and their mothers were assessed at baseline and at 3 and 12 months post baseline via self-report surveys. After consenting and meeting with the HCP for their appointment, adolescents completed baseline questionnaires in a confidential room. Surveys included a measure of social desirability response tendencies and warm-up questions to familiarize participants with the measurement scales.38  English and Spanish surveys were available to participants and were administered on the basis of language preference. Before the study, surveys were pilot tested for readability and comprehension.

Three months post baseline, project staff set up appointments for follow-up assessments in participants’ homes or at a mutually agreed on location in the community. Staff administered 3-month follow-up assessments to detect group differences in mother-adolescent communication about intervention content. Twelve months post baseline, a follow-up assessment was scheduled to determine group differences in adolescents’ reports of primary and secondary outcomes. For each assessment, mothers and adolescents received incentives of $15 and $10, respectively.

The primary outcome measures for this study were ever having had vaginal intercourse, sexual debut (defined as the first act of vaginal intercourse) within the past year, and condom use at last vaginal intercourse. At the 12-month follow-up, condom use at last sexual intercourse was assessed among sexually active adolescents.

The secondary outcome measures were related to adolescent reports of maternal monitoring and communication about sex. Maternal communication about sex was assessed by using a 5-point Likert-type scale. Adolescents reported their level of agreement with 3 items regarding communication within the previous 3 months about delaying sexual intercourse, STIs, and contraception use (including condoms). Maternal monitoring of knowledge was assessed by using a 5-point Likert-type scale via the item “My mother knows where I am after school.” Maternal monitoring of behavior was assessed with 4 statements regarding discussing plans with mothers, discussing when rules are broken, checking in on adolescents’ lives, and expectations for adolescents to call home when running late.

To assess the extent to which adolescents in the experimental arm were exposed to specific intervention content and to evaluate risk for potential contamination in the control arm, mean levels of exposure to specific FTT intervention content were measured at 3 months post baseline by using a 5-point Likert-type scale (described in Table 1).

TABLE 1

Mean Values of Exposure to FTT Intervention Dosage, Control Versus Experimental Arms

FTT Intervention Content3-mo Follow-up
FTTControlDifference in Mean95% CI
Mean (SE)Mean (SE)
Maternal values regarding sex 3.84 (0.06) 3.22 (0.09) 0.62* 0.41–0.83 
Healthy relationship meaning 3.75 (0.06) 3.29 (0.09) 0.46* 0.25–0.67 
Teenager reasons for delay of sexa 3.92 (0.06) 3.20 (0.09) 0.72* 0.51–0.94 
Resisting peer pressure 3.78 (0.06) 2.88 (0.09) 0.90* 0.68–1.12 
Dating rules and maternal expectations 3.89 (0.06) 3.35 (0.09) 0.53* 0.33–0.74 
FTT Intervention Content3-mo Follow-up
FTTControlDifference in Mean95% CI
Mean (SE)Mean (SE)
Maternal values regarding sex 3.84 (0.06) 3.22 (0.09) 0.62* 0.41–0.83 
Healthy relationship meaning 3.75 (0.06) 3.29 (0.09) 0.46* 0.25–0.67 
Teenager reasons for delay of sexa 3.92 (0.06) 3.20 (0.09) 0.72* 0.51–0.94 
Resisting peer pressure 3.78 (0.06) 2.88 (0.09) 0.90* 0.68–1.12 
Dating rules and maternal expectations 3.89 (0.06) 3.35 (0.09) 0.53* 0.33–0.74 
a

Refers to mother communication about why social reasons for having sex are not good reasons on a scale from 1 to 5, with higher scores reflecting more mother-adolescent communication about teenager reasons for delay of sex.

*

Statistically significant at P < .05.

A computer program was used to generate a randomly permutated scheme to allocate subject identification numbers to the experimental, passive control, and active control conditions in a 4:1:1 ratio. The principal investigator for the study generated the allocation sequence. After mothers completed the baseline assessment, a sealed envelope was opened by the project staff member who administered the assessment to assign dyads an identification number. Follow-up data collectors were blinded to participant conditions.

Formal evaluation of the RCT relied on linear and logistic regression for continuous and dichotomous outcome variables, respectively. Primary and secondary outcomes were analyzed by using intention-to-treat analyses. For intention to treat, all dyads randomly assigned at baseline were included in the analysis.39  During preliminary analysis, no statistically significant differences in primary and secondary outcomes emerged between the active and passive control conditions; therefore, both control conditions were pooled into one control condition during subsequent analyses (Fig 1). Power analyses were based on pilot data.33  For single degree-of-freedom contrasts of means, a sample size of ∼75 per group at α = .05 yielded power of 0.80 to detect a medium effect size, as defined by Cohen (standardized d value = 0.50).40  For comparing percentages, a sample size of ∼280 per group yielded power of 0.80 for detecting a seven-percentage-point difference between 2 groups. To have sufficient power for subanalyses among sexually active youth, a sample size of 900 dyads was obtained for this study.

FIGURE 1

Consolidated Standards of Reporting Trials flow diagram.

FIGURE 1

Consolidated Standards of Reporting Trials flow diagram.

To address missing data, we employed multiple imputation with the mice package of the R statistical computing environment.41,42  A total of 50 imputed data sets were generated, with primary outcome logistic regression analyses repeated for each imputation. Results were then pooled across imputations, with inferences and confidence intervals (CIs) considering within- and between-imputation variance. Diagnostic plots revealed good convergence of the data-augmentation algorithm for multiple imputations.

From July 19, 2010, to May 31, 2016, we screened 1256 mother-adolescent dyads for eligibility, of whom 984 were eligible for study participation. Eighty-four dyads declined to participate. Six hundred dyads were randomly assigned to the FTT group, whereas 300 dyads were randomly assigned to either the passive standard-of-care or active nutrition intervention control groups. Participants were followed for 12 months.

Of the 900 dyads participating in the study, 73.4% identified as Hispanic, 20.4% identified as African American, and 6.2% identified as mixed race (both Hispanic and African American). The mean (SD) age of mothers (range 18–78 years) was 38.8 (8.4) years, and the mean (SD) grade of adolescents (range grades 6–8) was 6.9 (0.9). Three percent of adolescents reported having had sexual intercourse. Complete demographic information for participating dyads, stratified by condition, is displayed in Table 2. Attrition was low; 91.4% of dyads interviewed at baseline completed the 12-month follow-up survey.

TABLE 2

Demographics of Study Sample

CharacteristicsFTT (n = 600)Control (n = 300)
Mothersa   
 Age, y, mean (SD) 38.6 (8.0) 39.3 (9.1) 
 Spanish speaker at home, n (%) 317 (52.8) 174 (58.0) 
 Born in the United States, n (%) 242 (40.3) 117 (39.0) 
 Religiosity, mean (SD)b 3.3 (1.0) 3.3 (1.0) 
 Married, n (%) 176 (29.3) 92 (31.0) 
 Education, n (%)c   
  Completed high school or less 337 (56.2) 170 (56.9) 
  Some college or associate’s or bachelor’s degree 249 (41.6) 119 (39.8) 
  Graduate degree 13 (2.2) 10 (3.3) 
  Reported parent-adolescent communication about sexc 440 (73.6) 228 (76.0) 
Adolescents   
 Grade, n (%)c   
  Sixth 263 (44.1) 125 (41.8) 
  Seventh 139 (23.3) 76 (25.4) 
  Eighth 194 (32.6) 98 (32.8) 
 Male sex, n (%) 267 (44.5) 125 (41.7) 
 Race/ethnicity, n (%)c   
  Hispanic 437 (72.8) 221 (73.7) 
  African American 116 (19.3) 63 (21.0) 
  Mixed race 47 (7.8) 16 (5.3) 
 Spanish speaker, n (%) 163 (27.2) 73 (24.3) 
 Born in the United States, n (%) 465 (77.5) 223 (74.3) 
 Religiosity, mean (SD)b 2.7 (1.1) 2.8 (1.1) 
 Reported parent-adolescent communication about sex, n (%)c 394 (65.8) 193 (64.5) 
 Sexual behavior, n (%)d   
  Ever sex at baseline 12 (2.0) 12 (4.0) 
  Current sex at baseline 6 (1.0) 6 (2.0) 
CharacteristicsFTT (n = 600)Control (n = 300)
Mothersa   
 Age, y, mean (SD) 38.6 (8.0) 39.3 (9.1) 
 Spanish speaker at home, n (%) 317 (52.8) 174 (58.0) 
 Born in the United States, n (%) 242 (40.3) 117 (39.0) 
 Religiosity, mean (SD)b 3.3 (1.0) 3.3 (1.0) 
 Married, n (%) 176 (29.3) 92 (31.0) 
 Education, n (%)c   
  Completed high school or less 337 (56.2) 170 (56.9) 
  Some college or associate’s or bachelor’s degree 249 (41.6) 119 (39.8) 
  Graduate degree 13 (2.2) 10 (3.3) 
  Reported parent-adolescent communication about sexc 440 (73.6) 228 (76.0) 
Adolescents   
 Grade, n (%)c   
  Sixth 263 (44.1) 125 (41.8) 
  Seventh 139 (23.3) 76 (25.4) 
  Eighth 194 (32.6) 98 (32.8) 
 Male sex, n (%) 267 (44.5) 125 (41.7) 
 Race/ethnicity, n (%)c   
  Hispanic 437 (72.8) 221 (73.7) 
  African American 116 (19.3) 63 (21.0) 
  Mixed race 47 (7.8) 16 (5.3) 
 Spanish speaker, n (%) 163 (27.2) 73 (24.3) 
 Born in the United States, n (%) 465 (77.5) 223 (74.3) 
 Religiosity, mean (SD)b 2.7 (1.1) 2.8 (1.1) 
 Reported parent-adolescent communication about sex, n (%)c 394 (65.8) 193 (64.5) 
 Sexual behavior, n (%)d   
  Ever sex at baseline 12 (2.0) 12 (4.0) 
  Current sex at baseline 6 (1.0) 6 (2.0) 
a

Refers to both biological and nonbiological primary adult female caregivers. Nonbiological caregivers include older siblings, grandmothers, foster parents, etc. In all instances, mothers were defined as the adult female caregiver primarily responsible for the adolescent.

b

Refers to how important religion is to the adolescent and/or parent on a scale from 1 to 4, with higher scores reflecting higher levels of religiosity.

c

Variable has missing data at baseline. Table reflects a valid percentage.

d

Assessed with 2 indicators at baseline. Ever sex refers to whether the adolescent has ever engaged in vaginal intercourse over his or her lifetime. Current sex refers to vaginal intercourse within the past 90 d.

At the 12-month follow-up, 5.2% of adolescents who received the FTT intervention had engaged in sexual activity, compared with 18.0% of adolescents in the control group (relative risk [RR] 3.50; [95% CI: 2.30–5.32]; P < .05). Additionally, only 4.7% of adolescents who received the FTT reported sexual debut within the past 12 months, compared with 14.7% of adolescents in the control group (RR 3.12 [95% CI: 1.98–4.91]; P < .05).

At the 12-month follow-up, among adolescents who reported ever having sexual intercourse, 74.2% of adolescents who received the FTT intervention reported using a condom at the last sexual intercourse, compared with 49.1% of adolescents in the control group (RR 1.48 [95% CI: 1.05–2.08]; P < .05) (see Table 3).

TABLE 3

Effects of FTT Triadic on Adolescent Sexual Behavior Outcomes

12 mo Follow-up
FTTControlRR95% CI
n (%)n (%)
Primary outcomes     
 Ever vaginal intercourse 31 (5.2) 54 (18.0) 3.50* 2.30–5.32 
 Sexual debut during past 12 moa 28 (4.7) 44 (14.7) 3.12* 1.98–4.91 
 Condom use at last sexual intercourseb 23 (74.2) 26 (49.1) 1.48* 1.05–2.08 
12 mo Follow-up
FTTControlRR95% CI
n (%)n (%)
Primary outcomes     
 Ever vaginal intercourse 31 (5.2) 54 (18.0) 3.50* 2.30–5.32 
 Sexual debut during past 12 moa 28 (4.7) 44 (14.7) 3.12* 1.98–4.91 
 Condom use at last sexual intercourseb 23 (74.2) 26 (49.1) 1.48* 1.05–2.08 
a

Dichotomous outcome; 1 = adolescent reported ever having sex at 12-mo follow-up and not at baseline, and 0 = adolescent reported ever having sex at baseline or never having sex at 12-mo follow-up.

b

Dichotomous outcome assessed among adolescents who reported ever having sex at the 12-mo follow-up.

*

Statistically significant at P < .05.

At the 12-month follow-up, adolescents in the experimental group reported higher levels of parent-adolescent communication about delay of sex (unstandardized beta coefficient [B] = 0.64 [95% CI: 0.42–0.86]; P < .05), STIs and HIV (B = 0.60 [95% CI: 0.37–0.83]; P < .05), and using contraception and/or condoms (B = 0.37 [95% CI: 0.13–0.61]; P < .05) compared with adolescents in the control group. Furthermore, adolescents in the experimental group reported increased maternal monitoring knowledge and behavior, including monitoring of whereabouts after school (B = 0.15 [95% CI: 0.03–0.61]; P < .05), monitoring of plans with friends (B = 0.32 [95% CI: 0.15–0.50]; P < .05), discussion after breaking a rule or previous agreement (B = 0.28 [95% CI: 0.15–0.40]; P < .05), checking in regularly (B = 0.23 [95% CI: 0.05–0.40]; P < .05), and being expected to call when late (B = 0.13 [95% CI: 0.01–0.25]; P < .05) (see Table 4).

TABLE 4

Effects of FTT Triadic on Parental Influence Outcomes

12-mo Follow-up
FTT (n = 600)Control (n = 300)Difference in Mean95% CI
Mean (SE)Mean (SE)
Mother-adolescent communication     
 Delay of sex 3.76 (0.06) 3.12 (0.09) 0.64* 0.42–0.86 
 STIs or HIV 3.83 (0.07) 3.23 (0.09) 0.60* 0.37–0.83 
 Using contraception and/or condoms 3.55 (0.07) 3.18 (0.10) 0.37* 0.13–0.61 
Maternal monitoring of adolescent     
 Monitoring knowledge     
  Knows whereabouts after school 4.64 (0.04) 4.49 (0.05) 0.15* 0.03–0.27 
 Monitoring behavior     
  Discusses plans with mother 4.35 (0.05) 4.02 (0.07) 0.32* 0.15–0.50 
  Discussion after breaking rule 4.65 (0.04) 4.37 (0.05) 0.28* 0.15–0.40 
  Checks in regularly 4.19 (0.05) 3.96 (0.08) 0.23* 0.05–0.40 
  Call mother when late 4.64 (0.04) 4.52 (0.05) 0.13* 0.01–0.25 
12-mo Follow-up
FTT (n = 600)Control (n = 300)Difference in Mean95% CI
Mean (SE)Mean (SE)
Mother-adolescent communication     
 Delay of sex 3.76 (0.06) 3.12 (0.09) 0.64* 0.42–0.86 
 STIs or HIV 3.83 (0.07) 3.23 (0.09) 0.60* 0.37–0.83 
 Using contraception and/or condoms 3.55 (0.07) 3.18 (0.10) 0.37* 0.13–0.61 
Maternal monitoring of adolescent     
 Monitoring knowledge     
  Knows whereabouts after school 4.64 (0.04) 4.49 (0.05) 0.15* 0.03–0.27 
 Monitoring behavior     
  Discusses plans with mother 4.35 (0.05) 4.02 (0.07) 0.32* 0.15–0.50 
  Discussion after breaking rule 4.65 (0.04) 4.37 (0.05) 0.28* 0.15–0.40 
  Checks in regularly 4.19 (0.05) 3.96 (0.08) 0.23* 0.05–0.40 
  Call mother when late 4.64 (0.04) 4.52 (0.05) 0.13* 0.01–0.25 
*

Statistically significant at P < .05.

In the analysis of the intervention dosage, we explored the extent to which adolescents were exposed to specific FTT intervention content. Adolescents in the experimental group reported higher levels of mother-adolescent communication across topics (Table 1). The control arm of the study was evaluated for potential intervention content contamination. Less than 5% of the control arm reported previous exposure to FTT material.

We examined the potential moderating effects of race and/or ethnicity and sex on the overall treatment effects for each primary outcome. The treatment effects did not vary significantly for boys compared with girls or by race and ethnicity. To assess the generalizability of results across traditional and robust methods of analysis, we repeated all analyses with bootstrapping. No differences were detected. Furthermore, we conducted outlier and specification-error diagnostics for all analyses. The statistical checks returned no problematic results. Missing data were minimal (91% of the subjects randomly assigned at baseline completed the study). No statistically significant differential attrition between arms was observed.

With this study, we provide evidence for the efficacy of a clinic-based triadic intervention implemented with HCPs, provider extenders, and adolescents and their mothers for delaying sexual activity and reducing sexual risk behavior. Adolescents in the intervention group were significantly more likely to delay sexual debut, use a condom at the last sexual intercourse, and report increased maternal communication about delay of sex and maternal monitoring.

Noteworthy in our data was the enhanced condom use in the FTT group. Condoms represent an important multipurpose technology for the prevention of unintended pregnancy, STIs, and HIV.43  However, condom use among ninth-graders has declined significantly over the past decade, with only 54.5% reporting condom use at the last sexual intercourse in 2017.44  At the 12-month follow-up, only 49.1% of sexually active adolescents in the control group indicated condom use at the last sexual intercourse, similar to baseline rates. In contrast, adolescents in the experimental group reported significantly elevated rates of condom use at the last sexual intercourse (74.2%). With the current study, we provide evidence that triadic interventions are effective in shaping both adolescent condom use and parent-adolescent communication about contraception and/or condoms. Therefore, triadic interventions represent a novel mechanism for supporting national STI and HIV prevention efforts in the United States.

Taken as a whole, brief HCP endorsement of FTT content to mothers and adolescents represents a powerful, novel, and practical tool for promoting adolescent SRH. Previous research has revealed that parents are influential in adolescent SRH.1922,28  However, clinical responsibilities and associated time constraints limit HCPs’ ability to provide extensive consultations regarding parental involvement in adolescent SRH. Our results support the efficacy and added benefit of brief HCP endorsements of a parent-based intervention delivered by provider extenders. Provider extenders include medical assistants, social workers, counselors, etc, who can deliver the most time-intensive interventions (ie, face-to-face sessions and phone booster calls) and are easily embedded in the clinical setting. Given clinical realities, a provider extender–delivered SRH triadic intervention that includes a brief HCP component is a practical solution for addressing calls from parents and national health organizations for more parental involvement in adolescent SRH care. In summary, the FTT intervention for clinical settings represents an innovative, feasible, and low-cost tool45  to strengthen partnerships between HCPs, parents, and adolescents to reduce negative SRH outcomes among younger adolescents.

Despite the strengths of this study, there are some limitations to our findings. First, the outcome measures relied on self-reports, which may be biased on the basis of social desirability. However, the random assignment of participants and the use of a social desirability index controlled for potential self-report bias. Second, we recruited participants in a single geographic and clinic setting, so generalizability to other settings may be limited. Furthermore, the follow-up (12 months) for the study was relatively short given that the mean age at sexual debut is 17 years.46  Findings must be interpreted with caution when generalizing to older adolescents. Third, the research was limited to mother-adolescent dyads, as mothers were most likely to be present at their adolescent children’s health care clinic appointments. Future researchers should explore strategies to increase paternal involvement in adolescent SRH and ideal settings to recruit fathers.47  Fourth, for subanalyses of condom use among sexually active youth, we were only able to include a proportion of the 900 enrolled dyads. Future researchers should extend the findings of this study to understand how triadic interventions can impact condom use among the more sexually active older age groups. Fifth, future research should specifically be focused on sexual minority youth and their families. Lastly, primary outcomes were limited to adolescent reports of vaginal intercourse. Future researchers should explore how triadic clinic-based interventions influence adolescent oral and anal sexual behavior.

The FTT triadic intervention implemented with HCPs, mothers, and adolescents delayed sexual debut and reduced sexual risk behaviors among Hispanic and African American adolescents. Intervention delivery by provider extenders, combined with a brief HCP component, represents an innovative, brief, and comparatively low-cost option45  for broad dissemination of triadic SRH interventions in pediatric and adolescent health clinical settings. Broad uptake and implementation of the FTT triadic intervention in pediatric and adolescent health clinics represents a potential opportunity to achieve progress toward national goals to reduce STIs, HIV, and unplanned pregnancies among adolescents across the United States.79 

Deidentified individual participant data will not be made available.

The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Dr Guilamo-Ramos conceptualized and designed the study, oversaw data collection and intervention delivery, and drafted the initial manuscript; Mr Benzekri and Mr Thimm-Kaiser assisted with analysis and interpretation of the data and drafted the initial manuscript; Dr Dittus assisted with the conceptualization and design of the study; Dr Ruiz was involved in the acquisition of data; Dr Cleland served as a biostatistician, was involved in the review of data, and assisted with the analyses and interpretation of data; Dr McCoy was involved in the implementation of the project and the acquisition of data; and all authors reviewed and revised the manuscript, approved the final manuscript as submitted, agree to be accountable for all aspects of the work.

This trial has been registered at www.clinicaltrials.gov (identifier NCT01326806).

FUNDING: Funded by the National Institutes of Health (NIH) (R01HD066159; principal investigator: Dr Guilamo-Ramos). Funded by the National Institutes of Health (NIH).

     
  • B

    unstandardized beta coefficient

  •  
  • CI

    confidence interval

  •  
  • FTT

    Families Talking Together

  •  
  • HCP

    health care provider

  •  
  • RCT

    randomized clinical trial

  •  
  • RR

    relative risk

  •  
  • SRH

    sexual and reproductive health

  •  
  • STI

    sexually transmitted infection

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Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.