Project IMAGE is a cognitive-behavioral intervention intended to reduce high-risk sexual behavior and sexually transmitted infections (STIs) among ethnic minority adolescent women with a history of psychological, sexual or physical abuse and STIs. The intervention draws on health-promoting elements of African- and Mexican-American culture to help adolescents recognize the risks of STI acquisition and learn strategies to reduce sexual risk behavior. The program is comprised of workshops, support group sessions and individual counseling sessions.
Project IMAGE is a cognitive behavioral intervention intended to reduce subsequent sexually transmitted infections (STIs) among ethnic minority adolescent women with a history of psychological, sexual or physical abuse and STIs.
The Project IMAGE adaptation is for use with adolescents with a history of STIs and abuse, and draws on health-promoting elements of African- and Mexican-American culture to help adolescents recognize the risks of STI acquisition and learn strategies to reduce sexual risk behavior. The intervention includes three components:
Project IMAGE draws on health-promoting elements of African- and Mexican-American culture to help adolescents recognize the risks of STI acquisition and learn strategies to reduce sexual risk behavior. The intervention is recommended for use with adolescents with risky sexual behavior, not just African- and Mexican-American youth.
Jane Dimmitt Champion, PhD, DNP, FNP, FAAN, FAANP, is an internationally renowned researcher and scholar in the area of sexual health promotion and risk reduction of rural and ethnic minority adolescents and women. She has served as Principal, Co-Principal, or Co-Investigator on 37 interdisciplinary research projects of which 25 were NIH funded. By developing and testing her interventions in primary care clinics, she has directly increased access to health care and health promotion for an underserved population.
Dr. Champion’s early research work focused largely on sexual health promotion and reduction of sexual- related risk behaviors. More recently, she has added components to her interventions to improve interpersonal relationships and communication, reduce interpersonal violence, and increase general health promotion behaviors. These additional components have contributed to positive participant responsiveness to the interventions with astonishingly high retention rates (nearly 90%) for longitudinal studies lasting 12 months.
Dr. Champion has an impeccable record of dissemination with a direct link from research to presentations to publications. She has over 90 peer-reviewed publications in inter-disciplinary journals, and has presented her work over 250 times at international, national and regional/local conferences. Her expertise has been sought by the National Institutes of Health and the Centers for Disease Control and Prevention for reviews of research grants and program applications. These activities led her to be recognized as a prestigious Fellow in the American Academy of Nursing and as a Fellow in the American Academy of Nurse Practitioners.
Sites that have used Project IMAGE include the San Antonio Metropolitan Health District and rural primary-care-based clinics.
Project IMAGE consists of two 3- to 4-hour workshops, three 1.5- to 2-hour support group sessions, and two or more individual counseling sessions. The more support and counseling sessions the youth participate in, the greater the expected outcome.
The Project IMAGE Basic Set includes the facilitator's manual, slide presentations, participant handouts, DVDs and pamphlets on STIs and birth control.
One female leader (community health worker or women’s sexual health professional) is recommended to lead each Project IMAGE workshop. Support groups and counseling sessions should be led by women’s sexual health professionals. To insure success, it is critical for staff members leading the program to have extensive experience with the target population and to have attended proper training on delivering the intervention.
Project IMAGE is based upon adaptations of the AIDS Risk Reduction Model and is grounded in knowledge of the target populations’ behavior and culture. Knowledge of African- and Mexican-American culture informed conceptualization of behavior change in terms of adolescent perceptions of costs versus benefits. A great deal of emphasis is placed upon understanding and dealing with male-female power relationships in the African- and Mexican-American culture. The greatest cost of behavior change to an adolescent may be the consequences of saying "no" to non-safe sex or questioning a partner about other relationships. The cost—the potential risk of losing a partner—may be greater than the benefit of behavior change.
The impact of violence in the lives of adolescents is compounded by their history of violence and the potential for a current partner to become violent. The complexity of situational factors such as level of education, job skills, social support and psychological distress further complicate the effect of violence on adolescent lives. To the extent that perceptions of poverty-related stress, self-esteem deficits and substance abuse issues are also present, the threat of violence or the loss of a partner may appear worse than the possible contraction of a STI, even HIV. The intervention respects cultural norms, seeking neither to change culture nor to change social and economic situations that result from being poor. Rather, interventions were created to utilize cultural strengths that promote health and enhance self-esteem.
A cultural strength of members of the African- and Mexican-American culture—the valuation of childbearing, children and family—was incorporated into the intervention. The emphasis on childbearing issues is used to remind the adolescents of the benefit of reducing risk behavior or maintaining low-risk behavior to prevent STI/HIV, thereby preserving fertility and overall health to provide for children and family. The intervention stresses contraceptive use, reconsidering choice of partner, and skills training in meeting new partners with whom having and up-bringing of children would be more viable. Emphasis is on incorporation of sexual health promotion behaviors as part of daily living to promote well-being.
The program logic model can be found here:
Logic Model (pdf) (coming soon)
Clinical research was conducted to evaluate the effects of Project IMAGE (theory-based [AIDS Risk Reduction Model] cognitive behavioral intervention) versus enhanced counseling for ethnic minority adolescent women on infection with sexually transmitted infection. A randomized controlled trial with longitudinal follow-up at 6 and 12 months was conducted with 409 African- and Mexican-American adolescent women with histories of high-risk sexual behavior; psychological, physical or sexual abuse; or sexually transmitted disease who were seeking sexual health care at a metropolitan community-based clinic in the southwestern United States. The mean age of participating adolescents was 16.5 years; 16% were African American and 84% were Mexican American.
Participants were recruited from a community-based health clinic and screened for HIV/STIs, pregnancy and history of physical or sexual abuse. Among those participants who were determined to be eligible and agreed to participate, about half were randomly selected for a treatment group that received the Project IMAGE intervention and half were selected for a control group. Intervention participants received workshop, support group and individual counseling sessions. Control participants received abuse and enhanced clinical counseling. STI testing was conducted before the intervention (baseline) and during a 12-month follow-up period.
Extensive preliminary study for intervention development was conducted including individual interviews, focus groups, secondary data analysis, pre-testing and feasibility testing for modification of an evidence-based intervention prior to testing in the randomized controlled trial. Following informed consents for participation in the trial, detailed interviews concerning demographics, abuse history, sexual risk behavior, sexual health and physical exams were obtained.
Follow-up including detailed interviews and physical exams conducted at 6 and 12 months following study entry to assess for infection. Intention to treat analysis was conducted to assess intervention effects using chi-square and multiple regression models.
This cognitive behavioral intervention specifically designed for Mexican-and African- American adolescent women with a history of abuse and sexually transmitted infection was effective for prevention of infection.
At both the 6- and 12-month follow-up, adolescents participating in the intervention were significantly less likely to experience any new STI. These results provided evidence for further development and translation of evidence-based interventions for community- based prevention of sexually transmitted infection/HIV. Implications include translation to community-clinic-based settings for prevention of adverse outcomes regarding sexual health of adolescent women.
Champion, J. D., J. L. Collins. 2012. Comparison of a theory-based (AIDS risk reduction model) cognitive behavioral intervention versus enhanced counseling for abused ethnic minority adolescent women on infection with sexually transmitted infection: Results of a randomized controlled trial. International Journal of Nursing Studies 49 (2): 138–150.
ETR is a leader in developing adaptation guidelines to enable professionals to adapt evidence-based intervention programs for implementation in underserved communities, while maintaining fidelity to the intervention's core components. ETR works with program developers to ensure that these tools are of the highest quality and meet the different needs of the field and end users, e.g., teachers, trainers, program mangers/staff, research teams, and funders.
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For over 30 years, ETR has been building the capacity of community-based organizations, schools, school districts, and state, county and local agencies in all 50 states and 7 U.S. territories to implement and replicate evidenced-based programs (EBPs) to prevent teen pregnancy, STD/STI and HIV. Our nationally recognized training and research teams work in partnership with clients to customize training and technical assistance (TA) to address the needs of their agencies and funding requirements.
It is highly recommended that clinic staff selected to implement Project IMAGE receive research-based professional development to prepare them to effectively implement the curriculum with its intended target group.
Training on Project IMAGE is available through ETR’s Professional Learning Services. Training options include:
ETR provides in-person and web- or phone-based TA before, during and/or after program implementation. TA is tailored to the needs of the site and is designed to support quality assurance, trouble-shoot adaptation issues, and boost implementation.
To support a holistic approach to teen pregnancy and HIV prevention programs, ETR offers a number of additional training and technical assistance opportunities, including content-specific workshops, skill-based trainings, organizational development consultation and much more. To learn more about these opportunities, visit our Training & TA pages >>
Adaptation support materials, training and/or TA are available to assist educators/clinic staff in meeting the needs of individual communities by implementing EBPs effectively and consistently with core components. All adaptation support is based on ETR's groundbreaking, widely disseminated adaptation guidelines and kits for effective adaptations.
ETR also provides evaluation support for EBP implementation. ETR uses well-established tools for measuring fidelity and outcomes. ETR's evaluation support blends participatory approaches with cutting-edge evaluation science. Services address process and outcome evaluation and include assistance with evaluation planning, instrument design and development, implementation fidelity, data management and analysis, performance measurement, continuous quality improvement (CQI) protocols, and effective tools and strategies for reporting results.