of white adolescents. However, when one recent study of 403 San Francisco teens controlled for the number of sexual partners and the perceived costs and benefits of condoms, no racial/ethnic differences in condom use were observed.259 Less is known about sexual and drug-related behaviors in youth from other racial and ethnic minority populations. However, one recent study of over 14,000 rural Native American students in grades 7-12 found that 35% of males and 27% of females reported having had sexual intercourse.260 By grade 12, 65% of males and 57% of females reported being sexually experienced. Rates of contraceptive use were low among those students who were sexually active. Among students in grades 79, 36% of males and 57% of females reported using no method of contraception. By grades 10-12, 25% of sexually active males and 39% of sexually active females still reported no contraception. Among sexually experienced youth who did use contraceptives, 49% of males and 24% of females reported using only condoms.261 Minority Teens Know How HIV Is Transmitted But Have Misconceptions About How to Protect Themselves Culturally "universal" solutions ignore emerging evidence that HIV prevention efforts have not been as effective with minority youth as with whites. Ethnic and racial differences in knowledge, attitudes, beliefs and behaviors relevant to risk of HIV infection have been documented, both between and within racial and ethnic groups. As outlined below, researchers have come to different conclusions about whether levels of general AIDS knowledge vary by race and ethnicity, but several experts have shown that certain dangerous misconceptions, attitudes and behaviors are more typical of minority youth. A study conducted in San Francisco in 1985 found that white adolescents were more knowledgeable than African-American youth about the cause, transmission, and prevention of AIDS. Both white and African-American teens knew more than Latino youth. African-American and Latino adolescents were twice as likely as white adolescents to have misconceptions about casual transmission. African-American and Latino youth in this sample felt they were at greater risk than white respondents.262 By contrast, a study conducted in New York City in 1988 found that more than two-thirds of a sample of African-American and Hispanic teens had accurate information about HIV transmission. Unlike previous findings, this study revealed no difference between African Americans and Hispanics in knowledge. However, as shown in previous research, most of these adolescents harbored misconceptions about risk reduction (e.g., only 34% believed that abstinence reduced risk and 79% thought that oral contraceptives provided some protection from AIDS),263 Extremely low levels of knowledge about HIV infection and AIDS have been found in African-American female adolescents ages 13-15. In one study, only 30% of these young teens "passed" a test of AIDS knowledge by obtaining a score of 75% correct. In another sample, even though female AfricanAmerican and Hispanic adolescents were more likely to believe that condoms are a good way to decrease risk of HIV, they were less likely than males to insist on condom use. 264 265 Noting the increasing incidence of AIDS in minority groups, Congress directed the Department of Health and Human Services to conduct a study of prevention programs targeting minority populations. The Health Omnibus Programs Extension of 1988 (Section 251) included a request that the Office of Minority Health study minority knowledge, attitudes, and beliefs regarding AIDS transmission and risk, and examine the effectiveness of AIDS prevention programs for minorities.266 However, the data base used for the DHHS analysis (the National Health Interview Survey), includes only persons over the age of 18. Despite high levels of general knowledge about AIDS in all racial ethnic groups, whites have shown a greater knowledge of risk factors than other minority groups, and more knowledge of effective prevention strategies than African Americans.267 Socioeconomic and Cultural Factors Play Strong Roles in Success of Prevention/Intervention Strategies The socioeconomic and cultural characteristics of racial and ethnic minority populations differ significantly from those of nonminority populations. Minority populations have experienced higher rates of poverty and unemployment and lower levels of education. Substantial percentages of minority populations live in inner cities, where they are more likely to experience substandard housing, crime, and other environmental hazards. 268 Because poverty is also often associated with an inadequate social-support network, poor nutrition, and diminished access to health care, children growing up in poor or near-poor families probably confront more risks and benefit from fewer protections and supports than their more advantaged peers. Like all behavior, AIDS risk-related behavior is tied to other facets of people's lives, and change in one realm can affect others. 269 270 Psychosocial barriers to behavioral change characteristic of those in extreme poverty can include limited self-efficacy, low self-esteem, perceived peer group disapproval, or beliefs about lack of the control of the future." 271 Potentially compensating community strengths are described by Friedman, et al.: Minorities are constantly developing resources and dynamics Working through existing community entities is likely to be the most effective way to affect counterproductive community values and beliefs. Through them, HIV prevention/education programs can build on community strengths which may be neither recognized nor fully understood by outsiders. Consequently, key components of the community must be involved in both planning and carrying out the prevention strategy. The objective is to mobilize communities to utilize, or, if necessary, rebuild their social networks in order to stimulate and support sustained behavioral changes among their members.273 Diverse Minority Population Requires a Variety of Targeted HIV Interventions The nation's ethnic and cultural diversity, apparent in language, cultural practices, beliefs about illness, and healthseeking behavior, requires the development of culturally appropriate HIV/AIDS information and education.274 Although some of these cultural elements constitute barriers to HIV prevention that must be overcome, HIV prevention can build on other beliefs and practices that promote health, and should identify and respect cultural elements that do not threaten health 275 Similarities among cultures can suggest strategies for effective communication and education.276 For example, one study found that among Asian and Pacific Islander cultures, family and community are vital parts of the lives of youths and the needs of the nuclear or extended family almost always supercede the needs of the individual.277 Thus,..."for Asian-American adolescents, services that gain family involvement, use supportive family networks, and promote family decision-making are believed likely to be more effective, although there have been no tests of this model."278 However, when designing a program for the Asian and Pacific Islander communities, planners must take into account the diversity of these populations which include at least 43 different Asian and Pacific Islander groups from more than 40 countries and territories, and who speak more than 100 different languages and dialects. Materials and messages should be tested with local groups for acceptability and effectiveness.279 Latino communities in in the United States exhibit heterogeneity despite a common language. Nuances of language or tradition can affect basic credibility and ultimate effectiveness. For example, in many Spanish speaking communities, "jeringa" means injecting equipment.2 280 In Puerto Rico, however, "jeringa" means "don't bother me"; using this word may mean that a key prevention message would be incomprehensible to the segment of the Hispanic community with the highest rate of AIDS.2 281 Jose Duran, Executive Director of the Hispanic Office of Planning and Evaluation, Inc. (HOPE), testified at a Select Committee hearing that an AIDS intervention with Latino youth should be community-based, involve community outreach, present factual and explicit information, be bilingual, utilize peer leaders, and involve parents as well as adolescents. He also suggested use of focus groups to explore levels of acceptance of prevention messages in various forms.282 African-American communities have been most disproportionately affected by the HIV epidemic, but few have marshalled community resources to confront it.283 A myriad of other, more immediately visible problems (including poverty, unemployment, racism, drugs, lower levels of education, and poor overall health), and distrust of the motives of the majority culture in imposing involvement,(s) prevent more immediate response to the threat of HIV infection.285 Efforts to resolve these larger problems are crucial to the success of HIV interventions.286 Involving African-American people with AIDS in educational efforts can help overcome denial of the AIDS threat in AfricanAmerican communities.287 Some have also suggested that culture-specific barriers to sexual negotiation be taken into account in program planning.288 The message should reach community members wherever they usually congregate, and should be a part of efforts to change the health-delivery system (s) A recent study by Thomas and Crouse-Quinn describes the Tuskegee Syphilis study, led by the Public Health Service, which was the longest known nontherapeutic experiment on human beings in medical history. The Tuskegee study tracked the results of deliberately untreated syphilis among African-American males over a 40 year period (1932 to 1972). Participants were never told that they were infected with a treatable disease, nor were they told that the disease could be transmitted sexually and from a mother to her fetus. According to Thomas and Crouse-Quinn, strategies used to recruit and retain participants for this study were very similar to those being advocated for HIV/AIDS prevention programs in African-American communities today, including: extensive collaboration of community-based and grass-roots organizations, local churches, public schools, and the use of local African-American nurses and personnel. The authors note: "Almost 60 years after the Tuskegee study began, there remains a trail of distrust and suspicion that hampers HIV education efforts in black communities."284 |