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This paper considers strategies for preventing human immunodeficiency virus (HIV) infection among African-American and Hispanic-American adolescents. We describe culturally sensitive interventions based on social learning theory. The interventions combine elements of cognitive-behavioral skills for problem solving, coping, and interpersonal communication with elements of ethnic pride and HIV facts. The paper discusses the strengths and limitations of skills intervention for AIDS prevention and concludes with directions for research.
In De La Cancela’s 1989 article, “Minority AIDS prevention: Moving beyond cultural perspectives toward sociopolitical empowerment,” he advanced cogent arguments for innovative AIDS prevention programs especially designed for ethnic–racial minority groups. De La Cancela observed,
Urban teenagers who, be they black, Latino, or white are not prone to attend to drab public service announcement warnings, but will best respond to approaches that present peers or positive role models as primary agents or which utilize familiar vehicles such as comic books, humor, music videos, soap operas, rap songs, dance clubs, and street theater (p. 150)
Unfortunately, such approaches do not exist for African-American and Hispanic-American adolescents. This paper presents strategies for implementing culturally sensitive HIV prevention interventions. We begin by discussing the alarming rates of AIDS and HIV infection among African-American and Hispanic-American populations. Based on that evidence, we argue for culturally sensitive, theoretically grounded, and rigorously tested preventive interventions to limit the spread of HIV infection. We conclude by outlining an agenda for future research on AIDS risk reduction among African-American and Hispanic-American youth.
Relative to all ethnic-racial groups of Americans, African-American and Hispanic-Americans are disproportionately afflicted with AIDS. Combined, African-Americans and Hispanic-Americans account for 70% of all cases of AIDS among heterosexual men, 70% of all AIDS cases among women, and 75% of all pediatric AIDS cases (Selik, Castro, & Pappaioanou, 1988). Separately, African-Americans represent 26% of all adult AIDS cases and 58% of all pediatric AIDS cases (Heyward & Curran, 1988; Morgan & Curran, 1986). Hispanic-Americans account for 14% and 22% of all adult and pediatric AIDS cases, respectively. To put these figures in perspective, African-Americans and Hispanic-Americans are 12% and 6% of the country’s population, respectively.
African-American women have a cumulative incidence of AIDS 13.1 times the incidence for white women (Centers for Disease Control, 1986). The incidence of AIDS for Hispanic-American women is 11.1 times the incidence for white women. African-Americans and Hispanic-Americans represent 51% and 30% of all AIDS cases associated with intravenous drug abuse in the U.S. For white children with AIDS, 31% were born to a mother who injected drugs or whose sexual partner did so; comparable rates for African-American and Hispanic-American children with AIDS are 61% and 76%, respectively (Chaisson, Moss, Onishi, Deslondes, & Nelson, 1987; Hopkins, 1987; Mascola, et al., 1989).
Given the risks of HIV infection faced by African-American and Hispanic-American youth, comparisons between these adolescents and majority culture adolescents are informative. DiClemente, Boyer, and Morales (1988) found that African-American and Hispanic-American adolescents were more likely than nonminority adolescents to harbor incorrect information about AIDS risk factors, myths, and prevention.
In a survey of AIDS knowledge, Seltzer and Smith (1988) reported similar findings. They found
racial differences in knowledge and attitudes about the disease, with blacks being somewhat more misinformed about its modes of transmission, more fearful of contracting it, and more likely to indicate that AIDS affected their personal lifestyles but also more likely to report high-risk (multiple sex partners) heterosexual behavior, (p. 35)
A survey of 35,239 high school students, collected by the Centers for Disease Control (1988a) shed more light on AIDS risk among youth. Findings from the national survey showed that high school students were relatively well-informed about risk factors for HIV transmission. Nearly all adolescent respondents in the study knew that intravenous drug use and sexual intercourse were risk factors, and that shaking hands was not Nonetheless, many students were misinformed about many nonrisk factors for the transmission of HIV infection. For example, fewer than one-half of all youths knew that giving blood was not a risk factor; between 35% and 58% of all youths identified use of public toilets as a risk factor.
The most disquieting data from the CDC study concerned adolescents’ behavioral risks for HIV infection. As reported by youths from four sampled geographical areas, illustrative rates of those risks show that among females, between 2.1% and 4.6% admitted to having injected drugs (Table 1). Lifetime rates of intravenous drug use for males were between 3.4% and 8.7%. Between 22.1% and 65.6% of surveyed female adolescents reported having sexual intercourse; the comparable rates for male adolescents were between 37.3% and 90.7%.
Youths also were asked to state their ethnicity. Using these data, ethnic-racial differences in intravenous drug use and sexual intercourse can be inferred. The lowest rates of reported intravenous drug use are shown for adolescents from Michigan, a predominately white sample. The highest rates of intravenous drug use were from Washington, D.C., a sample that was predominately African-American. As for reported sexual intercourse, the San Francisco sample, which was heavily Asian-American, had the lowest rates, and the Washington, D.C. sample had the highest rates.
The two behavioral risks most associated with HIV infection, intravenous drug use and unsafe sexual practices, are preventable (Centers for Disease Control, 1988b; Day, Houston-Hamilton, Deslondes, & Nelson, 1988). Yet, interventions targeted at the majority population are not always appropriate for high-risk youth. One example, is the promotion of condom use.
Though condom use is a popular and well-publicized AIDS prevention strategy, research has shown that this intervention is less effective among young people (Remafedi, 1988; Valdiserri, et al., 1988). Youth dislike using condoms because of beliefs about impaired pleasure, misperceptions about HIV infection risk, unavailability at time of intercourse, and the countervailing influences of alcohol and drug use that compete with sound judgments (Feldblum & Fortney, 1988).
Theory based, culturally sound, and empirically tested interventions are needed to prevent AIDS among African-American and Hispanic-American youth. Below we describe a cognitive-behavioral skills approach to this problem.
Social learning theorists contend that an individual’s behavior is based on the fusing of internal perceptions with external events and observations (Bandura 1977). Derived from social learning theory, skills interventions help adolescents avoid problems and promote their health through a repertoire of cognitive and behavioral techniques, including problem solving, personal coping, and interpersonal communication skills (Botvin, Schinke, & Orlandi, in press; Schinke & Gilchrist, 1984; Schinke & Gilchrist, 1985).
Through these strategies, youths gain the social and personal competence with which to advance their lives educationally, vocationally, and socially. Skills intervention nurtures and strengthens African-American and Hispanic-American youths’ self-image, lending a positive tone to AIDS prevention content, and helping subjects integrate this knowledge into their everyday lives.
In previous research we documented the efficacy of skills interventions to prevent adolescent substance abuse problems, and postpone adolescent sexual activity (Schinke & Gilchrist, 1985; Orlandi, 1986; Schinke, Orlandi, Botvin, Moncher, & Schinke, in press; Schinke & Gilchrist, 1984). Skills interventions have the potential to prevent HIV infection and AIDS among African-American and Hispanic-American adolescents. These interventions would address two modes of transmission for the HIV virus: intravenous drug use and unprotected sexual activity (Brooks-Gunn, Boyer, & Hein, 1988; Flora & Thoresen, 1988; Schilling, et al., 1989).
The following section describes a prevention curriculum developed by the authors for African-American and Hispanic-American female and male adolescents in New York City, which is currently undergoing evaluation in the field.
To address African-American and Hispanic-American adolescents’ cultural and age preferences, living situations, and everyday realities respective to behavioral risks for AIDS, the preventive intervention curriculum emphasizes ethnic pride and HIV facts. Cognitive-behavioral methods are included in the curriculum through problem solving, coping, and communication skills. Each of these skills intervention curriculum elements is described below.
A major component of our skills curriculum for AIDS prevention among African-American and Hispanic-American adolescents is ethnic pride. The curriculum emphasizes African-American and Hispanic-American cultural values, preferences, and language. Examples of ethnic pride content are materials that recognize African-American and Hispanic-American Americans’ achievements through excerpts of African-American and Hispanic-American literature, poetry, and inspirational sayings. Ethnic content also gives adolescents opportunities to note, critique, and respond to everyday examples of African-American and Hispanic-American cultural material.
Intervention content covers known facts about AIDS, HIV infection, and behavioral risks and prevention strategies. This information is delivered through illustrative vignettes which demonstrate how youths can choose for themselves ways to limit their risks for HIV infection. The vignettes are another means for youth to integrate facts with life-style variables and everyday behavior.
During intervention sessions, youths trace the course of AIDS among fictional characters. Some of these vignettes begin with the characters’ who engage in risk-taking behavior and subsequently contract AIDS. Other vignettes depict characters who avoid high-risk behaviors and escape HIV infection. For homework assignments, youths gather additional facts about AIDS, HIV infection, and preventive interventions.
Skills intervention teaches African-American and Hispanic-American adolescents a five-step sequence. Adapted from prior skills interventions, steps in the sequence are: Stop, Options, Decide, Act, and Self-praise. The first step, Stop, teaches youths to pause when confronted with HIV infection risk related problems. By pausing youths can define the problem and their role in solving it. In the second step, Options, youths are taught to consider alternative solutions to problems. The Options step is followed by brainstorming sessions where youths practice developing solutions to problems.
In the Decide step youths learn to systematically choose the best solution from their options. They rank their options on costs, benefits, and feasibility. Act, the fourth step, involves planning and rehearsal. Adolescents visualize themselves faced with drug use and sexual risk taking problems. After they silently plan the appropriate response to the risk or problem situation, youths verbalize their strategies. In the fifth step, self-praise, adolescents reward themselves for problem solving in high-risk situations. Throughout the skills intervention, youths complete problem-solving exercises of increased complexity.
This component of the intervention teaches African-American and Hispanic-American adolescents skills for coping with stresses that may trigger risk taking associated with HIV infection. This intervention employs cognitive and behavioral strategies to help adolescents adaptively handle interpersonal stress such as peer pressure and negative modeling, and intrapersonal stress such as temptations and urges. Second, youths learn to reward themselves for adaptive, appropriate responses to risk-taking situations and problems.
For example, instruction in cognitive skills shows adolescents how to use positive subvocalizations, relaxing thoughts, and relabeling statements to manage their behavior. These strategies are taught within small group settings, where young people see the skills demonstrated by clinicians and peers and then rehearse the skills aloud and silently.
Communication skills for AIDS prevention among African-American and Hispanic-American adolescents are introduced through videotaped vignettes in which youths see other African-American and Hispanic-American adolescents successfully manage risk taking situations around HIV infection. Youths draw upon the vignettes to learn communication skills. For example, youths practice communication techniques for achieving an objective, maintaining a relationship, and gaining self-respect. In role plays, youths rehearse these communication skills as both protagonists and antagonists. First in nonthreatening situations, then in more challenging interactions, subjects refine their communication skills.
For homework assignments, youths observe communication interactions among adolescent peers. These homework assignments let subjects apply communication skills within the context of HIV infection risks and other interpersonal situations.
As thus far developed, our skills intervention curriculum for African-American and Hispanic-American adolescents is suited for delivery within school and non-school settings. An optimal schedule for intervention delivery is weekly or semi-weekly sessions for a total of 12 to 15 meetings. Based on prior research, this intervention schedule provides adolescents with sufficient intensity and detail to learn cognitive-behavioral skills and AIDS information for preventive actions related to HIV infection (Mantell & Schinke, in press; Rotheram-Borus, 1987). After their initial receipt of skills intervention, African-American and Hispanic-American adolescents can profit from semiannual booster sessions to upgrade and strengthen their learning.
Research by the authors is currently underway to implement and test skills intervention for preventing HIV infection among African-American and Hispanic-American adolescents within the previously described format and content. Employing a randomized clinical trial design, that test will determine the efficacy of skills intervention for reducing African-American and Hispanic-American adolescents’ risks of AIDS through their avoidance or delay of substance abuse and sexual activity.
Cognitive-behavioral skills interventions can equip African-American and Hispanic-American adolescents with the ability to avoid HIV infection. The focus on behavioral risks, rather than on the contraction of HIV infection and AIDS, reflects the nature of this prevention research. By changing behaviors associated with HIV infection, preventive interventions achieve risk reduction and promote positive alternative responses that, in theory and according to the available data, will lead to a lower incidence of end-stage problem rates (Block, Block, & Keyes, 1988; Jessor, 1984; Yamaguchi & Kandel, 1984).
Prevention research on HIV infection and AIDS relies especially on theoretical and empirical links between behavior and end-stage problems. Due to the length and latency of the disease after initial exposure, skills interventions that target drug use and unsafe sexual activity among high-risk youth are important. For adults and those who are HIV seropositive, skills interventions aimed at drug use and sexual activity warrant considerable modification relative to the approaches described in this paper. Such modifications are richly discussed elsewhere, and are beyond the scope of the present paper (Mantell, Schinke, & Akabas, 1989).
Currently, many of the cognitive-behavioral skills interventions aimed at adolescents have not been empirically tested. Until data from the present investigators and other research groups are available to document the efficacy of skills interventions with African-American and Hispanic-American adolescents and HIV infection risks, these intervention approaches are best viewed as experimental and promising.
More work lies ahead to accomplish such testing and to shed empirical light on the problems of AIDS and HIV infection among African-American and Hispanic-American youth. That work can take several courses. For example, few data are available on the mechanisms of risk taking, on the accurate and reliable measurement of HIV infection risks, and on gender and ethnic-racial differences in adolescents’ acquisition and application of knowledge and attitudes about AIDS (Jaffe & Wortman, 1988; Sandberg, Rotheram-Borus, Bradley, & Martin, 1988). Above all, aggressive and innovative research efforts are needed to discover and test interventions for reducing the risks of HIV infection among African-American and Hispanic-American adolescents, and among other vulnerable groups of Americans. Perhaps the guidelines described in this paper will assist investigators to move forward with that intervention research agenda.
The preparation of this article was supported by the National Institute on Drug Abuse (DA 05321).