Complete a case analysis of Avon Corporation A formal, in-depth .docx

Complete a case analysis of Avon Corporation
A formal, in-depth case analysis requires you to utilize the
entire strategic-management process. Assume your group is a
consulting team asked by Avon Corporation to analyze its
external/internal environment and make strategic
recommendations. You will be required to make
exhibits/matrices to support your analysis and
recommendations. The case analysis must encompass 10–12
pages plus the exhibits/matrices, cover page, and reference
page. The cover page must include the company name, your
group name, and the date of submission. The matrices must not
be part of the analysis body but exhibits.
The completed case must include:
Executive summary;
Existing vision, mission, objectives, and strategies;
SWOT analysis;
Porter's 5 Forces;
Value Chain Analysis;
Financial Ratio Analysis;
Balance Score Card;
Intellectual Assets: Human Capital, Social Capital, Technology;
Organizational Design;
A list of alternative strategies, giving advantages and
disadvantages for each;
A recommendation of specific strategies and long-term
objectives;
An action timetable/agenda.
Have your group leader place the results of the case analysis in
a single document and post it to the Group Case Analysis 2
forum of your Group Discussion Board Forum. Be sure that the
assignment is in a business-professional format; include current
APA citing and referencing.

Research Article
CHOICES-TEEN: Reducing Substance-
Exposed Pregnancy and HIV Among
Juvenile Justice Adolescent Females
Danielle E. Parrish
1
, Kirk von Sternberg
2
, Laura J. Benjamins
3
,
Jacquelynn Duron
4
, and Mary Velasquez
2
Abstract
Objective: The feasibility and acceptability of CHOICES-
TEEN—a three-session intervention to reduce overlapping risks
of
alcohol-exposed pregnancy (AEP), tobacco-exposed pregnancy
(TEP), and HIV—was assessed among females in the juvenile
justice system. Method: Females aged 14–17 years on
community probation in Houston, TX, were eligible if
presenting with
aforementioned health risks. Outcome measures—obtained at 1-

and 3-months postbaseline—included the Timeline Followback,
Client Satisfaction Questionnaire-8, session
completion/checklists, Working Alliance Inventory–Short, and
open-ended ques-
tions. Twenty-two participants enrolled (82% Hispanic/Latina;
mean age ¼ 16). Results: The results suggest strong
acceptability
and feasibility with high client satisfaction and client/therapist
ratings, 91% session completion, and positive open-ended
responses. All youth were at risk at baseline, with the following
proportions at reduced risk at follow-up: AEP (90% at
1 month, 71.4% at 3 months), TEP (77% of smokers [n ¼ 17] at
reduced risk at 1 month, 50% at 3 months), and HIV (52.4% at
1 month, 28.6% at 3 months).
Keywords
adolescent, HIV infections, alcohol, juvenile justice, substance-
exposed pregnancy
Adolescent females detained or on probation in juvenile justice
settings often engage in multiple health behaviors that place
them at risk of HIV and substance-exposed pregnancies
(Lawrence, Snodgrass, Robertson, & Baird-Thomas, 2008;
Rosengard et al., 2006). Specifically, they engage in frequent
sexual behaviors that put them at risk of unplanned pregnancy,
sexually transmitted infections (STIs; Belenko et al., 2008),
and HIV (Committee on Pedatric AIDS, 2006) while also
smoking (Helstrom, Bryan, Hutchison, Riggs, & Blechman,

2004) and engaging in alcohol use (Lawrence et al., 2008),
which further place them at risk of both tobacco-exposed preg-
nancy (TEP) and alcohol-exposed pregnancy (AEP; Delpisheh,
Attia, Drammond, & Brabin, 2006; Helstrom et al., 2004).
There are well-documented health consequences of smoking
and drinking during pregnancy for both female youth and the
fetus (Delpisheh et al., 2006; Kulig, 2005; Wiemann &
Berenson, 1998). While many cease alcohol or cigarette use
after discovering they are pregnant (Forray, Merry, Lin, Ruger,
& Yonkers, 2015), nearly half of the U.S. pregnancies are
unplanned (Finer & Zolna, 2016) with females unaware of their
pregnancy continuing to drink or smoke during the early and
critical weeks of gestation. Compared with adult women, ado-
lescents are more likely to have an unplanned pregnancy, take
longer to recognize they are pregnant (De Genna, Larkby, &
Cornelius, 2007), and are less likely to reduce alcohol or
tobacco consumption once they find out they are pregnant
(Cornelius et al., 1994), putting them at higher risk of TEP or

AEP. These pregnancies are also at risk for mother-to-child
HIV or STI, as many of these youth may not seek early or
regular prenatal care (CDC, 2018a).
The association between substance use and STI/HIV sexual
risk behavior among youth is well-documented, with younger,
female, and racially/ethnic minority populations at highest risk
of HIV infection through heterosexual contact (CDC, 2018b;
Howard & Wang, 2004). Co-occurring substance use and sex-
ual risk behaviors are more pronounced among juvenile justice
populations, with females in these settings presenting with a
unique, multirisk profile (Rosengard et al., 2006; Teplin,
Mericle, McClelland, & Abram, 2003). While nationally rep-
resentative samples are generally lacking for this population,
1 Baylor University, Houston, TX, USA
2
University of Texas at Austin, Austin, TX, USA
3
University of Texas Mc Govern Medical School, Houston, TX,
USA
4 Rutgers University, The State University of New Jersey, New

Brunswick, NJ,
USA
Corresponding Author:
Danielle E. Parrish, Baylor University, 4100 Main St., Houston,
TX 77002, USA.
Email: [email protected]
Research on Social Work Practice
2019, Vol. 29(6) 618-627
ª The Author(s) 2018
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several trends have been identified in the literature. Alcohol use
and smoking are more prevalent and comorbid among females
in criminal justice settings (Helstrom et al., 2004; Parrish et al.,
2011), with delinquent adolescent females reporting more fre-
quent smoking than males and nearly a third meeting clinical

criteria for a substance use disorder (Cropsey, Linker, & Waite,
2008; Domalanta, Risser, Roberts, & Risser, 2003; Helstrom
et al., 2004; Lederman, Dakof, Larrea, & Li, 2004). In addition,
most (90%) are sexually active and less than half use condoms
or contraception (Crosby et al., 2004; Kingree, Braithwaite, &
Woodring, 2000; Lawrence et al., 2008; Teplin et al., 2003).
Approximately a third of female youth in these settings have
previously been pregnant one or more times (Lawrence et al.,
2008; Lederman et al., 2004; Schmiege, Broaddaus, Levin, &
Bryan, 2009). Compared with community female youth sam-
ples, this population engages in earlier and more frequent
sexual risk behavior with multiple partners (Lederman
et al., 2004).
Females in juvenile justice settings are also consistently at
high risk of STIs and sexually transmitted HIV compared to
their noninvolved peers and at an even higher risk than their
male involved counterparts (Belenko et al., 2008), reporting
less frequent condom use (Belzer et al., 2001; Broaddus &
Bryan, 2008; Committee on Pedatric AIDS, 2006; Kelly,

Lesser, & Paper, 2008; Robertson, Stein, & Baird-Thomas,
2006) and more frequent acquisition of STIs placing them at
further risk of HIV infection (CDC, 2018a).
Despite this population’s unique, multirisk health profile
and the critical opportunity to intervene while youth are on
community probation, there is a paucity of gender-specific
prevention programming to reduce these risks (DiClemente
et al., 2014; Lawrence et al., 2008). This presents a challenge
for prevention and highlights an urgent need to develop effica-
cious, gender-specific, multirisk “bundled” (targeting more
than one behavior) prevention approaches for this vulnerable
population (Belenko et al., 2008; Committee on Pediatric
AIDS, 2006; Ickovics, 2008). Bundling efficiently aggregates
services to promote synergistic gain when intervening with
high-risk populations that do not routinely seek services
(Ickovics, 2008) and is increasingly being used in medical or
other opportunistic settings. While not yet tested with adoles-
cents, a bundling (Ickovics, 2008; Parrish et al., 2011) or

multiple-behavior approach (Geller, Lippke, & Nigg, 2017;
Nigg, Allegrante, & Ory, 2002) has shown promise in more
efficiently reducing health risk behavior (Werch, 2007). There
is a need, however, to conduct research to better understand
which and how many behaviors can be bundled and for which
target populations (Werch, 2007).
The CHOICES Line of Research
and CHOICES-TEEN
One possibility to meet these overlapping needs among the
female juvenile justice population is to adapt an existing
empirically supported prevention intervention for adult women
called the CHOICES preconception intervention. This
intervention utilizes the transtheoretical model of behavior
change, motivational interviewing (MI), and content aimed to
increase participants’ motivation to change risky alcohol use,
smoking, and contraception use, along with a referral for con-
traception education and services (Velasquez, von Sternberg, &
Parrish, 2013). The need for the CHOICES intervention and its

efficacy has been demonstrated through a line of epidemiolo-
gical and intervention research funded by the Centers for Dis-
ease Control and Prevention (CDC; Floyd et al., 2007; Project
CHOICES Intervention Research Group, 2003; Velasquez
et al., 2017). In the first multisite randomized controlled trial
testing the efficacy of a four-session version of CHOICES
among high-risk women of childbearing age (18–44), the
CHOICES intervention group, relative to a brief advice group,
significantly reduced their risk of AEP (69.1% vs. 54.3%) and
had 2-fold greater odds of being at reduced risk of AEP at
9 months (Floyd et al., 2007). This intervention has been
broadly disseminated to the public, with the original manual
and related training materials available on the CDC website
(https://www.cdc.gov/ncbddd/fasd/choices-implementing-choi
ces.html). This first aforementioned efficacy study highlighted
the need (and opportunity) to also prevent nicotine-exposed
pregnancies, as more than 70% of those at risk of AEP were
also smoking (Floyd et al., 2007). Analysis of study data also
indicated that women receiving two sessions were as likely to

reduce their risk of AEP as those receiving four. Consequently,
a second efficacy trial was funded by the CDC to test a two-
session version of CHOICES, called CHOICES Plus, that
would also focus on reducing the overlapping risk of TEP
within a large, public medical setting (Velasquez et al.,
2017). This study also supported the efficacy of CHOICES Plus
in significantly reducing the risk of both AEP and TEP among
women aged 18–44 years compared to a brief advice group
(Velasquez et al., 2017).
CHOICES-TEEN was adapted from the original CHOICES
and CHOICES Plus preconception interventions to be devel-
opmentally appropriate for adolescent females and reduced
HIV/STI risk in addition to reducing risks of AEP and TEP
(Floyd et al., 2007; Project CHOICES Intervention Research
Group, 2003; Velasquez et al., 2010; Velasquez et al., 2017).
CHOICES-TEEN builds upon the CHOICES line of research
by expanding the reach of this intervention to high-risk adoles-
cent females who are—compared to adult women—more

likely to have an unplanned pregnancy, take longer to realize
they are pregnant, and less likely to stop using substances once
they realize they are pregnant (Cornelius et al., 1994; Cnattin-
gius, 2004; De Genna et al., 2007). This intervention, which
will be described in more detail in the Methods section, con-
sists of two sessions with a master’s level counselor, a session
with an adolescent medicine specialist to discuss HIV/STI and
pregnancy prevention, possible referral for HIV/STI testing
and contraceptive services, and a referral to a phone-based
smoking cessation program called the Texas Quitline. The
intervention was delivered to female youth on intensive juve-
nile community probation.
Parrish et al. 619
https://www.cdc.gov/ncbddd/fasd/choices-implementing-
choices.html
choices.html
The aims of this one-arm pilot study were to further under-
stand the feasibility of targeting multiple bundled health risks

in high-risk adolescents as well as to evaluate the feasibility
and potential promise of an adapted gender-specific prevention
intervention—CHOICES-TEEN—in reducing the risks of
HIV/STI, TEP, and AEP among adolescent females on com-
munity probation.
Materials and Method
Following Stage 1a/1b intervention development guidelines
(Rounsaville, Carroll, & Onken, 2001), a one-arm design was
used to assess the reductions of risk (among an all-risk sample
at baseline) following the CHOICES-TEEN intervention at 1-
and 3-month follow-up. Supplemental data were collected to
assess client adherence, retention, acceptability, and the feasi-
bility and quality of treatment delivery. Data were collected by
research assistants trained in the study protocol. This study was
approved by the Harris County Juvenile Justice, University of
Houston and University of Texas Health Science Center at
Houston Institutional Review Boards.
Female adolescents aged 14–17 years were recruited from

three community probation programs in Houston, TX. Youth
assent and the parent/guardian permission were obtained in
person or by phone to conduct eligibility screenings. To be
eligible, participants were at risk of HIV/STI, AEP, and TEP
and had all of the following behaviors in the prior 3 months:
(1) sexual intercourse with a male, (2) inconsistent/ineffec-
tive condom use, (3) inconsistent/ineffective contraception
use, (4) drinking at risky levels (>3 drinks in 1 day or >7
drinks in a week), and (5) current smoking. Given that this
was a feasibility study, and the initial recruitment numbers
were lower than expected, the smoking inclusion criterion
was relaxed after 6 months to ensure an adequate sample.
Of the 150 females screened, 31 (21%) were at risk of both
AEP and TEP and 37 (25%) at risk of AEP. If eligible, the
voluntary nature and details of the study were described to
the youth and guardian using IRB-approved assent and per-
mission documents, questions were elicited and answered,
and written informed consent was obtained from youth and
parent/guardians prior to study participation. As shown in

Figure 1, three (8.1%) declined participation and six
(16.2%) did not return to the site for various reasons (e.g.,
additional criminal charges and noncompliance with the pro-
gram). Of the 28 who returned for assent/parental permission
and baseline assessment, 2 were identified as ineligible, leav-
ing a pool of 26 from which 4 did not return for similar
aforementioned reasons. Of the 22 participants who started
the intervention, 20 completed all three sessions (91%) and 2
completed one session. One- and 3-month follow-up assess-
ments were obtained for all 21 of the 22 (95%) youth who
received the intervention. While two youth initiated the
smoking Quitline fax referral, none of them completed this
component of the program.
CHOICES-TEEN Intervention
HIV risk (Floyd et al., 2007; Project CHOICES Intervention
Research Group, 2003; Velasquez et al., 2010, 2017). The effi-
cacy of the CHOICES and CHOICES Plus bundled preconcep-

tion interventions in reducing the risks of AEP and TEP among
adult women in high-risk settings has been established through
a series of CDC-funded studies (Floyd et al., 2007; Project
et al., 2017). CHOICES-TEEN builds upon this work by
expanding the reach of this intervention to high-risk adolescent
females. As shown in Table 1, CHOICES-TEEN includes two
motivational counseling sessions with a master’s level counse-
lor, one session with an adolescent medicine physician, and a
referral to the Texas Tobacco Quitline. The Quitline accepts
fax referrals from physicians of youth who are ready to quit
smoking. A Quitline counselor then assesses the youth for one
or more of the following referrals: telephone counseling,
community-based cessation services, and youth friendly smok-
ing cessation materials.
Master’s level counselors, previously trained for prior
CHOICES intervention studies, provided the counseling ses-
sions and were supervised by experts in MI and the CHOICES-

TEEN intervention. The majority of sessions (68.2%) were
provided by one of the three master’s level counselors, and
outcome did not differ by counselor at 3-month outcome. All
sessions were audio-recorded, and 15% were reviewed for
quality and fidelity using the Motivational Interviewing Integ-
rity Scale 3.1.1 and CHOICES-TEEN protocol checklist. All
counselors were deemed as proficient in the intervention by a
CHOICES expert who is also a member of the Motivational
Interviewing Network of Trainers. The adolescent medicine
physicians, who provided the second session focused on HIV
and pregnancy risk reduction education and the development of
a healthy behavior plan, received a 3-hr training on the use of
MI in a medical context and the CHOICES-TEEN protocol.
Measures
Demographic and background health variables. Demographic
and
background health variables, including sexual activity/risk
behaviors and substance use history/frequency, were collected
using an audio computer-assisted self-administered interview
(ACASI). The AUDIT, a 10-item questionnaire used to mea-

sure alcohol use and problems, was also used to describe the
sample with regard to harmful drinking (Babor, de la Fuente,
Saunders, & Grant, 1992).
Timeline followback interview (TLFB). The TLFB interview,
which
collected detailed self-report behavior data using a calendar
recall method, was administered by a trained interviewer at
baseline (i.e., 90 days prior), 1-month postbaseline follow-up,
and 3-month postbaseline follow-up (Floyd et al., 2007; Sobell,
620 Research on Social Work Practice 29(6)
Brown, Leo, & Sobell, 1996; Velasquez et al., 2017). Data
collected included number of daily alcohol drinks, sexual activ-
ity, condom use, effective contraception, and smoking. These
data were divided into 30-day increments to calculate the fol-
lowing: (1) risk drinking (>3 drinks in 1 day or >7 drinks in a
week), (2) risk of pregnancy (any occurrence of vaginal inter-
course without effective contraception including condoms), (3)
HIV risk (any occurrence of vaginal or anal sex without a

condom), (4) AEP risk (any occurrence of risk drinking plus
any occurrence of vaginal intercourse without effective contra-
ception during the same time period), and (5) TEP risk (any
smoking plus any occurrence of vaginal intercourse without
effective contraception during the same period).
Client Satisfaction Questionnaire–8 (CSQ-8). Client satisfaction
was measured using the CSQ-8 (Attkisson & Zwick, 1982).
This standardized measure consists of eight questions followed
by a 4-point Likert-type scale, with possible scores ranging
between 8 and 32, and higher scores indicating higher levels
of satisfaction. This questionnaire was administered, along
with five open-ended questions about the intervention, using
the ACASI in a private setting at the end of the 3-month follow-
Assessed for eligibility (n=150)
Excluded (n= 122)
♦ Not meeting inclusion criteria (n= 83)
■ No risk of pregnancy (n=83)
■ No sex (n=64)
■ No risk drinking (n=84)
■ No smoking (n=83)
♦ Declined to participate (n= 3)

♦ Other reasons; program attrition (n= 6)
Lost to follow-up 1-month (n=1)
Lost o follow-up 3-months (n=0)
Allocated to intervention (n= 22)
■ Completed Counseling Session One (n=22)
■ Completed Adolescent Fellow Session (n=20)
■ Completed Counseling Session Two (n=20)
■ Accepted Smoking Referral (n=3)
■ Health Clinic Visit (n=7)
Program Attrition, Did Not Return
(n=4)
Found Ineligible at Baseline (n=2)
Returned for Parental
Permission/Assent (n= 28)
Figure 1. Study flow diagram.
Parrish et al. 621
up. The five open-ended questions solicited comments/sugges-
tions, what was liked about the intervention, what was liked
least about the intervention, suggestions for improvement, and
the most important aspects of the intervention.
Working-Alliance Inventory–Short (client/therapist). This

measure is
used to assess three key aspects of the therapeutic alliance—
agree-
ment on the goals of therapy, tasks of therapy, and the develop-
ment of an affective bond (Hatcher & Gillaspy, 2006). This
scale
consists of 12 items followed by a 7-point Likert-type scale,
which
ranges from never to always. This scale was administered to
both
the youth and the counselor at each of two counseling sessions.
Data Analysis
The Statistical Package for Social Sciences (SPSS Version 23)
was used to conduct all analyses. Descriptive statistics were
used to describe the sample, reductions in dichotomous risk of
AEP, TEP, and HIV among an all risk sample at baseline,
feasibility and acceptability measures, and responses to the
CSQ-8 at 3-month follow-up. Inferential statistics were not
used to assess behavior change, as all youth were considered
to be at risk of AEP, TEP, and HIV at baseline. A simple
thematic analysis was conducted of brief open-ended responses

concerning the acceptability of the intervention provided by the
youth when completing the CSQ-8 at 3-month follow up. These
questions asked about what was liked most and least about the
intervention and suggestions for improving the intervention.
Results
Participants ranged in age from 14 to 17, with a mean age of
16 years (SD ¼ .89). Eighty-two percent were Hispanic/Latina,
with 55% reporting Mexican origin. The sample was racially
Table 1. CHOICES-TEEN Intervention Session Components.
Session 1
Provided by Master’s Level
Counselor
Session 2
Contraceptive/HIV Risk
Reduction Counseling
Provided by Adolescent
Physician
Session 3
Provided by Master’s
Level Counselor
Smoking Cessation Referral
Provided by American
Cancer Society’s Texas

State Quitline, Which Serves
Adolescents 13 and Older
� Rapport building
� Review of fact sheets:
� Important things for young
women to know about alcohol,
smoking, pregnancy, and birth
control
� Important facts for young
women about HIV/STDs
� Abstinence or safer sex
� Introduce and encourage
contraceptive and HIV risk
reduction counseling visit
� Advice and referral to smoking
cessation program if currently
smoking
� Decisional balance for pros and
cons of
� Drinking
� Smoking
� Contraceptive use
� Condom use
� Complete Self-evaluation rulers
addressing readiness to change
drinking, smoking, condom use,
and contraception

� Introduce Daily Journal for drinking,
smoking, intercourse, and
contraception (including condoms)
� Brochures on alcohol, smoking,
HIV, contraceptive methods, and
community resources
� Summarize session
� Discuss and answer questions
about HIV transmission and
ways to reduce risk
� Determine appropriate and
suitable contraceptive
methods including the option
of abstinence
� Provide referral for HIV
testing at most convenient
testing site that provides
condoms
� Complete a healthy behavior
plan, which details plans/
referral for preventing
pregnancy and HIV
� Provide condoms if desired
(parental permission was
required by site)
� Provide follow-up clinical care
or referral as needed

� Provide personalized
feedback (derived from
baseline assessment)
� Discussion of
temptation and
confidence profiles for
all four behaviors
� Review and discussion
of information recorded
in the Daily Journal
� Discuss contraception
and counseling/HIV risk
reduction visit
� Review smoking
brochure and discuss
smoking cessation
referral (as applicable)
� Review of decisional
balance exercises for
each behavior
� Completion of initial
goal statement and
change plans for each
behavior
� Provide community
resource list (if
applicable)

� Determine readiness to
change
� Provide behavioral counseling
for smoking cessation
Note. STDs ¼ sexually transmitted diseases.
diverse with 18% Black, 18% White, 9% American Indian/
native Hawaiian, 4.5% multiracial, and 27% reporting race
as Hispanic/Mexican American. The youth were all English
speaking. However, we did have a Spanish-speaking counse-
lor available to provide the intervention in Spanish if needed
and to communicate with Spanish-speaking parents/guar-
dians. Prior arrests ranged from 1 to 10 or more, with 59%
only having 1 or 2. Participants reported prior arrests for the
following reasons: 45% assault, 41% petty theft, 27% truancy,
22% possession of marijuana or other drugs, 18% running
away, and 14% trespassing. With regard to sexual orientation,
73% were heterosexual and 23% bisexual. All youth reported
using drugs in the last 6 months, and among those who
smoked, five were daily smokers. The mean AUDIT score
was 2.5 (SD ¼ 2.87).

Risk of AEP, TEP, and HIV/STI
Of the 22 participants who received the intervention, one did
not complete the follow-up assessments. Reduction of AEP,
TEP, and HIV risk was based on the frequency of youth in the
at-risk or reduced risk category based on the TLFB at each
follow-up period. Successful change was categorized as
“reduced risk” instead of “no risk” because all contraception
methods, including condoms, fail a certain percentage of the
time even with perfect use. As noted previously, these data
were divided into 30-day increments to calculate the presence
of combined or single risk behaviors within each time frame
over a continuous 7-month period: 3-month baseline (3
months prior to baseline), 1-month follow-up (from baseline
to 1 month later), and 3-month follow-up (from 1 month to 3
months postbaseline). AEP risk was defined as the presence of
risk drinking and risk of unplanned pregnancy during the
same time period, TEP risk was defined as any smoking plus
risk of unplanned pregnancy during the same period, and

HIV/STI risk as any occurrence of vaginal or anal sex without
a condom.
Ninety percent (n ¼ 19) of participants were at reduced risk
of AEP at 1 month, and 71.4% (n ¼ 15) were at reduced risk at
3 months. Using an intent-to-treat analysis (treating the drop
out as a failure), 86.4% were at reduced risk at 1 month and
68.2% were at reduced risk at 3 months.
Seventeen of the 22 (77%) participants were smokers and at
risk of TEP at baseline. Of those at risk at baseline, 68.8% (n ¼
11) were at reduced risk at 1 month and 50% (n ¼ 8) were at
reduced risk at 3 months. With the intent-to-treat analysis,
64.7% were at reduced risk at 1 month and 47.1% were at
reduced risk at 3 months. Of those who smoked at baseline,
71.4% reported currently smoking cigarettes at 1 month and
73.3% at 3 months.
All 22 participants who received the intervention were at
HIV/STI risk at the baseline. Fifty-two percent were at reduced
risk at 1 month, and 28.6% were at reduced risk at 3 months. Of
the 11 who were not at risk of unplanned pregnancy at
3 months, only 2 were not using condoms while sexually active
and using another contraceptive method. Using an intent-to-
treat analysis, 50% were at reduced risk for HIV/STI at 1 month
and 27.3% were at reduced risk at 3 months.

The route by which the youth reduced their AEP and TEP
risk is provided in Figure 2.
A = Used Effective Contraception/Abstinence A = Used
Effective Contraception/Abstinence
B= Reduced Risk Drinking Only B= Smoking Cessation Only
AB = Reduced Both Risks AB = Reduced Both Risks
AB
33.3%
(n=5)
B
26.7%
(n=4)
A
40%
(n=6)
B
36.8%
(n=7)
AB
42.1%
(n=8)
A
21.1%
(n=4)
Routes of Reduced AEP Risk

1 month
3 months
Routes of Reduced TEP Risk
B
18.2%
(n=2)
AB
27.3%
(n=3)
A
54.5%
(n=6)
A
75%
(n=6)
AB
25%
(n=2)
B
(n=0)
Figure 2. Distribution of youth achieving reduced risk of
alcohol-exposed pregnancy and tobacco-exposed pregnancy at 1
month and 3 months.
Parrish et al. 623

Feasibility
The CHOICES-TEEN intervention checklist indicated that all
aspects of the intervention were delivered and that the sessions
did not exceed the planned 45- to 60-min duration. The
CHOICES-TEEN MI Scale, which assessed the degree to
which counselors believed they emphasized various aspects
of an MI approach, was rated as over a 4 on a 1–5 scale for
all items. CHOICES-TEEN counselors indicated per structured
session notes that all participants appeared to comprehend ses-
sion tasks. The average per-item mean for youth on the task
(M¼ 5.99, SD¼ .97), bond (M¼6.04, SD¼ .95), and goal (M¼
5.56, SD ¼ 1.12) subscales of the Working Alliance Inventory–
Short ranged between 5 (often) and 7 (always) on a 1–7 scale.
Participant Acceptance/Satisfaction With Intervention
All except one of the 22 youth enrolled in the intervention
completed all three sessions delivered on site at a weekly
community-based probation program. In response to the anon-
ymously administered CSQ-8 at 3-month follow-up, female

youth (n ¼ 20) reported high levels of satisfaction (M ¼ 24,
SD ¼ .71; average per-item mean ¼ 3) with the intervention,
with scores ranging from 23 to 25. Specifically, 60% described
the quality of services as “excellent” and 40% described the
services as “good.” Despite being a nontreatment seeking pop-
ulation, fifty-five percent of youth indicated that they
“definitely” received the service desired, with 45% indicating
they “generally” did. Sixty percent indicated “most” of their
needs have been met by the intervention, while 35% indicated
“almost all” of their needs were met, and one youth indicated
their needs were not met. All youth indicated they would refer a
friend in need of similar help to the program. Ninety-five per-
cent of youth reported being “mostly” or “very” happy with the
amount of help they received. With regard to overall satisfac-
tion, 65% reported being very satisfied, and 35% mostly satis-
fied. Ninety-five percent indicated they would return to the
program if they were to seek help again. Twenty of the 22
participants provided anonymous written feedback to the
open-ended questions that followed the CSQ-8. Responses
indicated that youth valued the opportunity to be honest in a
relational, confidential setting and that the counselors and doc-
tors provided useful information that they did not know or had

not considered. In particular, the youth appreciated the oppor-
tunity to have a conversation with a physician to obtain accu-
rate information about their options for preventing unplanned
pregnancy and HIV/STIs. Youth suggested the program may be
more successful if assistance was provided for transportation
and appointment setting with the health clinics. They also sug-
gested that the program expand to reduce the health and preg-
nancy risks associated with marijuana and other drugs.
Discussion
This one-arm feasibility study suggests that the CHOICES-
TEEN intervention is feasible, acceptable, and promising with
regard to reducing the risk of AEP, TEP, and HIV/STI among
female youth involved with the juvenile justice system. The
retention of youth who began the intervention was 91% for all
three sessions, and youth reported feeling positively about the
intervention, suggesting that the intervention was acceptable.
With regard to feasibility, all intervention components were
completed with ease within the designated session time frames.

Taken together, these findings suggest that it is feasible to
target multiple health-risk behaviors (smoking, risk drinking,
contraception use, and condom use) simultaneously with this
high-risk population. However, future research with a control
group will be necessary to test the efficacy of this intervention.
The reductions in risk of AEP were comparable to reduc-
tions of risk found in CHOICES intervention studies with
women (Floyd et al., 2007; Velasquez et al., 2017). With regard
to TEP, the reduction of risk was 50% in this study and 69.8%
in the CHOICES Plus study (Velasquez et al., 2017). However,
this sample only included five youth reporting daily smoking,
suggesting many of these youth may be engaging in light and
intermittent smoking which often mistakenly perceived by
youth as less harmful or addictive (Amrock & Weitzman,
2015). This may be one of the reasons that few youth accepted
and followed up with the smoking cessation referral. In addi-
tion, open-ended feedback from the youth suggested that smok-
ing was a temporary replacement for marijuana, while they
were being randomly drug tested by probation. This suggests

a need to better understand the patterns of smoking and mar-
ijuana use among high-risk females in these settings for pur-
poses of preventing substance-exposed pregnancy.
The proportions of youth reducing HIV/STI risk at 3-month
follow-up were not as high compared to AEP and TEP, which
is not surprising as there is only one way to reduce this risk—
condom use. While it is most ideal that youth reduce their risk
of pregnancy by either abstinence or using both condoms and
other contraceptive methods, it is encouraging that the large
majority of youth who reduced their risk of pregnancy in the
study were using condoms, which protect against both
unplanned pregnancy and HIV/STIs. In addition, HIV/STI pre-
vention research with juvenile justice populations has generally
resulted in more modest effect sizes for behavioral change
(Tolou-Shams, Stewart, Fasciano, & Brown, 2010), highlight-
ing a need to develop more robust interventions.
Despite encouraging findings, these results should be inter-
preted with some caution, given the small sample size and lack

of a control group. Also, while self-report measures are a major
data source for clinical and resource purposes, they have been
criticized for potential bias. However, retrospective self-reports
of behavior collected in settings which minimize these poten-
tial biases have been shown to be reliable and valid. Still, future
research would benefit by incorporating biological measures
that further substantiate self-report. Finally, given feedback
from the youth and the providers, it may be useful to expand
the CHOICES-TEEN model to incorporate marijuana and other
drugs as well as to explore the utility of providing all of the
aspects of the intervention in a postadjudication placement
setting to reduce client transportation challenges and the time
commitment for travel of providers.
Implications for Practice and/or Policy
Given the limited research on gender-sensitive interventions
with female youth in juvenile justice settings, this research

highlights several implications for practice and policy. First,
this is the first study to report on the prevalence of substance-
exposed pregnancy in a sample of female youth in the juvenile
justice system. Of the 150 youth screened, 25% were at risk of
AEP in this study, which is much higher than the 3.4% at risk in
the general population (Cannon et al., 2015). This finding,
combined with the aforementioned literature documenting
these overlapping risks in multiple, larger samples of female
youth, suggests an urgent need for interventions and/or policy
to reduce these risks. Specifically, programming should be
provided that informs female youth of these risks as well as
efficient, prevention interventions that have promise for broad
prevention impact. AEP is 100% preventable, has been recently
estimated to be more prevalent than autism (May et al., 2018),
and can lead to costly lifelong cognitive, behavioral, emotional,
and adaptive functioning deficits. Smoking and HIV/STIs can
also severely affect the health of both female youth and their
children both during and after pregnancy (e.g., second-hand
smoke; HHS, 2014; Delpisheh et al., 2006; Kulig, 2005; Wie-

mann & Berenson, 1998). As such, the development of and
funding for early prevention programs for one of the society’s
highest risk populations that rarely receives integrated health
care are essential.
Second, this study suggests integrated, multirisk bundled
motivational enhancement interventions provided at opportu-
nistic times can be feasible, acceptable, and potentially promis-
ing for female youth in the juvenile justice system. As such,
programs that focus on more than just one risk behavior during
times of detention or community probation may be more effi-
cient and cost-effective. Finally, youth appreciated the oppor-
tunity to receive individualized information about their sexual
health and substance use in an accepting and supportive con-
text. Such efforts can be further bolstered by ensuring better
access to referrals by providing transportation to follow-up
medical visits, as this can be a major service barrier for this
population. Finally, none of the youth in this study accepted the
incoming smoking cessation Quitline referral phone calls. As

such, nontelephonic options, such as the U.S. Health and
Human Service’s QuitSTART technology application, may
be a better fit for some youth.
Conclusions
CHOICES-TEEN is acceptable and feasible and appears pro-
mising for reducing overlapping, bundled health risks—AEP,
TEP, and HIV—among high-risk female youth in juvenile jus-
tice settings. Given the potential for impacting multiple, over-
lapping health risks in an opportunistic manner, future research
should examine the efficacy of this intervention with a more
robust sample.
Acknowledgments
Harris County Juvenile Probation provided essential support of
this
project by facilitating essential partnerships and space in the
field.
Robin Harris provided coordination of the project in the field,
and
Barbie Atkinson, Matiko Bivens and Lisa Connelly were the
CHOICES-TEEN counselors. Rebecca Beyda, M.D. and Laura

Grubb M.D., provided the Adolescent Medicine risk reduction
coun-
seling sessions. Alicia Kowalchuk, M.D. provided Motivational
Interviewing training for the Adolescent Medicine Fellows, and
Nanette Stephens provided fidelity monitoring and training for
the
CHOICES-TEEN counselors. Ralph DiClemente, Ph.D. and
Carrie
Randall, Ph.D. provided consultation to support the
implementation
of this project.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with
respect to
the research, authorship, and/or publication of this article.
Funding
The authors disclosed receipt of the following financial support
for the
research, authorship, and/or publication of this article: This
study was
funded by Grant Number 1R03DA034099 from the National
Institute

of Drug Abuse, National Institutes of Health.
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Research Article
CHOICES-TEEN: Reducing Substance-
Exposed Pregnancy and HIV Among
Juvenile Justice Adolescent Females
Danielle E. Parrish1, Kirk von Sternberg2, Laura J. Benjamins3,
Jacquelynn Duron4, and Mary Velasquez2
Abstract
Objective: The feasibility and acceptability of CHOICES-
TEEN—a three-session intervention to reduce overlapping risks
of
alcohol-exposed pregnancy (AEP), tobacco-exposed pregnancy
(TEP), and HIV—was assessed among females in the juvenile
justice system. Method: Females aged 14–17 years on
community probation in Houston, TX, were eligible if
presenting with
aforementioned health risks. Outcome measures—obtained at 1-
and 3-months postbaseline—included the Timeline Followback,

Client Satisfaction Questionnaire-8, session
completion/checklists, Working Alliance Inventory–Short, and
open-ended ques-
tions. Twenty-two participants enrolled (82% Hispanic/Latina;
mean age ¼ 16). Results: The results suggest strong
acceptability
and feasibility with high client satisfaction and client/therapist
ratings, 91% session completion, and positive open-ended
responses. All youth were at risk at baseline, with the following
proportions at reduced risk at follow-up: AEP (90% at
1 month, 71.4% at 3 months), TEP (77% of smokers [n ¼ 17] at
reduced risk at 1 month, 50% at 3 months), and HIV (52.4% at
1 month, 28.6% at 3 months).
Keywords
adolescent, HIV infections, alcohol, juvenile justice, substance-
exposed pregnancy
Adolescent females detained or on probation in juvenile justice
settings often engage in multiple health behaviors that place
them at risk of HIV and substance-exposed pregnancies
(Lawrence, Snodgrass, Robertson, & Baird-Thomas, 2008;
Rosengard et al., 2006). Specifically, they engage in frequent
sexual behaviors that put them at risk of unplanned pregnancy,
sexually transmitted infections (STIs; Belenko et al., 2008),
and HIV (Committee on Pedatric AIDS, 2006) while also
smoking (Helstrom, Bryan, Hutchison, Riggs, & Blechman,

AEP. These pregnancies are also at risk for mother-to-child
HIV or STI, as many of these youth may not seek early or
regular prenatal care (CDC, 2018a).
The association between substance use and STI/HIV sexual
risk behavior among youth is well-documented, with younger,
female, and racially/ethnic minority populations at highest risk
of HIV infection through heterosexual contact (CDC, 2018b;
Howard & Wang, 2004). Co-occurring substance use and sex-
ual risk behaviors are more pronounced among juvenile justice
populations, with females in these settings presenting with a
unique, multirisk profile (Rosengard et al., 2006; Teplin,
Mericle, McClelland, & Abram, 2003). While nationally rep-
resentative samples are generally lacking for this population,
1 Baylor University, Houston, TX, USA
2 University of Texas at Austin, Austin, TX, USA
3 University of Texas Mc Govern Medical School, Houston, TX,
USA
4 Rutgers University, The State University of New Jersey, New
Brunswick, NJ,
USA
Corresponding Author:

Danielle E. Parrish, Baylor University, 4100 Main St., Houston,
TX 77002, USA.
Email: [email protected]
Research on Social Work Practice
2019, Vol. 29(6) 618-627
ª The Author(s) 2018
Article reuse guidelines:
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DOI: 10.1177/1049731518779717
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several trends have been identified in the literature. Alcohol use
and smoking are more prevalent and comorbid among females
in criminal justice settings (Helstrom et al., 2004; Parrish et al.,
2011), with delinquent adolescent females reporting more fre-
quent smoking than males and nearly a third meeting clinical
criteria for a substance use disorder (Cropsey, Linker, & Waite,
2008; Domalanta, Risser, Roberts, & Risser, 2003; Helstrom
et al., 2004; Lederman, Dakof, Larrea, & Li, 2004). In addition,

most (90%) are sexually active and less than half use condoms
or contraception (Crosby et al., 2004; Kingree, Braithwaite, &
Woodring, 2000; Lawrence et al., 2008; Teplin et al., 2003).
Approximately a third of female youth in these settings have
previously been pregnant one or more times (Lawrence et al.,
2008; Lederman et al., 2004; Schmiege, Broaddaus, Levin, &
Bryan, 2009). Compared with community female youth sam-
ples, this population engages in earlier and more frequent
sexual risk behavior with multiple partners (Lederman
et al., 2004).
Females in juvenile justice settings are also consistently at
high risk of STIs and sexually transmitted HIV compared to
their noninvolved peers and at an even higher risk than their
male involved counterparts (Belenko et al., 2008), reporting
less frequent condom use (Belzer et al., 2001; Broaddus &
Bryan, 2008; Committee on Pedatric AIDS, 2006; Kelly,
Lesser, & Paper, 2008; Robertson, Stein, & Baird-Thomas,
2006) and more frequent acquisition of STIs placing them at

further risk of HIV infection (CDC, 2018a).
Despite this population’s unique, multirisk health profile
and the critical opportunity to intervene while youth are on
community probation, there is a paucity of gender-specific
prevention programming to reduce these risks (DiClemente
et al., 2014; Lawrence et al., 2008). This presents a challenge
for prevention and highlights an urgent need to develop effica-
cious, gender-specific, multirisk “bundled” (targeting more
than one behavior) prevention approaches for this vulnerable
population (Belenko et al., 2008; Committee on Pediatric
AIDS, 2006; Ickovics, 2008). Bundling efficiently aggregates
services to promote synergistic gain when intervening with
high-risk populations that do not routinely seek services
(Ickovics, 2008) and is increasingly being used in medical or
other opportunistic settings. While not yet tested with adoles-
cents, a bundling (Ickovics, 2008; Parrish et al., 2011) or
multiple-behavior approach (Geller, Lippke, & Nigg, 2017;
Nigg, Allegrante, & Ory, 2002) has shown promise in more

efficiently reducing health risk behavior (Werch, 2007). There
is a need, however, to conduct research to better understand
which and how many behaviors can be bundled and for which
target populations (Werch, 2007).
The CHOICES Line of Research
and CHOICES-TEEN
One possibility to meet these overlapping needs among the
female juvenile justice population is to adapt an existing
empirically supported prevention intervention for adult women
called the CHOICES preconception intervention. This
intervention utilizes the transtheoretical model of behavior
change, motivational interviewing (MI), and content aimed to
increase participants’ motivation to change risky alcohol use,
smoking, and contraception use, along with a referral for con-
traception education and services (Velasquez, von Sternberg, &
Parrish, 2013). The need for the CHOICES intervention and its
efficacy has been demonstrated through a line of epidemiolo-
gical and intervention research funded by the Centers for Dis-
ease Control and Prevention (CDC; Floyd et al., 2007; Project

et al., 2017). In the first multisite randomized controlled trial
testing the efficacy of a four-session version of CHOICES
among high-risk women of childbearing age (18–44), the
CHOICES intervention group, relative to a brief advice group,
significantly reduced their risk of AEP (69.1% vs. 54.3%) and
had 2-fold greater odds of being at reduced risk of AEP at
9 months (Floyd et al., 2007). This intervention has been
broadly disseminated to the public, with the original manual
and related training materials available on the CDC website
(https://www.cdc.gov/ncbddd/fasd/choices-implementing-choi
ces.html). This first aforementioned efficacy study highlighted
the need (and opportunity) to also prevent nicotine-exposed
pregnancies, as more than 70% of those at risk of AEP were
also smoking (Floyd et al., 2007). Analysis of study data also
indicated that women receiving two sessions were as likely to
reduce their risk of AEP as those receiving four. Consequently,
a second efficacy trial was funded by the CDC to test a two-
session version of CHOICES, called CHOICES Plus, that

would also focus on reducing the overlapping risk of TEP
within a large, public medical setting (Velasquez et al.,
2017). This study also supported the efficacy of CHOICES Plus
in significantly reducing the risk of both AEP and TEP among
women aged 18–44 years compared to a brief advice group
(Velasquez et al., 2017).
HIV/STI risk in addition to reducing risks of AEP and TEP
(Floyd et al., 2007; Project CHOICES Intervention Research
Group, 2003; Velasquez et al., 2010; Velasquez et al., 2017).
CHOICES-TEEN builds upon the CHOICES line of research
by expanding the reach of this intervention to high-risk adoles-
cent females who are—compared to adult women—more
likely to have an unplanned pregnancy, take longer to realize
they are pregnant, and less likely to stop using substances once
they realize they are pregnant (Cornelius et al., 1994; Cnattin-

gius, 2004; De Genna et al., 2007). This intervention, which
will be described in more detail in the Methods section, con-
sists of two sessions with a master’s level counselor, a session
with an adolescent medicine specialist to discuss HIV/STI and
pregnancy prevention, possible referral for HIV/STI testing
and contraceptive services, and a referral to a phone-based
smoking cessation program called the Texas Quitline. The
intervention was delivered to female youth on intensive juve-
nile community probation.
Parrish et al. 619
choices.html
choices.html
The aims of this one-arm pilot study were to further under-
stand the feasibility of targeting multiple bundled health risks
in high-risk adolescents as well as to evaluate the feasibility
and potential promise of an adapted gender-specific prevention
intervention—CHOICES-TEEN—in reducing the risks of

HIV/STI, TEP, and AEP among adolescent females on com-
munity probation.
Materials and Method
Following Stage 1a/1b intervention development guidelines
(Rounsaville, Carroll, & Onken, 2001), a one-arm design was
used to assess the reductions of risk (among an all-risk sample
at baseline) following the CHOICES-TEEN intervention at 1-
and 3-month follow-up. Supplemental data were collected to
assess client adherence, retention, acceptability, and the feasi-
bility and quality of treatment delivery. Data were collected by
research assistants trained in the study protocol. This study was
approved by the Harris County Juvenile Justice, University of
Houston and University of Texas Health Science Center at
Houston Institutional Review Boards.
Female adolescents aged 14–17 years were recruited from
three community probation programs in Houston, TX. Youth
assent and the parent/guardian permission were obtained in
person or by phone to conduct eligibility screenings. To be

eligible, participants were at risk of HIV/STI, AEP, and TEP
and had all of the following behaviors in the prior 3 months:
(1) sexual intercourse with a male, (2) inconsistent/ineffec-
tive condom use, (3) inconsistent/ineffective contraception
use, (4) drinking at risky levels (>3 drinks in 1 day or >7
drinks in a week), and (5) current smoking. Given that this
was a feasibility study, and the initial recruitment numbers
were lower than expected, the smoking inclusion criterion
was relaxed after 6 months to ensure an adequate sample.
Of the 150 females screened, 31 (21%) were at risk of both
AEP and TEP and 37 (25%) at risk of AEP. If eligible, the
voluntary nature and details of the study were described to
the youth and guardian using IRB-approved assent and per-
mission documents, questions were elicited and answered,
and written informed consent was obtained from youth and
parent/guardians prior to study participation. As shown in
Figure 1, three (8.1%) declined participation and six
(16.2%) did not return to the site for various reasons (e.g.,
additional criminal charges and noncompliance with the pro-
gram). Of the 28 who returned for assent/parental permission

and baseline assessment, 2 were identified as ineligible, leav-
ing a pool of 26 from which 4 did not return for similar
aforementioned reasons. Of the 22 participants who started
the intervention, 20 completed all three sessions (91%) and 2
completed one session. One- and 3-month follow-up assess-
ments were obtained for all 21 of the 22 (95%) youth who
received the intervention. While two youth initiated the
smoking Quitline fax referral, none of them completed this
component of the program.
CHOICES-TEEN Intervention
HIV risk (Floyd et al., 2007; Project CHOICES Intervention
Research Group, 2003; Velasquez et al., 2010, 2017). The effi-
cacy of the CHOICES and CHOICES Plus bundled preconcep-
tion interventions in reducing the risks of AEP and TEP among
adult women in high-risk settings has been established through
a series of CDC-funded studies (Floyd et al., 2007; Project

et al., 2017). CHOICES-TEEN builds upon this work by
expanding the reach of this intervention to high-risk adolescent
females. As shown in Table 1, CHOICES-TEEN includes two
motivational counseling sessions with a master’s level counse-
lor, one session with an adolescent medicine physician, and a
referral to the Texas Tobacco Quitline. The Quitline accepts
fax referrals from physicians of youth who are ready to quit
smoking. A Quitline counselor then assesses the youth for one
or more of the following referrals: telephone counseling,
community-based cessation services, and youth friendly smok-
ing cessation materials.
Master’s level counselors, previously trained for prior
CHOICES intervention studies, provided the counseling ses-
sions and were supervised by experts in MI and the CHOICES-
TEEN intervention. The majority of sessions (68.2%) were
provided by one of the three master’s level counselors, and
outcome did not differ by counselor at 3-month outcome. All

sessions were audio-recorded, and 15% were reviewed for
quality and fidelity using the Motivational Interviewing Integ-
rity Scale 3.1.1 and CHOICES-TEEN protocol checklist. All
counselors were deemed as proficient in the intervention by a
CHOICES expert who is also a member of the Motivational
Interviewing Network of Trainers. The adolescent medicine
physicians, who provided the second session focused on HIV
and pregnancy risk reduction education and the development of
a healthy behavior plan, received a 3-hr training on the use of
MI in a medical context and the CHOICES-TEEN protocol.
Measures
Demographic and background health variables. Demographic
and
background health variables, including sexual activity/risk
behaviors and substance use history/frequency, were collected
using an audio computer-assisted self-administered interview
(ACASI). The AUDIT, a 10-item questionnaire used to mea-
sure alcohol use and problems, was also used to describe the
sample with regard to harmful drinking (Babor, de la Fuente,
Saunders, & Grant, 1992).

Timeline followback interview (TLFB). The TLFB interview,
which
collected detailed self-report behavior data using a calendar
recall method, was administered by a trained interviewer at
baseline (i.e., 90 days prior), 1-month postbaseline follow-up,
and 3-month postbaseline follow-up (Floyd et al., 2007; Sobell,
Brown, Leo, & Sobell, 1996; Velasquez et al., 2017). Data
collected included number of daily alcohol drinks, sexual activ-
ity, condom use, effective contraception, and smoking. These
data were divided into 30-day increments to calculate the fol-
lowing: (1) risk drinking (>3 drinks in 1 day or >7 drinks in a
week), (2) risk of pregnancy (any occurrence of vaginal inter-
course without effective contraception including condoms), (3)
HIV risk (any occurrence of vaginal or anal sex without a
condom), (4) AEP risk (any occurrence of risk drinking plus
any occurrence of vaginal intercourse without effective contra-
ception during the same time period), and (5) TEP risk (any

smoking plus any occurrence of vaginal intercourse without
effective contraception during the same period).
Client Satisfaction Questionnaire–8 (CSQ-8). Client satisfaction
was measured using the CSQ-8 (Attkisson & Zwick, 1982).
This standardized measure consists of eight questions followed
by a 4-point Likert-type scale, with possible scores ranging
between 8 and 32, and higher scores indicating higher levels
of satisfaction. This questionnaire was administered, along
with five open-ended questions about the intervention, using
the ACASI in a private setting at the end of the 3-month follow-
Assessed for eligibility (n=150)
Excluded (n= 122)
♦ Not meeting inclusion criteria (n= 83)
■ No risk of pregnancy (n=83)
■ No sex (n=64)
■ No risk drinking (n=84)
■ No smoking (n=83)
♦ Declined to participate (n= 3)
♦ Other reasons; program attrition (n= 6)
Lost to follow-up 1-month (n=1)
Lost o follow-up 3-months (n=0)

Allocated to intervention (n= 22)
■ Completed Counseling Session One (n=22)
■ Completed Adolescent Fellow Session (n=20)
■ Completed Counseling Session Two (n=20)
■ Accepted Smoking Referral (n=3)
■ Health Clinic Visit (n=7)
Program Attrition, Did Not Return
(n=4)
Found Ineligible at Baseline (n=2)
Returned for Parental
Permission/Assent (n= 28)
Figure 1. Study flow diagram.
Parrish et al. 621
up. The five open-ended questions solicited comments/sugges-
tions, what was liked about the intervention, what was liked
least about the intervention, suggestions for improvement, and
the most important aspects of the intervention.
Working-Alliance Inventory–Short (client/therapist). This
measure is
used to assess three key aspects of the therapeutic alliance—
agree-
ment on the goals of therapy, tasks of therapy, and the develop-

ment of an affective bond (Hatcher & Gillaspy, 2006). This
scale
consists of 12 items followed by a 7-point Likert-type scale,
which
ranges from never to always. This scale was administered to
both
the youth and the counselor at each of two counseling sessions.
Data Analysis
The Statistical Package for Social Sciences (SPSS Version 23)
was used to conduct all analyses. Descriptive statistics were
used to describe the sample, reductions in dichotomous risk of
AEP, TEP, and HIV among an all risk sample at baseline,
feasibility and acceptability measures, and responses to the
CSQ-8 at 3-month follow-up. Inferential statistics were not
used to assess behavior change, as all youth were considered
to be at risk of AEP, TEP, and HIV at baseline. A simple
thematic analysis was conducted of brief open-ended responses
concerning the acceptability of the intervention provided by the
youth when completing the CSQ-8 at 3-month follow up. These

questions asked about what was liked most and least about the
intervention and suggestions for improving the intervention.
Results
Participants ranged in age from 14 to 17, with a mean age of
16 years (SD¼ .89). Eighty-two percent were Hispanic/Latina,
with 55% reporting Mexican origin. The sample was racially
Table 1. CHOICES-TEEN Intervention Session Components.
Session 1
Provided by Master’s Level
Counselor
Session 2
Contraceptive/HIV Risk
Reduction Counseling
Provided by Adolescent
Physician
Session 3
Provided by Master’s
Level Counselor
Smoking Cessation Referral
Provided by American
Cancer Society’s Texas
State Quitline, Which Serves
Adolescents 13 and Older
� Rapport building
� Review of fact sheets:

� Important things for young
women to know about alcohol,
smoking, pregnancy, and birth
control
� Important facts for young
women about HIV/STDs
� Abstinence or safer sex
� Introduce and encourage
contraceptive and HIV risk
reduction counseling visit
� Advice and referral to smoking
cessation program if currently
smoking
� Decisional balance for pros and
cons of
� Drinking
� Smoking
� Contraceptive use
� Condom use
� Complete Self-evaluation rulers
addressing readiness to change
drinking, smoking, condom use,
and contraception
� Introduce Daily Journal for drinking,
smoking, intercourse, and
contraception (including condoms)
� Brochures on alcohol, smoking,

HIV, contraceptive methods, and
community resources
� Discuss and answer questions
about HIV transmission and
ways to reduce risk
� Determine appropriate and
suitable contraceptive
methods including the option
of abstinence
� Provide referral for HIV
testing at most convenient
testing site that provides
condoms
� Complete a healthy behavior
plan, which details plans/
referral for preventing
pregnancy and HIV
� Provide condoms if desired
(parental permission was
required by site)
� Provide follow-up clinical care
or referral as needed
� Provide personalized
feedback (derived from
baseline assessment)
� Discussion of

temptation and
confidence profiles for
all four behaviors
� Review and discussion
of information recorded
in the Daily Journal
� Discuss contraception
and counseling/HIV risk
reduction visit
� Review smoking
brochure and discuss
smoking cessation
referral (as applicable)
� Review of decisional
balance exercises for
each behavior
� Completion of initial
goal statement and
change plans for each
behavior
� Provide community
resource list (if
applicable)
� Determine readiness to
change
� Provide behavioral counseling

for smoking cessation
Note. STDs ¼ sexually transmitted diseases.
diverse with 18% Black, 18% White, 9% American Indian/
native Hawaiian, 4.5% multiracial, and 27% reporting race
as Hispanic/Mexican American. The youth were all English
speaking. However, we did have a Spanish-speaking counse-
lor available to provide the intervention in Spanish if needed
and to communicate with Spanish-speaking parents/guar-
dians. Prior arrests ranged from 1 to 10 or more, with 59%
only having 1 or 2. Participants reported prior arrests for the
following reasons: 45% assault, 41% petty theft, 27% truancy,
22% possession of marijuana or other drugs, 18% running
away, and 14% trespassing. With regard to sexual orientation,
73% were heterosexual and 23% bisexual. All youth reported
using drugs in the last 6 months, and among those who
smoked, five were daily smokers. The mean AUDIT score
was 2.5 (SD ¼ 2.87).
Risk of AEP, TEP, and HIV/STI
Of the 22 participants who received the intervention, one did
not complete the follow-up assessments. Reduction of AEP,

TEP, and HIV risk was based on the frequency of youth in the
at-risk or reduced risk category based on the TLFB at each
follow-up period. Successful change was categorized as
“reduced risk” instead of “no risk” because all contraception
methods, including condoms, fail a certain percentage of the
time even with perfect use. As noted previously, these data
were divided into 30-day increments to calculate the presence
of combined or single risk behaviors within each time frame
over a continuous 7-month period: 3-month baseline (3
months prior to baseline), 1-month follow-up (from baseline
to 1 month later), and 3-month follow-up (from 1 month to 3
months postbaseline). AEP risk was defined as the presence of
risk drinking and risk of unplanned pregnancy during the
same time period, TEP risk was defined as any smoking plus
risk of unplanned pregnancy during the same period, and
HIV/STI risk as any occurrence of vaginal or anal sex without
a condom.
Ninety percent (n ¼ 19) of participants were at reduced risk

of AEP at 1 month, and 71.4% (n ¼ 15) were at reduced risk at
3 months. Using an intent-to-treat analysis (treating the drop
out as a failure), 86.4% were at reduced risk at 1 month and
68.2% were at reduced risk at 3 months.
Seventeen of the 22 (77%) participants were smokers and at
risk of TEP at baseline. Of those at risk at baseline, 68.8% (n ¼
11) were at reduced risk at 1 month and 50% (n ¼ 8) were at
reduced risk at 3 months. With the intent-to-treat analysis,
64.7% were at reduced risk at 1 month and 47.1% were at
reduced risk at 3 months. Of those who smoked at baseline,
71.4% reported currently smoking cigarettes at 1 month and
73.3% at 3 months.
All 22 participants who received the intervention were at
HIV/STI risk at the baseline. Fifty-two percent were at reduced
risk at 1 month, and 28.6% were at reduced risk at 3 months. Of
the 11 who were not at risk of unplanned pregnancy at
3 months, only 2 were not using condoms while sexually active
and using another contraceptive method. Using an intent-to-
treat analysis, 50% were at reduced risk for HIV/STI at 1 month
and 27.3% were at reduced risk at 3 months.
The route by which the youth reduced their AEP and TEP
risk is provided in Figure 2.
A = Used Effective Contraception/Abstinence A = Used

Effective Contraception/Abstinence
B= Reduced Risk Drinking Only B= Smoking Cessation Only
AB = Reduced Both Risks AB = Reduced Both Risks
AB
33.3%
(n=5)
B
26.7%
(n=4)
A
40%
(n=6)
B
36.8%
(n=7)
AB
42.1%
(n=8)
A
21.1%
(n=4)
Routes of Reduced AEP Risk
1 month
3 months

Routes of Reduced TEP Risk
B
18.2%
(n=2)
AB
27.3%
(n=3)
A
54.5%
(n=6)
A
75%
(n=6)
AB
25%
(n=2)
B
(n=0)
Figure 2. Distribution of youth achieving reduced risk of
alcohol-exposed pregnancy and tobacco-exposed pregnancy at 1
month and 3 months.
Parrish et al. 623
Feasibility
The CHOICES-TEEN intervention checklist indicated that all

aspects of the intervention were delivered and that the sessions
did not exceed the planned 45- to 60-min duration. The
CHOICES-TEEN MI Scale, which assessed the degree to
which counselors believed they emphasized various aspects
of an MI approach, was rated as over a 4 on a 1–5 scale for
all items. CHOICES-TEEN counselors indicated per structured
session notes that all participants appeared to comprehend ses-
sion tasks. The average per-item mean for youth on the task
(M¼ 5.99, SD¼ .97), bond (M¼ 6.04, SD¼ .95), and goal (M¼
5.56, SD ¼ 1.12) subscales of the Working Alliance Inventory–
Short ranged between 5 (often) and 7 (always) on a 1–7 scale.
Participant Acceptance/Satisfaction With Intervention
All except one of the 22 youth enrolled in the intervention
completed all three sessions delivered on site at a weekly
community-based probation program. In response to the anon-
ymously administered CSQ-8 at 3-month follow-up, female
youth (n ¼ 20) reported high levels of satisfaction (M ¼ 24,
SD ¼ .71; average per-item mean ¼ 3) with the intervention,
with scores ranging from 23 to 25. Specifically, 60% described
the quality of services as “excellent” and 40% described the
services as “good.” Despite being a nontreatment seeking pop-

ulation, fifty-five percent of youth indicated that they
“definitely” received the service desired, with 45% indicating
they “generally” did. Sixty percent indicated “most” of their
needs have been met by the intervention, while 35% indicated
“almost all” of their needs were met, and one youth indicated
their needs were not met. All youth indicated they would refer a
friend in need of similar help to the program. Ninety-five per-
cent of youth reported being “mostly” or “very” happy with the
amount of help they received. With regard to overall satisfac-
tion, 65% reported being very satisfied, and 35% mostly satis-
fied. Ninety-five percent indicated they would return to the
program if they were to seek help again. Twenty of the 22
participants provided anonymous written feedback to the
open-ended questions that followed the CSQ-8. Responses
indicated that youth valued the opportunity to be honest in a
relational, confidential setting and that the counselors and doc-
tors provided useful information that they did not know or had
not considered. In particular, the youth appreciated the oppor-
tunity to have a conversation with a physician to obtain accu-

rate information about their options for preventing unplanned
pregnancy and HIV/STIs. Youth suggested the program may be
more successful if assistance was provided for transportation
and appointment setting with the health clinics. They also sug-
gested that the program expand to reduce the health and preg-
nancy risks associated with marijuana and other drugs.
Discussion
This one-arm feasibility study suggests that the CHOICES-
TEEN intervention is feasible, acceptable, and promising with
regard to reducing the risk of AEP, TEP, and HIV/STI among
female youth involved with the juvenile justice system. The
retention of youth who began the intervention was 91% for all
three sessions, and youth reported feeling positively about the
intervention, suggesting that the intervention was acceptable.
With regard to feasibility, all intervention components were
completed with ease within the designated session time frames.
Taken together, these findings suggest that it is feasible to
target multiple health-risk behaviors (smoking, risk drinking,
contraception use, and condom use) simultaneously with this

high-risk population. However, future research with a control
group will be necessary to test the efficacy of this intervention.
The reductions in risk of AEP were comparable to reduc-
tions of risk found in CHOICES intervention studies with
women (Floyd et al., 2007; Velasquez et al., 2017). With regard
to TEP, the reduction of risk was 50% in this study and 69.8%
in the CHOICES Plus study (Velasquez et al., 2017). However,
this sample only included five youth reporting daily smoking,
suggesting many of these youth may be engaging in light and
intermittent smoking which often mistakenly perceived by
youth as less harmful or addictive (Amrock & Weitzman,
2015). This may be one of the reasons that few youth accepted
and followed up with the smoking cessation referral. In addi-
tion, open-ended feedback from the youth suggested that smok-
ing was a temporary replacement for marijuana, while they
were being randomly drug tested by probation. This suggests
a need to better understand the patterns of smoking and mar-
ijuana use among high-risk females in these settings for pur-

poses of preventing substance-exposed pregnancy.
The proportions of youth reducing HIV/STI risk at 3-month
follow-up were not as high compared to AEP and TEP, which
is not surprising as there is only one way to reduce this risk—
condom use. While it is most ideal that youth reduce their risk
of pregnancy by either abstinence or using both condoms and
other contraceptive methods, it is encouraging that the large
majority of youth who reduced their risk of pregnancy in the
study were using condoms, which protect against both
unplanned pregnancy and HIV/STIs. In addition, HIV/STI pre-
vention research with juvenile justice populations has generally
resulted in more modest effect sizes for behavioral change
(Tolou-Shams, Stewart, Fasciano, & Brown, 2010), highlight-
ing a need to develop more robust interventions.
Despite encouraging findings, these results should be inter-
preted with some caution, given the small sample size and lack
of a control group. Also, while self-report measures are a major
data source for clinical and resource purposes, they have been

criticized for potential bias. However, retrospective self-reports
of behavior collected in settings which minimize these poten-
tial biases have been shown to be reliable and valid. Still, future
research would benefit by incorporating biological measures
that further substantiate self-report. Finally, given feedback
from the youth and the providers, it may be useful to expand
the CHOICES-TEEN model to incorporate marijuana and other
drugs as well as to explore the utility of providing all of the
aspects of the intervention in a postadjudication placement
setting to reduce client transportation challenges and the time
commitment for travel of providers.
Implications for Practice and/or Policy
Given the limited research on gender-sensitive interventions
with female youth in juvenile justice settings, this research
highlights several implications for practice and policy. First,
this is the first study to report on the prevalence of substance-

exposed pregnancy in a sample of female youth in the juvenile
justice system. Of the 150 youth screened, 25% were at risk of
AEP in this study, which is much higher than the 3.4% at risk in
the general population (Cannon et al., 2015). This finding,
combined with the aforementioned literature documenting
these overlapping risks in multiple, larger samples of female
youth, suggests an urgent need for interventions and/or policy
to reduce these risks. Specifically, programming should be
provided that informs female youth of these risks as well as
efficient, prevention interventions that have promise for broad
prevention impact. AEP is 100% preventable, has been recently
estimated to be more prevalent than autism (May et al., 2018),
and can lead to costly lifelong cognitive, behavioral, emotional,
and adaptive functioning deficits. Smoking and HIV/STIs can
also severely affect the health of both female youth and their
children both during and after pregnancy (e.g., second-hand
smoke; HHS, 2014; Delpisheh et al., 2006; Kulig, 2005; Wie-
mann & Berenson, 1998). As such, the development of and
funding for early prevention programs for one of the society’s
highest risk populations that rarely receives integrated health

care are essential.
Second, this study suggests integrated, multirisk bundled
motivational enhancement interventions provided at opportu-
nistic times can be feasible, acceptable, and potentially promis-
ing for female youth in the juvenile justice system. As such,
programs that focus on more than just one risk behavior during
times of detention or community probation may be more effi-
cient and cost-effective. Finally, youth appreciated the oppor-
tunity to receive individualized information about their sexual
health and substance use in an accepting and supportive con-
text. Such efforts can be further bolstered by ensuring better
access to referrals by providing transportation to follow-up
medical visits, as this can be a major service barrier for this
population. Finally, none of the youth in this study accepted the
incoming smoking cessation Quitline referral phone calls. As
such, nontelephonic options, such as the U.S. Health and
Human Service’s QuitSTART technology application, may
be a better fit for some youth.

Conclusions
CHOICES-TEEN is acceptable and feasible and appears pro-
mising for reducing overlapping, bundled health risks—AEP,
TEP, and HIV—among high-risk female youth in juvenile jus-
tice settings. Given the potential for impacting multiple, over-
lapping health risks in an opportunistic manner, future research
should examine the efficacy of this intervention with a more
robust sample.
Acknowledgments
Harris County Juvenile Probation provided essential support of
this
project by facilitating essential partnerships and space in the
field.
Robin Harris provided coordination of the project in the field,
and
Barbie Atkinson, Matiko Bivens and Lisa Connelly were the
CHOICES-TEEN counselors. Rebecca Beyda, M.D. and Laura
Grubb M.D., provided the Adolescent Medicine risk reduction
coun-
seling sessions. Alicia Kowalchuk, M.D. provided Motivational

Interviewing training for the Adolescent Medicine Fellows, and
Nanette Stephens provided fidelity monitoring and training for
the
CHOICES-TEEN counselors. Ralph DiClemente, Ph.D. and
Carrie
Randall, Ph.D. provided consultation to support the
implementation
of this project.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with
respect to
the research, authorship, and/or publication of this article.
Funding
The authors disclosed receipt of the following financial support
for the
research, authorship, and/or publication of this article: This
study was
funded by Grant Number 1R03DA034099 from the National
Institute
of Drug Abuse, National Institutes of Health.
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