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Latino youth are the fastest growing ethnic group in the United States and are at considerable risk for HIV and other sexually transmitted infections (STIs), given that they have an earlier onset of sexual activity and use condoms less consistently than European American adolescents. Theorists and scholars have emphasized the importance of taking culture into account in sexuality interventions with Latino adolescents, yet few culturally tailored interventions have been developed for this population. Given the emphasis on familismo and collectivism among Latinos, family-based programs are likely to be well received and could contribute to long-term maintenance of adolescent safety. In this synthesis of the relevant literature, cultural factors that have been identified as relevant to Latino sexuality are reviewed and implications for family-based intervention with Latinos are addressed.
HIV/AIDS is a leading cause of death among Latinos (individuals of Latin American origin or descent) in the United States (CDC, 2005a). Although Latinos represent only 13% of the U.S. population (U.S. Census Bureau, 2004), in 2006 they represented 18% of males and 15% of females living with HIV (CDC, 2006). Consistent with this larger pattern, Latino youth are at risk for HIV and other sexually transmitted infections (STIs). Latino adolescents have an earlier onset of sexual activity than White adolescents and are less likely to use condoms consistently, resulting in higher rates of pregnancy (Driscoll, Briggs, Brindis, & Yankah, 2001; Gilliam, Berlin, Kozloski, Hernandez, & Grundy, 2007) and heightened risk of contracting HIV and STIs (CDC, 2006). Nationally, 20% of 13–24-year-olds living with and newly diagnosed with AIDS are Latino (CDC, 2000). It is estimated that by 2050, Latino youth will comprise 33% of the youth population (U.S. DHHS, 2001); thus, there is an urgent need to develop effective HIV/AIDS prevention programs for Latino youth.
Fighting the spread of HIV/AIDS among Latinos will involve confronting multiple factors that contribute to increased risk in this population. In 2006, 21% of U.S. Latinos were living below the poverty level (compared to 8% of the overall population; U.S. Census Bureau, 2007), and 52% of Latinos aged 25 years and older had a high school diploma (versus 80% of the total population; U.S. Census Bureau, 2004). These statistics alone point to significant risk for Latino youth given previous associations found between poverty, education level, and adolescent risk behaviors (Petridou et al., 1997). Moreover, compared to other ethnic groups, Latinos are less likely to discover they are HIV positive until they have symptoms of AIDS (Driscoll et al., 2001), which contributes directly to higher death rates (Nash, Katyal, & Shah, 2005). The situation is worsened because many Latinos lack knowledge about the disease, do not have health insurance, and experience barriers to health care access due to language or cultural differences (Driscoll et al., 2001). Marín (2003) described the “cycle of disempowerment” including cultural, experiential, and societal factors that combine to increase risk of HIV infection and death among Latinos. To be effective, prevention programs must take these factors into account.
One particularly promising approach for HIV prevention with Latinos is the development of family-based, culturally tailored programs. Different cultural groups experience specific risk and protective factors and are typically more receptive to interventions that reflect cultural realities and avoid mismatches stemming from language preference and use, discrepant values and attitudes, and contextual characteristics such as delivery method (e.g., Castro, Barrera, & Martinez, 2004; Lau, 2006; Szapocznik, Prado, Burlew, Williams, & Santisteben, 2007). It should be noted that there is some disagreement about the extent to which cultural tailoring of prevention programs is necessary or desirable, although these debates tend to focus on substance use prevention (e.g., Kumpfer, Alvarado, Smith, & Bellamy, 2002; for reviews, see Castro & Alarcón, 2002; Szapocznik et al., 2007) or mental health delivery (e.g., Hall, 2005). Since the early days of the AIDS epidemic, sexuality researchers have emphasized the need to take cultural factors into account in HIV prevention efforts (e.g., Amaro, 1988; Marín, 1996). There is considerable work indicating the value of considering aspects of ethnicity that contribute to Latino adolescents’ sexual risk (see Raffaelli & Iturbide, in press). For example, Faryna and Morales (2000) reported that ethnicity was consistently more significant in predicting risk behaviors among adolescent populations than gender and sexual knowledge, attitudes, and beliefs. Unfortunately, the majority of HIV prevention studies have either involved non-Hispanic samples or involved multiethnic samples but do not report results by race/ethnicity (Pantin, Prado, & Schwartz, 2005).
The goal of this article is to synthesize the literature relevant to family-based HIV prevention among Latinos and provide suggestions for intervention that can be employed by pediatric psychology researchers and clinicians. For the purposes of this review, we consider Latinos as one cultural group; however, it is important to acknowledge the heterogeneous nature of the Latino population. Despite the shared experience of Spanish colonization, the countries of Latin America have distinct histories, and Latino subgroups vary in terms of (among other things) circumstances and timing of arrival in the United States, geographic distribution, and socioeconomic status (see Raffaelli, Carlo, Carranza, & Gonzalez-Kruger, 2005). However, there are also many similarities among Latino subgroups in terms of culturally based beliefs and values related to sexuality (Raffaelli & Iturbide, in press). We recognize that some of our specific suggestions may not work with all Latino families but propose them as a starting point for further consideration and refinement.
From the diverse and emerging literature specific to Latinos, we identified a set of family cultural factors that have been linked to adolescent risk behavior. These factors include acculturation, religiosity, HIV knowledge and sexual communication, gender role and sexual socialization, and parental monitoring practices. We recognize that this list is not exhaustive and that there may be other important processes at play; however, these factors have been theoretically and empirically linked with HIV risk among Latinos. We conducted a search of the PsychINFO and MEDLINE databases from 1990 to 2008 using each factor as a keyword in combination with “youth or adolescent,” “family(ies),” “intervention or prevention,” “HIV or AIDS,” and “Hispanic or Latino(a).” We also identified articles cited in recent publications on Latinos and HIV/AIDS. In the following sections, we review how each factor impinges on HIV risk behavior of Latino adolescents within the United States, consider implications for the design and delivery of HIV prevention interventions, and present suggestions for intervention activities to address these risk and protective factors.
According to the U.S. Census Bureau (2000) more than half (55.7%) of Latino youth have at least one foreign-born parent and just 21% speak only English at home. Thus, an important factor to consider in HIV prevention interventions is acculturation, the extent to which immigrants and their descendents have adopted the values, beliefs, customs, and traditions of the host culture (Szapocznik, Scopetta, Kurtines, & Arnalde, 1978). Acculturation is a multidimensional construct that is variously measured by place of birth, length of residence in the receiving country, language fluency and preference, ethnicity of friends, preferences in food and music, attitudes toward family and gender roles, and ethnic self-identity (Driscoll et al., 2001). In general, more acculturated individuals are less likely to endorse traditional Latino beliefs (Marín & Gómez, 1997). Because children tend to adjust to the new environment more quickly than adults, they often take on roles (interpreter, information gatherer) that may disrupt traditional hierarchical patterns in Latino families (Driscoll et al., 2001). This has been termed differential acculturation (Szapocznik & Kurtines, 1980) and has negative implications for communication and monitoring practices necessary for delaying or avoiding sexual risk behaviors and is in direct opposition to the concept of respeto, the need to maintain respectful hierarchical relationships in Latino families (Raffaelli & Ontai, 2001). For example, a longitudinal study of adolescent boys in south Florida showed that as acculturation increased, closeness to the family (familismo) and respect for parents (respeto) decreased (Gil, Wagner, & Vega, 2000).
Contradictory associations between acculturation and sexual attitudes and behavior have been reported. For example, less acculturated Latinos, especially females, have more negative attitudes toward condoms, more inaccurate and negative viewpoints about HIV/AIDS risk, and are less likely to carry and use condoms (Marín, 1996; Marín & Gómez, 1997); however, they also tend to delay their sexual debut and have fewer sexual partners than more acculturated Latinos (for review, see Raffaelli & Iturbide, in press). Other research has documented that more acculturated Latinos are more likely to engage in unsafe sexual behavior, such as younger age of sexual initiation (Afable-Munsuz & Brindis, 2006; Gil et al., 2000; Guilamo-Ramos, Jaccard, Pena, & Goldberg, 2005). These findings are likely to be affected by the participants’ country of origin and gender as well as the measure of acculturation used in the study (Afable-Munsuz & Brindis, 2006; Gil et al., 2000; Raffaelli, Zamboanga, & Carlo, 2005).
Intervening with Latino families is challenging in a number of ways, particularly with respect to values and practices important to the family. To avoid contradicting the values of Latino parents, interventions can attempt to clarify parents’ attitudes on such issues as teen sexual activity and pregnancy. Interventionists can then work with parents to increase their understanding of typical U.S. norms, which their teens are exposed to and often readily accept. In this way, parental values (obtained via their country of origin or descent) are respected, whereas a greater understanding of U.S. norms allows them to appreciate what their teens are experiencing. To address acculturation issues and, in particular, differential acculturation, interventions can encourage parents to discuss with their children (and other more acculturated parents) the social norms found in schools and in the community, such as norms regarding sexuality and parental monitoring. Also, while recognizing that maintaining cultural values and practices is important, interventions can stress the importance of learning English to facilitate communication and diminish the problem of role confusion and hierarchy (respeto) issues. In addition, Driscoll et al. (2001) indicated that tailoring programs to families’ stage of acculturation will make programs more effective. Practically, this means determining in what language the intervention should be delivered.
Religiosity has been associated with HIV risk. Some studies find religion to be a protective factor, which makes sense (Velez-Pastrana, Gonzalez-Rodriguez, & Borges-Hernandez, 2006): Most religions stress delay of sexual debut, abstinence, and monogamy, which minimize HIV risk. In a cross-sectional study of adolescents from various racial backgrounds who reported never having had sexual intercourse, involvement in religion was a protective factor (Vesely, Wyatt, & Oman, 2004). Another cross-sectional study of sexually active Latino adolescents found that religiosity positively predicted females’ recent condom use above and beyond factors such as familismo and gender roles (Villarruel, Jemmott, Jemmott, & Ronis, 2007). Other aspects of religiosity may serve as risk factors; for example, the fatalistic notion that events in one's life result from factors beyond one's control (Davis & Voegtle, 1994) may lead to helplessness and the belief that efforts to protect oneself from HIV are in vain. In this case, there may be little communication between parents and youth about sexual behavior and protection against HIV and STIs.
Interventions that allow for discussion of how religion affects sexual decision making should be helpful. Both the protective aspects of religion (i.e., encouragement of the delay of initiation of sex and focus on abstinence) and those that inhibit communication and decrease parental monitoring can be explored. In addition, to dispel myths surrounding the acquisition of sexually transmitted infections and the notion that luck or fate determines what happens to people, interventions can include a discussion of the epidemiology of HIV transmission, prevention, and treatment. Aspects of religiosity that emphasize personal protection as healthy for self, family, and community could be emphasized.
Acculturation and religiosity are larger aspects of the family system that influence family socialization practices, particularly with respect to parent–adolescent communication. Studies of non-Latino samples document that open parent–child communication about sexual topics and harmonious family relationships are associated with delays in initial sexual activity, fewer pregnancies and sexual partners, more responsible sexual behavior, greater efforts to avoid AIDS, and increased contraceptive use and knowledge about AIDS and birth control (Benavides, Bonazzo, & Torres, 2006; Donenberg, Wilson, Emerson, & Bryant, 2002). In one cross-sectional study, perception of parental responsiveness to sexual communication was found to offset the negative influence of peers on initiation of sexual activity (Fasula & Miller, 2006).
Although it is widely acknowledged that increasing knowledge does not lead to behavior change, it is notable that Latino adolescents, especially girls, have less knowledge about sexuality compared to adolescents from other ethnic groups (Ford & Norris, 1991). Latinos are less likely than other groups to provide children with information on sex and AIDS (Marín & Gómez, 1997); for example, Latino girls report that parents tell them to protect themselves, but do not give them specific information on how to do so (Raffaelli & Ontai, 2001; Villarruel, 1998). A qualitative study of 63 mother–daughter dyads revealed that mothers were more likely to talk about abstinence and the consequences of sex than to provide specific, fact-based information about sex and birth control (Guilamo-Ramos et al., 2006), replicating a retrospective study of college students (Raffaelli & Green, 2003).
Research indicates that Latino adolescents and their parents want to discuss sexual issues but that communication is often difficult. Parents may be embarrassed or reluctant to appear to endorse teen sexual involvement (especially in the case of daughters; McKee & Karasz, 2006), and teens may fear that parents will think that they are sexually active and punish them (Guilamo-Ramos et al., 2006). Factors related to whether sexual discussions occur include parent gender, with mothers more likely than fathers to communicate with children; adolescent gender, with girls reporting more communication with parents than boys; and parental education, with those with more education communicating with children more frequently (Raffaelli & Green, 2003). Several cross-sectional studies indicate that Latino youth who communicate with parents about sex have decreased sexual activity and pregnancy rates (Adolph, Ramos, Linton, & Grimes, 1995; Gilliam et al., 2007).
Didactic instruction in the etiology and prevention of HIV may be useful to parents who wish to talk with their children about sexual issues but lack the knowledge to do so. After sufficient discussion about parental and familial values surrounding sexuality, skills-based activities can be implemented. More than 100 Latino parents and their adolescents have received a family-based HIV prevention intervention (Lescano, 2008) in which this type of information is provided and hands-on activities introduced (e.g., condom use with penis models) with both the parents and adolescents in the room. To date, no Latino parents or adolescents refused the condom demonstration portion of the intervention. Furthermore, anecdotal reports indicate that parents and adolescents are often relieved to be discussing the topic and understand that engaging in such skills-based activities does not condone sexual activity but provide useful factual information.
In targeting communication between parents and adolescents, a useful activity is to engage them in role plays with feedback from other group members regarding their tone of voice, communication content, and body language. Our experience has shown that Latinos consider themselves to be more expressive and tolerant of affect (i.e., high expressed emotion) than other cultures. Generational differences in this style of communication may be a barrier between adolescents and parents and this can be addressed directly in the intervention. Guilamo-Ramos et al. (2006) suggested providing parents with recommendations generated by adolescents (e.g., try to figure out what the adolescents know before presuming that they know nothing or everything, use terminology the adolescent is likely to understand, use reading materials or videos to stimulate discussion). While emphasizing the importance of familismo and respeto, parents can be led to be more open to frank communication with their adolescents concerning even the most difficult of topics. Through role-play activities, parents and adolescents can practice mutually acceptable methods of disagreement. These discussions can be made tolerable by identifying areas of agreement, as well as disagreement. Parents also learn that the timing of discussion is important; sexual communication may be precipitated by exposure to sexual events in the media, knowledge of peers who are pregnant, and parental concern about the onset of sexual activity in their children (Romo, Lefkowitz, Sigman, & Au, 2001).
Gender role and sexual socialization may play an important part in Latino youth risk/prevention behaviors. From a young age, Latinas learn that “good” women are not supposed to know about sex (Cianelli, Ferrer, & McElmurry, 2008; Deardorff, Tschann, & Flores, 2008). This concept is consistent with marianismo, the idea that women are expected to emulate the Virgin Mary, that they remain a virgin until marriage and be submissive and obedient in relationships (Marín & Gómez, 1997; Raffaelli & Ontai, 2001). Meanwhile, the attitude of machismo implies that penetrative sex and procreation are a reflection of manhood (Cianelli et al., 2008; Raffaelli & Ontai, 2001). Men are encouraged to believe that they are unable to control sexual impulses; therefore, compromising their ability to stop while aroused to put on a condom (Marín, Gómez, Tschann, & Gregorich, 1997). In addition, condom use is viewed as most appropriate outside of primary relationships and is generally seen as unnecessary (and, therefore, not negotiated) within marriages or main-partner relationships (Marín, Gómez, & Hearst, 1993).
Some research suggests that attitudes about sexual communication and negotiation may be in flux among adults (Deardorff et al., 2008). However, it is unclear to what extent these changes are evident among adolescent Latinos. There is evidence that power and privilege in the broader Latino culture continue to favor males as the dominant player in sexual encounters. A study of Latino adolescents found that males were significantly more likely to report using condoms at first intercourse than females (Sneed, Morisky, & Rotheram-Borus, 2001). Moreover, the expectation that Latinas be submissive to male partners has important implications for negotiation of condom use in relationships, particularly for adolescent Latinas who are in relationships with older men. Young girls dating older men is a common occurrence in the Latino community, and one that is often sanctioned by parents because they believe these older men will be responsible and able to provide for the family (Driscoll et al., 2001; Marín, 2003).
Most work on gender roles and sexual socialization focuses on heterosexual Latinos, but it should be noted that homosexual Latino males are at significant risk for HIV and other STIs. Sixteen percent of men who have sex with men living with HIV/AIDS are Latino, and among Latino males (who self-identify as either homosexual or heterosexual), the highest category of HIV exposure is through sexual contact with other men (CDC, 2005b). There is no question that prevention interventions need to target this vulnerable group and that the cultural issues discussed in this article can significantly affect sexual behavior in this group. Diaz and colleagues (2001) have done extensive studies on Latino gay men and one consistent finding is that acceptance by their families is very important to them. Therefore, though no family-based interventions have been developed for Latino gay men, it stands to reason that they are needed and would be of significant benefit to this population.
Because of power imbalance in Latino male and female relationships, the theory of gender and power (Connell, 1987), which emphasizes sexual division of labor and power, may be an appropriate intervention framework. The theory of gender and power has been applied to African Americans (Wingood & DiClemente, 2000) but not yet to Latinos. Within family-based interventions, the concept of distribution of power in relationships and that prevention is the shared responsibility of both men and women (Scott, Gilliam, & Braxton, 2005) can be targeted through structured parent–adolescent tasks to modify strongly held values about machismo and power in relationships. In addition, it is likely that adolescents in various types of relationships, whether same sex or opposite sex, will be enrolled in HIV prevention interventions and activities such as role plays, for example, should be sensitive to diverse sexuality in these intervention groups.
All of the previously mentioned family context factors may influence monitoring practices of Latino parents. In general, teens whose parents keep track of their whereabouts and interactions initiate sex at a later age, have sex less often, and have fewer sexual partners than those whose parents monitor less (Paikoff et al., 1997; Velez-Pastrana et al., 2006). Because of concern about the family's image in the community, Latino parents from traditional (i.e., less acculturated) backgrounds tend to disapprove of daughters engaging in American-style dating and enforce more stringent standards for girls than for boys (Raffaelli & Ontai, 2001; Villarruel, 1998). This double standard begins at an early age, with Latino boys enjoying more freedom than Latina girls (e.g., Finkelstein, Donenberg, & Martinovich, 2001; Raffaelli, 2005). Although intensive monitoring may be protective for Latinas, this restriction may lead to secrecy about dating and tension between adolescents and parents (Raffaelli & Ontai, 2001).
When, how, and how much to monitor adolescents is an interesting area of adolescent development to be targeted in family-based interventions. This is especially true in light of the data indicating that sexual-possibility situations increase the likelihood of teenagers’ engagement in risky sexual behavior (Paikoff et al., 1997). Instructing Latino parents in typical American culture norms surrounding monitoring will provide a rationale and improve their ability to monitor. Skills practice can help them respond reasonably and appropriately to their adolescents’ independence seeking, without being too lax or too intrusive. Based on anecdotal information from our clinical research experience, some Latino parents feel that their own upbringing in their country of origin was overly strict. Engaging parents in a discussion of what growing up was like for them and how their experiences affect their own parenting may help parents gain valuable perspective.
To date, no single integrative culturally based theory has been developed to guide interventions with Latino adolescents and their families. Theories developed and tested within general adolescent HIV prevention interventions include social cognitive theory (Bandura, 1977), the theory of reasoned action (Ajzen & Fishbein, 1973), and the social–personal framework (Donenberg & Pao, 2005). The model receiving the most attention with regard to behavioral intervention with Latino adolescents and families is ecodevelopmental theory, which incorporates elements of structural family therapy into Bronfenbrenner's ecological framework.
Bronfenbrenner (1986) conceptualized the ecology as a set of nested contexts that influenced human development through reciprocal interactions across time. Microsystems are settings in which children participate directly (e.g., family, schools, recreational settings). Mesosystems consist of linkages between microsystems; the degree of coherence or strength of linkages is an important factor in development. Exosystems are contexts that the developing individual does not participate in directly but that influence development indirectly, either by influencing what happens in the microsystem (e.g., events at the parent's job may affect parenting behavior) or by influencing mesosystem linkages (e.g., school policies that facilitate home–school connections). The most distal layer of influence is the macrosystem, consisting of values and beliefs that shape societal institutions (e.g., political and religious systems). In addition to this basic framework, ecodevelopmental theory draws on structural family therapy to conceptualize risk and protection and identify patterns of transactions within and across ecological levels (Coatsworth, Pantin, & Szapocznik, 2002). Ecodevelopmental theory has been applied to adolescent and family-based HIV prevention for Latinos, including the development of HIV/AIDS prevention programs for adolescents (Pantin, Schwartz, Sullivan, Prado, & Szapocznik, 2004; Perrino, Gonzalez-Soldevilla, Pantin, & Szapocznik, 2000).
The culturally relevant factors and processes reviewed in the previous section can be integrated into the ecodevelopmental framework, which provides a powerful way of conceptualizing how different levels of the ecology interact. As an example, the extent to which parents are able to monitor their children successfully may depend on microsystem factors (e.g., family composition), mesosystem linkages (e.g., the extent to which parents of the children's friends share parental values and goals), exosystem factors (e.g., whether parents are able to arrange their work schedules in a way that allows them to supervise their children), and macrosystem factors (e.g., parental acceptance of U.S. norms related to adolescent dating). Research that examines how factors at different levels of the ecology operate across time to influence Latino adolescents’ HIV/AIDS risk is needed to clarify the pathways of influence.
Just as theoretical models that capture the complexity of Latino sexual behavior are lacking, so too are HIV prevention interventions for Latino adolescents. Of 40 adolescent HIV prevention interventions published between 1983 and 1995, none was tailored to Latino adolescents (Kim, Stanton, Li, Dickersin, & Galbraith, 1997). Between 1994 and 2004, only 5 intervention studies that examined sexual behavior outcomes among a large proportion of Latino adolescents were published (Villarruel, Jemmott, & Jemmott, 2006). Only one of these studies described an intervention that had been culturally tailored for Latino adolescents (Project CHARM, adapted from Be Proud! Be Responsible!, originally developed for Black youth; Jemmott, Jemmott, & McCaffree, 1996). This intervention led to significant reductions in number of sex partners at 6 months postintervention, although the effects had diminished by 12 months (Koniak-Griffin et al., 2003). The tailoring of the intervention included discussing the impact of HIV/AIDS on inner-city communities and viewing culturally relevant videos; this may have been insufficient to address important cultural factors.
Herbst and colleagues (2007) reviewed behavioral HIV prevention interventions for Hispanics published between 1988 and 2005 (see also Wilson & Miller, 2003) and found 20 randomized controlled trials. Successful interventions targeted cultural factors such as machismo and were developed after interviewing the population of interest (Herbst et al., 2007). Two of the interventions focused on adolescents; both demonstrated efficacy in delaying onset of sexual activity and decreasing the incidence of multiple sex partners. Poder Latino was based on empowerment theory and was administered to a convenience sample of 481 inner-city Hispanic youth (94% Puerto Rican) in New England (Sellers, McGraw, & McKinley, 1994). The intervention was developed through interviews with the target population and focused on cultural pride. It included activities related to HIV awareness, self-efficacy, promotion and distribution of condoms, safe-sex negotiation, and a media campaign. Major limitations of the study included lack of control group and assessment of behavior immediately postintervention only.
¡Cuídate!, developed by Villarruel, and colleagues (Villarruel, Jemmott, Jemmott, & Eakin, 2006), was an adaptation of the Be Proud! Be Responsible! curriculum (Jemmott et al., 1996). The original intervention was based on social cognitive theory, the theory of reasoned action, and the theory of planned behavior. Interviews with the target population were used to inform the tailoring of the intervention. The cultural content included discussion of familismo, machismo, personalismo, and respeto. A randomized controlled trial of ¡Cuidate! was conducted with 553 Latino youth (85% Puerto Rican). The HIV prevention intervention was compared to a health promotion control, both delivered in small mixed-gender groups during six, 50-min sessions. Outcome data collected at multiple time points over 12 months demonstrated that adolescents in the HIV intervention were less likely to report sexual intercourse, multiple partners, days of unprotected intercourse, and unprotected intercourse than those in the control group (Villarruel, Jemmott, Jemmott, & Eakin, 2006).
More recently, Prado and colleagues (2007) developed a parent-centered intervention aimed at preventing substance use and unsafe sexual behavior among Latino adolescents. The experimental intervention (Familias Unidas, Pantin et al., 2004; + PATH, Krauss et al., 2000) consisted of 15 parent group sessions, 4 parent–adolescent sessions, 8 family visits, and 4 booster sessions. A randomized controlled trial compared the experimental intervention with two attention-control conditions in a sample of 266 8th-grade adolescents and their primary caregivers. Most intervention activities were delivered to the parents, who were directed to teach the information and skills to their adolescents at home. The intervention focused on Latino-specific factors, including the idea of respeto indicating parental authority and the role of parents as leaders and teachers within the family. Participants were assessed at baseline and 6, 12, 24, and 36 months thereafter. Few of the participants had begun engaging in sexual behavior and no significant changes in rates of unprotected sex during the past 90 days were observed. However, post hoc analyses revealed that adolescents in the experimental condition were less likely to report unsafe sex at last intercourse than those in one control condition; in addition, none of the adolescents in the experimental condition reported contracting a sexually transmitted infection, compared to 6 of the 165 adolescents in the two control conditions. The Familias Unidas + PATH intervention improved reports of positive parenting and parent–adolescent communication compared to the control conditions. Results suggest that Latino adolescents can benefit from an intervention in which parents act as change agents and in which family functioning is improved.
Although they address Latino cultural factors and in one case involved parents, none of these interventions worked with families as the main unit of intervention. It is a common misconception that Latino families consider the topic of sexuality taboo and would be unwilling to participate in interventions that address adolescent sexuality. Researchers are only beginning to confront these misconceptions and are successfully enrolling Latino families into HIV prevention interventions. We believe this is a promising path for future efforts.
For Latinos, intervention approaches that target family, rather than individual, health will likely be well received (Marín & Gómez, 1997). Two factors, collectivism and familismo, may contribute to families being the ideal unit of intervention for Latinos. Collectivism emphasizes the group over the individual, the need for consensus, and the priority of maintaining close interpersonal relationships as opposed to achieving tasks (Triandis, Marín, Lisansky, & Betancourt, 1984). Familismo emphasizes the family as the primary source of social support and identity (Raffaelli & Ontai, 2001). Extensive literature among non-Latino families documents the importance of parent–child communication and monitoring of youth in prevention of sexual risk behavior, both of which are influenced by cultural values and beliefs (Donenberg et al., 2002; Paikoff et al., 1997). Moreover, a review of other types of prevention and intervention programs for Latinos shows that family-based interventions are the most efficacious for this population (Szapocznik et al., 2007). Cultural factors that are relevant for family-based programs may be important to address to ensure that the family climate, acting through parent–child communication and monitoring, can contribute to long-term maintenance of adolescent safety.
A review of successful HIV/AIDS interventions for Latinos highlights several common dimensions: extensive preliminary work with the target community, theoretically based, nonjudgmental discussion of issues, and focusing on specific ethnicities and genders (Marín, 2003). More specifically, Bernal, Bonilla, and Bellido (1995) delineated eight factors that are important to developing culturally sensitive interventions. These include language (e.g., idioms), persons (e.g., facilitator/participant match), metaphors (e.g., cultural symbols and concepts), content (e.g., correcting myths about HIV), concepts (e.g., beliefs about participants), goals (e.g., what risk behaviors do we want to decrease?), methods (e.g., role plays), and context (e.g., poverty).
Once the intervention is developed, the work of bringing families into a room together begins. Several researchers have examined factors related to successful recruitment and retention of families into HIV prevention programs. The strongest predictor of engagement into the Familias Unidas intervention was the quality of the relationship between the parent and the facilitator at the initial contact (Prado, Pantin, Schwartz, Lupei, & Szapocznik, 2006). Families who reported more stress were more likely to participate, presumably because they were searching for immediate solutions to their problems, which Szapocznik et al. (1978) reported is essential for Latino engagement in interventions. Other factors that increase participation include being supported by peers and other family members, having incentives (e.g., money, spending time with family or friends), and experiencing feelings of commitment and personal gain from participation (Villarruel, Jemmott, Jemmott, & Eakin, 2006). Factors related to successful retention include high group cohesion and a shared sense of purpose (Prado et al., 2006). The most common barriers to participation include busy schedules, timing of follow-ups, and embarrassment about discussing sensitive topics (Villarruel, Jemmott, Jemmott, & Eakin, 2006).
This review of family factors relevant to HIV risk among Latino adolescents demonstrates that, although all of the contextual and cultural variables are important to the work of HIV prevention, the relations are neither simple nor linear. In fact, most cultural factors can confer either risk or protection on adolescents. For example, traditional gender role expectations that Latina girls be chaste and innocent can be protective; however, these ideals can also prevent young Latinas from being able to negotiate safer sex because of a feeling of disempowerment (Marín, 2003). For Latino men, the cultural value of machismo may instill a sense of responsibility and protectiveness but also allow men to feel entitled to sexual freedom and power (e.g., Cauce & Domenech-Rodriguez, 2002; Villarruel & Rodriguez, 2003). In addition, familismo and collectivism are an essential part of Latino culture. In a collectivist culture, adolescents are encouraged to stay safe as part of a network of family members and friends who provide support and hold individuals accountable for the impact of personal decisions on the community. However, this can make it difficult for adolescents to deviate from the norm and adopt potentially protective attitudes and behaviors.
Additional work is needed to investigate how cultural forces operate in conjunction with each other, and in interaction with individual and family factors, to influence HIV risk and ultimately intervention effectiveness. As noted earlier, factors at different levels of the social ecology interact with each other in ways that may increase or decrease risk. For example, in contexts where adolescent peer groups share values that discourage sexual risk (e.g., support of sexual abstinence), lack of parental communication regarding sexuality may not be a risk factor. However, if adolescents are receiving messages from various sources (e.g., peers, media) that conflict with views held by their parents, then lack of parent–child communication may pose a risk. Ultimately, we may find that it is the fit between the individual, their attitudes, the family's attitudes, and community norms that leads to decreased risk behavior. Moving beyond simplistic notions (e.g., that lack of acculturation is a risk) to a more complex, interactive framework is central to developing interventions tailored for specific cultural groups.
Engaging Latinos in family-based HIV prevention interventions may be associated with specific challenges, in light of the complex cultural processes and experiences families face. However, this is a vital task. Family is at the core of being Latino, but Latino parents need help communicating with their children about difficult topics. Given the focus on children and families, as well as on prevention of disease and other comorbidities, pediatric psychologists are well poised to be at the forefront of developing culturally relevant interventions. Reducing disparities in the incidence of HIV, as well as other preventable diseases, should be a priority for clinical and research pediatric psychologists. It is our hope that the information and suggestions in this article serve as a template for beginning this important work.
National Institutes of Health (MH63008-Supplement to C.L., MH078783 to C.L.); Lifespan/Tufts/Brown Center for AIDS Research (CFAR) Developmental Award to C.L.
Conflicts of interest: None declared.
The authors would like to thank Elizabeth A. Vazquez, Ph.D., Jacqueline Maya, B.A., and Jessica Zeidman, B.S., who assisted with various versions of this manuscript.