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Barriers and inroads to AIDS dialogue in the African American church : development of a strategic model and tool for network diffusion of abstinence-based HIV prevention advice

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Barriers and inroads to AIDS dialogue in the African American church : development of a strategic model and tool for network diffusion of abstinence-based HIV prevention advice
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Swain, Kristie Alley
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English
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xi, 740 leaves :29 cm.

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African American culture ( jstor )
African Americans ( jstor )
AIDS ( jstor )
Black communities ( jstor )
Condoms ( jstor )
Diseases ( jstor )
Focus groups ( jstor )
HIV ( jstor )
Pastors ( jstor )
Women ( jstor )
Dissertations, Academic -- Mass Communication -- UF ( lcsh )
Mass Communication thesis, Ph.D ( lcsh )
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bibliography ( marcgt )
non-fiction ( marcgt )

Notes

Thesis:
Thesis (Ph.D.)--University of Florida, 1999.
Bibliography:
Includes bibliographical references (leaves 563-636).
General Note:
Typescript.
General Note:
Vita.
Statement of Responsibility:
by Kristie Alley Swain.

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University of Florida
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Copyright [name of dissertation author]. Permission granted to the University of Florida to digitize, archive and distribute this item for non-profit research and educational purposes. Any reuse of this item in excess of fair use or other copyright exemptions requires permission of the copyright holder.
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BARRIERS AND INROADS TO AIDS DIALOGUE
IN THE AFRICAN AMERICAN CHURCH:
DEVELOPMENT OF A STRATEGIC MODEL AND TOOL FOR NETWORK
DIFFUSION OF ABSTINENCE-BASED HIV PREVENTION ADVICE





By

KRISTIE ALLEY SWAIN























A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
DOCTOR OF PHILOSOPHY

UNIVERSITY OF FLORIDA

1999




























.C.opyr.ight 1999 by

K..rist.i.e All.ey Swa.in













This study is dedicated to the memory of Allen L. Bunch, 1951-1997.


Allen's long fight with AIDS gave him the opportunity to motivate and uplift those around him, even the least fortunate, and it fueled his vision for founding the African American AIDS Task Force in Gainesville, Florida. His compassion toward fellow African Americans gave him the courage to share his testimony of rising from hopelessness and despair to finding a reason to live through helping others. It is hoped that this study will further Allen's dream of empowering the African American church to overcome its fears and denial, so that it can wam its youth about the dangers of AIDS and embrace those who suffer and place themselves at risk of HIV infection. While the family and friends Allen left behind continue to carry on his mission, he always will be dearly missed.














ACKNOWLEDGMENTS



First, I would like to thank Dr. Kent Lancaster for serving as chair of my

dissertation committee. I am also grateful for his assistance in developing the theoretical framework of this study and for his generosity in providing resources that enabled me to produce thefotonovela.

I also would like to extend special acknowledgments to my outside committee member, Dr. Richard Lutz, whose encouragement empowered me to surpass my own perceived limitations in the face of extraordinary obstacles. He courageously looked after my interests and diligently invested much of his time and scholarly expertise in helping me defend my scholarship. Without his support, I simply would not have endured.

I am also deeply appreciative of the time, assistance, and support that Dr. Bernell Tripp, another committee member, also generously provided. Ever since we were graduate students together at the University of Alabama in 1990-9 1, Bernell has been a consistent and trusted friend, a great listener, and an innovative and committed scholar. I thank her most of all for pushing me to persevere when I was ready to give up.

I also appreciate the insightful suggestions and guidance provided by Dr. Leonard Tipton, who also served on my committee. I am grateful for the Graduate Student


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Research Award provided by the College of Journalism & Communications, which helped cover the expense of the focus groups andfotonovela production.

I also would like to thank the many scholars throughout the national journalism academy who have rallied behind me throughout this difficult process. I particularly would like to thank Drs. Don Tomlinson, Marian Huttenstine, Charles Self, William Swain, and Will Norton for their encouragement and friendship. I arn fortunate to have such wonderful colleagues.

I also would like to acknowledge several African American leaders in

Gainesville, Florida, without whose help this study simply would not exist. First, I want to express my deepest appreciation to Pastor Linda King, who enthusiastically and tirelessly helped me set up all the focus group sessions and recruit participants for the study. I applaud her courage in addressing her colleagues about church-related stigma of people living with AIDS and in developing the first AIDS ministry in Gainesville's black community.

I am also indebted to Eltha-Leana Amaye-Obu and Dr. Portia Taylor, who both served in many different roles within this project. They both helped recruit excellent focus group moderators and provided constant encouragement, support, and insights about my evolving research goals and strategies. I also want to thank the Rev. John Cowart for coordinating the youth pilot study in his church, and Derrick James, a journalism student, for spending many hours in the health sciences library hunting journal articles for me.





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Finally, I would like to express my deepest gratitude to my husband, Brent Swain, whose patience and support throughout this long project taught me that no obstacle is too great when someone truly believes in you.











































vi













TABLE OF CONTENTS

Pne

ACKNOWLEDGMENTS .................................................................... iv

LIST O F FIG U R E S ............................................................................ viii

L IST O F T A B LE S ..................................................................................................... ix

A B ST R A C T ..................................................................................... x

CHAPTERS

I INTRODUCTION ........................................................................ I

O verview .................................................................................... 2
P roblem ..................................................................................... 2
R ationale .................................................................................... 6
O bjectives ................................................................................. 8
Overview of Chapters ..................................................................... 10

2 LITERATURE REVIEW ................................................................ 15

The Need for Culture-Specific Health Behavior Models ............................ 15
A Strategic Model of AIDS Preventive Behavior Change .......................... 17
The Conceptual Framework ............................................................. 19
Predisposing Factors ...................................................................... 27
Environmental Factors .................................................................... 59
Message Design and Delivery ............................................................ 74
Cognitive Processes ...................................................................... 112
Normative Processes ..................................................................... 128
Enabling Factors .......................................................................... 156
Potential B arriers .......................................................................... 173
Outcomes ..................... : ** *' *- ** '' '' 186
Summary of Literature Review ......................................................... 193

3 METHODOLOGY ....................................................................... 195

Selection of Method ...................................................................... 196
Site Selection .............................................................................. 198
Research Questions ....................................................................... 213

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Participant Observation .................................................................. 214
In-Depth Interviews ...................................................................... 215
Recruitment of Key Informants ........................................................ 218
Focus G roups ............................................................................. 224
Readability Analysis ..................................................................... 240
Inform ed C onsent ......................................................................... 243
Data Analysis Procedures ............................................................... 244
Threats to V alidity ....................................................................... 252

4 R E SU L T S ................................................................................. 258
Predisposing Factors ..................................................................... 260
Environmental Factors ................................................................... 290
Message Design and Delivery ........................................................... 300
Cognitive Processes ...................................................................... 330
Normative Processes ..................................................................... 347
E nabling Factors .......................................................................... 365
Potential B arriers ......................................................................... 405
O utcom es .................................................................................. 44 8

5 SUMMARY AND CONCLUSIONS .................................................. 462

Sum m ary ................................................................................... 462
K ey Findings .............................................................................. 465
Detailed Findings ......................................................................... 473
Limitations .......................................... 552
Implications for Future Fotonovela Interventions ............................................... 554
Future R esearch ........................................................................... 558

REFERENCES ................................................................................. 563

APPENDICES

A LONG INTERVIEW PROTOCOLS ................................................. 637
B FOCUS GROUP PROTOCOLS ...................................................... 647
C EDUCATIONAL MATERIALS ..................................................... 710
D "AFTERNOON DELIGHT"FOTONOVEL,4 ...................................... 723
E C O D E L IST ............................................................................. 728
F INFORMED CONSENT FORMS .................................................... 731

BIOGRAPHICAL SKETCH ................................................................. 738








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LIST OF FIGURES

Figure Page

I A Strategic Model of AIDS Preventive Behavior Change .......................... 25
2 Conceptual Framework for the Design of Culturally Relevant AIDS
Prevention Messages 26
3 Predisposing Factors that Influence AIDS Preventive Outcomes ................. 29
4 AIDS Cases among Black Males, Cumulative through June 1997 ................ 43
5 AIDS Cases among Black Females, Cumulative through June 1997 ............. 43
6 Sex-Ratio Imbalance among African Americans .................................... 54
7 The Role of Environmental Factors in AIDS Prevention ...... 60
8 Characteristics of AIDS Prevention Message Design and Delivery ............... 76
9 Cognitive Processes that Influence Individual AIDS Preventive Behavior....... 113
10 Normative Processes that Influence Individual AIDS Preventive Behavior...... 130
11 Factors that Enable an Individual to Comply with AIDS Prevention Advice ... 159
12 Barriers to Individual Compliance with AIDS Prevention Advice ................ 175
13 Responses to AIDS Prevention Advice ............................................... 188
14 Strategies and Procedures of Data Collection ........................................ 196
15 Revised Conceptual Framework Based on Data Analysis .......................... 259
16 Predisposing Factors, Identified by Research Participants, that Influence AID S Preventive Outcom es ............................................................ 260
17 Environmental Factors, Identified by Research Participants, that Influence AIDS Preventive Outcom es ............................................................ 291
18 Characteristics of AIDS Prevention Message Design and Delivery, as Identified by Research Participants .................................................... 301
19 Cognitive Processes, Identified by Research Participants, that Influence Individual AIDS Preventive Behavior ................................................ 330
20 Normative Processes, Identified by Research Participants, that Influence Individual AIDS Preventive Behavior ................................................ 347
21 Enabling Factors, Identified by Research Participants, that Facilitate Individual Compliance with AIDS Prevention Advice ............................. 366
22 Barriers to an Individual's Compliance with AIDS Prevention Advice .......... 405
23 Outcomes of AIDS Dialogue or Prevention Advice ................................ 448
24 Predisposing Factors in AIDS Prevention ............................................ 473
25 Environmental Factors in AIDS Prevention .......................................... 484
26 Message Design and Delivery in AIDS Prevention ................................. 488
27 Normative Processes and Outcomes of AIDS Prevention Advice in Religious C ontexts ................................................................................... 493
28 Cognitive Processes in AIDS Prevention ............................................. 500
29 Normative Processes in AIDS Prevention ............................................ 509
30 Behavioral Outcomes of Abstinence and Condom Advice for Single Individuals, in a Religious Context .................................................... 517
31 Enabling Factors in AIDS Prevention ................................................. 519
32 Barriers to AIDS Prevention ........................................................... 532
33 Outcomes of an AIDS Prevention Campaign ........................................ 547
viii









LIST OF TABLES


I In-Depth Interviews with African American Key Informants ..................... 222
2 Focus Groups of African American Adolescents and Women .................... 229











































ix













Abstract of a Dissertation Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy BARRIERS AND INROADS TO AIDS DIALOGUE IN THE AFRICAN AMERICAN CHURCH: DEVELOPMENT OF A STRATEGIC MODEL AND TOOL FOR NETWORK
DIFFUSION OF ABSTINENCE-BASED HIV PREVENTION ADVICE By

Kristie Alley Swain

May 1999

Chair: Dr. Kent M. Lancaster
Major Department: College of Journalism and Communications

While AIDS rates among many groups have leveled off or declined in recent years, Aftican Americans continue to be disproportionately diagnosed with the deadly disease. They constitute nearly half of reported AIDS cases in the U. S. but only 13 percent of the population. The black church has great potential for HIV prevention, despite religious stigmatism, because the institution is a touchstone for extended families.

The objectives of this exploratory study were to modify existing health behavior theory, develop directions for future research about culturally specific, church-based HIV prevention strategies, and to reveal factors that block or empower constructive AIDS dialogue in these settings. The qualitative study included 10 groups of focus group interviews with 85 lower-income adolescents and women, 13 in-depth interviews with clergy, church members, and AIDS organization leaders, and participant observations of events within AIDS organizations and churches.


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Adolescents collaboratively developed skits and "raps" for a photo-illustrated comic book that was used as both an HIV prevention tool and as a device for gathering information about how individuals engage in AIDS dialogue in religious contexts. When participants shared these booklets with others, the outcomes included initiation of AIDS dialogue, enthusiasm, momentum, ownership, increased self-efficacy, and intent to maintain of healthy behaviors.

The data revealed contexts, opportunities, and benefits of AIDS dialogue, as well as popular and prescriptive norms of AIDS knowledge and attitudes, health beliefs, religiosity, sexual behaviors and scripting, substance use, and source credibility. An organizing theoretical fiumework consisted of eight domains: predisposing and environmental factors, message design and delivery, cognitive and normative processes, enabling factors, potential barriers, and outcomes.

Clergy were blamed for prohibiting AIDS dialogue. However, many women

viewed themselves as "torch bearers" of HIV prevention in church settings, community sentinels, surrogate parents, and counselors. AIDS dialogue can be stimulated in religious contexts through interpersonal interventions sensitively tailored to address condom use, AIDS stigma, homosexual behaviors and other religious taboos, while utilizing Christian principles such as evangelism, prayer, behavioral accountability, and divine guidance.











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CHAPTER I
INTRODUCTION

The early sunlight streams through the sprawling oak trees lining the
sleepy downtown streets of a Florida town. Donning a lacy, emerald-green
pillbox hat this humid Sunday morning, a young mother makes her way toward an
old strip mall. Once housing several African American stores near the town's "red light" district, better known as "Porters Quarters," it is now rented to an
inter-denominational, African American church. The woman hugs several elderly friends at the door of the worship center, and she finds her seat among the rows of
metal folding chairs.
A worship team draped in golden satin robes hums a lively spiritual in
three-part, a cappella harmony. A minister wearing tasseled vestments rises to
greet his congregation, shouting words of encouragement: "I went to the rock to hide my face. The rock cried out, 'No hiding place! "' Amid a sea of fluttering paper fans each displaying a funeral home ad and scripture the congregation
begins a refrain of "Amazing Grace."
Just outside the church door, a homeless man stumbles down the sidewalk
clutching a wine bottle in a crumpled brown bag. A thin, disheveled woman in
spike heels emerges from a dilapidated house. Three men lounge on the concrete
steps of the comer plasma donation center, sipping malt liquor and setting up
"shop" for the addicts who come to sell their blood for drug money. In a nearby low-income apartment, young teens hang out just to "make out" and watch a sex
movie on cable TV, at least until Momma comes home from church.
Sheltered within the sanctuary, with windowless walls bearing bright
banners and activity calendars, the church members don't whisper about the
goings on outside the prostitution, drug addiction, drinking, teen sex,
homelessness, despair. The worlds of sin and worship, for the moment separated
only by the graffiti-covered paneling of the strip mall, do not collide even when
the smiling churchgoers venture to their cars and drive back home for Sunday
dinner.
As the weeks and months drift by, a deadly virus spreads silently through
the black community's social networks of friends, families, lovers, and victims of
abuse. Within the churches, believed to be resources of hope, healing, and
salvation, the ministers and their cloistered churchgoers do not speak of IRV nor express concern that their own children and grandchildren might be vulnerable to
the dreaded disease.'

This narrative is a composite of the investigator's observations of neighborhood activities, worship participation in three different churches in the African American community, and anecdotal evidence corroborated by key informants.










Overview

Although the African American church as a whole still denies the severity of the AIDS epidemic in the black community, as will be shown, the institution stands as the cornerstone of the extended family and has more potential than any other organization to mobilize activism in addressing social ills of every description.

The primary purpose of this qualitative study was to explore the factors that can enable and inhibit constructive dialogue about AIDS prevention in the Affican American community. A major goal was to develop strategies for promoting AIDS dialogue among younger adolescents and adult female opinion leaders, within a context that is sensitive to the religious norms of the church.

Problem

Public health experts speculate that at least a million Americans are infected with human immunodeficiency virus (IRV), a virus believed to weaken the immune system and lead to the diagnosis of a terminal, infectious condition known as acquired immunodeficiency syndrome (AIDS). In the United States, 581,429 cases of AIDS were reported between 1981 and 1996, and 62 percent of those individuals have died (CDC, 1996). Since the mid-1980s, when the number of reported cases began to increase exponentially, many authorities have regarded AIDS "as the greatest health crisis of our era" (Treichler, 1988, p. 195).

In 1997, the AIDS rate was seven times higher among blacks than among whites (UPI, 1997). The disproportionate infection rate among blacks became acute in 1993



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when the CDC reported that 55 percent of all new AIDS cases were among blacks and other minorities. As of June 1997, African Americans constituted 38 percent of all reported AIDS cases in the U.S. (CDC, 1997), but in total numbers constituted 13 percent of the population (U.S. Bureau of the Census, 1997). Every hour, one African American child or teen dies of AIDS and one contracts HIV somewhere in the United States. Six in 10 children born with HIV, and half of all intravenous drug users with AIDS are African American (HERO, 1994).

The sexual routes of FHV transmission are vaginal and anal sexual intercourse and oral sex, both fellatio and cunnilingus. AIDS is transmitted non-sexually through perinatal transmission, sharing infected needles, sharing toothbrushes or razors, blood transfusions, and the use of infected clotting factor or other blood products. FHV is not transmitted through insect bites, sharing dinnerware, blood donations, food handling, hot tubs, or saliva, nor through "casual social contact such as shaking hands, hugging, social kissing, crying, coughing, or sneezing" (Surgeon General, 1986, p. 21).

The prospects for a cure or vaccine still are remote, but risky behavior among Americans appears to have increased recently because of the discovery of increasingly effective AIDS treatments. While AIDS deaths rates have leveled or declined among most groups, public health leaders have called for rededication and reconceptualization of FHV prevention efforts because the virus continues to spread (Lifson, 1994). Although some believe that AIDS education has failed (Philipson, Posner & Wright, 1994), the first decade of the epidemic has shown that lasting behavior change can occur as the result of carefully tailored, targeted, and persistent prevention efforts (Stryker, Coates, DeCarlo, Haynes-Sanstad, Shriver & Makadon, 1995).

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Currently, the only means of slowing the spread of the virus is public information and education. The effectiveness of an AIDS campaign lies in its ability to modify AIDS-related attitudes, beliefs, and behaviors (Ross & Rosser, 1989). During the 1980s, televised public service announcements were used to try to change audience attitudes and behaviors about drug use and to change sexual practices (Gentry & Jorgensen, 199 1).

Although these PSAs have been helpful in delivering general information to

general audiences (Hastings, Eadie, & Scott, 1990; Blosser & Roberts, 1985), the general consensus of researchers is that such mass media campaigns alone exert limited influences on audience behaviors (Gantz, Fitzmaurice & Yoo, 1990).

Some argue that the greatest benefit of mass mediated health messages is the fact that these messages raise the public's awareness of health-related issues (i.e., Gantz, Fitzmaurice & Yoo, 1990; Lau, Kane, Berry, Ware & Roy, 1984). However, knowledge alone is not sufficient to inoculate individuals against risk taking because intellectual appreciation of risk does not necessarily translate into sustained behavior change, particularly for activities as inherently pleasurable as sexual intercourse (Stall, 1994).

AIDS is still generally considered a "bad" disease carried by "bad" people. AIDS prevention efforts continue to be limited by a widespread unwillingness to explore and frankly discuss sexual and drug use behaviors, including homosexuality, teen sex, condom use, oral and anal sex, injection drug use, prostitution, and promiscuity. These discussions are constrained by political considerations, law, and concerns about morality, and many people do not personally identify with the disease because they do not know anyone who is infected. These attitudes contribute to denial of personal risk, misperceptions about transmission, and discrimination against people with the disease or

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groups identified as high risk (Williams, Scarlett, Jimenez, Schwartz & Stokes-Nielson, 1991).

African Americans and other ethnic minorities have suffered disproportionately from HIV infection over the past 15 years. Public health officials began to take notice of this trend in 1993 when the U.S. Centers for Disease Control reported that 55 percent of all new AIDS cases were among minorities and that the AIDS per capita rate among African Americans was more than five times higher than the national rate (CDC, 1996). As of 1996, African Americans constituted 37 percent of all reported AIDS cases in the U.S. (CDC, 1997), but in total numbers constituted 13 percent of the population (U.S. Bureau of the Census, 1990). By 1997, the AIDS rate was seven times higher among blacks than among whites (UPI, 1997).

Although black women account for 13 percent of all women (U.S. Bureau of the Census, 1997), they account for nearly 60 percent of all AIDS cases among women (CDC, 1996). In 1996, black women were 15 times more likely than white women to be diagnosed with AIDS. African American males were nearly five times more likely than white males to get AIDS (CDC, 1996), even though there were seven times more white males than black males. Black males accounted for 12 percent of the U.S. male population (U.S. Bureau of the Census, 1997).

Identifying specific cultural elements that predict the effectiveness of FI1V

prevention programs and individual receptivity to prevention messages is a critical task for health communication researchers (Stryker, Coates, DeCarlo, Haynes-Sanstad, Shriver & Makadon, 1995). The need for cultural sensitivity in delivering 1HV prevention messages has become increasingly recognized by both scholars and public

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health practitioners (Bayer, 1994). For example, Nyarnathi, Leake, Flaskerud, Lewis, and Bennett ( 1992) found that presenting basic, culturally-relevant information alone can reduce high risk behaviors among impoverished Affican-American and Latina women participating in AIDS counseling programs. Hecht, Collier, and Ribeau (1993) argue that prerequisites for cultural sensitivity are communication competence and an understanding of African American ethnic identity and cultural variation, not 'ust an understanding of normative or otherwise "typical" behaviors among African Americans.

Rationale

Jones (1995) notes that the church is "the only indigenous institution" in the black community (p. 16). The primary formal and informal sources of assistance to individuals in the black community are churches, social clubs, and community organizations (Spector, 199 1). The interconnectedness of these groups and social support networks has important implications for risk behavior assessment and prevention (Gleaton & Johnson, 1995). Because of the pervasiveness of its religious norms within extended families and other social networks, the church has the potential to create the kind of cohesive atmosphere needed to carry out an effective AIDS prevention campaign.

Less education and low self-esteem among many African Americans, combined with fundamentalist religious beliefs common among members of most African American churches, tend to promote disapproval of sex education, condom distribution, or even discussion about AIDS. In addition, this disapproval, fear, and denial can contribute to a community environment of stigmatization, condemnation, and irrational fear of AIDS.



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African American adolescents are the target of a trial AIDS intervention in this study. However, the majority of African American youths across the U.S., with the exception of those in the South, are not committed to the church (Taylor, 1988). Many younger blacks who drop out of church feel the pastors of black churches are hypocritical and do not live up to their call as ministers (Trout, 1989). Others question the necessity of church because their fathers do not attend or because they feel that going to church is not a measure of religiosity (Moore & Waiters, 1995).

Despite these barriers, the unifying and empowering force of the church within the entire black community may justify attempts to provide some form of AIDS education that is grounded in church values and disseminated through social networks that have church-related linkages. Further, the church's ability to reach out to at-risk youth is highlighted by the fact that most black youths believe in God and Biblical teachings even if they do not attend church regularly (Moore & Waiters, 1995), and most are part of an extended family whose elders are highly religious.

The black church serves as a touchstone among both religious and non-religious individuals. It has a long and distinguished tradition of leading and caring for its people in times of great suffering. Often it has served as an impetus for education and change in times of crisis through pastoral activism and church mobilization. Many sociology and history scholars have argued that the Civil Rights Movement of the 1960s was born and sustained through the collaborative efforts of black churches (Findlay, 1993). The spread of activism, such as the black student sit-ins, followed the networks of black churches in the South (Morris, 1981). Many black churches also hosted informal grassroots academies that were crucial to the development of the movement (Edwards & McCarthy,

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1992). Because of this high level of activism, many black churches today still confront a variety of nonreligious community crises and thus maintain a dynamic tension between the spiritual and social missions of the church (Burris & Billingsley, 1994).

In exploring individual beliefs, environmental factors, and social norms, this

study used iterative and ethnographic methods to design AIDS prevention messages that are acceptable within African American church settings. The messages show who is vulnerable and why, promote personal control in AIDS prevention, provide information about HIV transmission, show that the AIDS threat is local and close, offer strategies for interpersonal communication about AIDS, and account for peer-group influence.

Objectives

This study was intended to examine a complex tapestry of interwoven factors, as suggested by a synthesis of existing behavioral theory, previous empirical studies, and sociological studies of the African American community. Of particular interest were the predisposing, environmental, cognitive, normative, enabling, barrier, and message design variables that can influence the effectiveness of an AIDS prevention message that is bounded by cultural and religious sensitivities and that targets African American youth, a high-risk population.

To that end, the study utilized an original, collaboratively createdfotonovela (photo-illustrated comic book) as a discussion tool to help the research participants articulate their views about AIDS prevention and to stimulate AIDS-related dialogue among youths and women in everyday, "real-life" settings. In light of known literature, this study is the first to develop afotonovela that targets African Americans with a health promotion message.

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An original conceptual framework synthesized major behavioral theories that have been used to predict compliance with health promotion advice. This model subsequently was used as an organizing framework to contextualize themes that emerged from transcript analysis, to use these findings to modify existing theory, and to construct grounded theory.

A triangulation of qualitative methods a battery of long interviews, two years of participant observation, and a unique, multi-stage focus group design facilitated the collection of data about cultural factors that inhibit and facilitate AIDS prevention efforts within various religious contexts. This information provided an understanding of how various risky behaviors are perceived by the Aftican American religious community and mediated by social relationships within this culture. In addition, this study explored group norms, individual values, and cultural beliefs about the realities and acceptability of unsafe sexual behaviors.

The primary research questions of this study were

1. What are the specific inroads and barriers to AIDS-related dialogue among

African Americans within various religious contexts?

2. What are the processes by which African American women and youth could

engage targeted youths in discussions of AIDS issues, and in what settings

does this kind of dialogue occur?

3. How could group construction of an originalfotonovela and the subsequent group

evaluation of this tool be used to assess attitudes, beliefs, and new ways that

AIDS-related dialogue could be facilitated within existing social networks among

African American youth and women?

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4. To what extent could thisfbionoveld change individual attitudes about FUV and

the risks associated with unsafe sex?

5. How effectively could afolonovela promote self-efficacy by offering strategies

for postponing sexual involvement, parent-child interaction, partner negotiation, resisting peer pressure, building self-esteem and personal responsibility, teaching

decision-making skills, and setting life goals?

6. Among African American youth, what factors serve as barriers to their

postponement of sexual involvement or sexual abstinence?

7. What kind of AIDS prevention advice would best legitimize sexual abstinence

for teens and empower them to comply with this advice, in a manner consistent

with both their social norms and religious norms rooted in church theology?

8. Which strategies could overcome barriers to FRV prevention, including denial of

threat and other attitudes that inhibit rational decision-making?

Overview of Chapters

Chapter 2 is a literature review organized by a theory synthesis model that shows the relationships among basic components of health behavior change theories. The discussion of existing literature is related to various domains and theoretical constructs of the model, and it serves as a point of departure for theory development and modification in later chapters.

The literature review discusses theoretical concepts of the model both in light of individual and cultural contexts. The eight domains of the model are predisposing and environmental factors, behavior change message components, cognitive and normative



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processes of health behavior, enabling factors and potential barriers to action, and behavioral outcomes.

Prior research about health communication and campaign theories includes

literature about Diffusion of Innovations, Social Cognitive Theory, Theory of Reasoned Action, Health Belief Model, Parallel Processing Model, and other theories. The discussion also addresses AIDS epidemiology among African Americans, social marketing strategies, use of afotonovela as an alternative micro-media campaign channel, opportunities for abstinence-based HIV prevention, the structure of the black community, religiosity among African Americans, barriers to AIDS prevention, and opportunities for AIDS activism in the black church.

Unlike many studies that are designed to test the stability or generalizability of one particular theory, this study addresses many issues and synthesizes a number of related behavior change theories. This broader approach offers an exploration of higherlevel theory, via an integration of variables and other concepts from numerous middlerange theories. Zucker, Aronoff, and Rabin (1984) lamented that in most behavioral studies, researchers merely

Take manageable problems, apply a middle-level theory for the portion of human
behavior related to that smaller realm, collect data on easily available (college
student) respondents, use the results to fine tune the theory, and then move on to
the next middle-level problem. (p. 1)

Maddi (1984) similarly contemplated this issue:

It is fashionable. these days to restrict conceptual effort to the middle ground,
in the belief that the grand theories of the recent past are impediments to
scientific advance ... An unfortunate feature of a commitment to middle-level
theorizing is the general distrust of any formulation that appears to have any
surplus meaning. This leads readily to reliance upon single explanatory
concepts, which appears so parsimonious but really turns out not to be, as we I I







must add more constructs each time we do another study.... Once one
recognizes that the various concepts in a comprehensive theory influence each
other as to meaning, it becomes less surprising that a concept called by the same
name in two different theories may have somewhat different connotations.
(pp. 26, 32)

In addition to exploring attitudes and behaviors of harder-to-reach populations using an integrated conceptual framework rather than a single middle-level theory, the present study also was designed

1. To build new theory, as well as to evaluate and modify existing theory.

2. To explore a rich and complex matrix of cultural factors of the research

participants through the development of a conceptual framework that shows

relationships among various facets of AIDS prevention targeting Aftican

Americans. Michal-Johnson and Bowen (1992) describe culture as a

dynamic, multifaceted process that is like layers of transparency film that

produce a composite color when illuminated. Applying their metaphor to this study, a goal of building the theoretical model from existing literature was to

use it to frame various cultural realities, and to see how these multifaceted realities, in tuM illuminated the limitations of traditional behavior change

strategies.

3. To better explain, by showing relationships among culturally relevant

concepts, why some individuals within particular cultural groups adopt

preventive behaviors while others do not, as well as to predict which types of messages or program strategies could be more effective. Although a general

concept of culture is implicit in many traditional health behavior models, most empirical studies that utilize or test these models do not adequately 12








explain the specific ways that culture influences various behavioral outcomes

(Michal-Johnson & Bowen, 1992).

4. To use an organized synthesis and discussion of existing theory and evidence

to help inform the development of afotonovela for use as an AIDS prevention

tool for African American audiences versus other types of media that

traditionally have been less effective.

Chapter 3 describes the methodology of the study, including a discussion of

qualitative communication research approaches, justifications for the site selection, and a description of the research questions and study objectives. The chapter discusses the methods used in the participant observation, in-depth interviews, focus groups, and recruitment of participants. This chapter also describes the procedures involved in developing the Jot onovela, conducting readability analysis, providing informed consent, in evaluating validity threats, and in transcribing, analyzing, and interpreting the datatexts.

The in-depth interviews included one-on-one discussions with African American clergy, as well as members of a minority AID)S advocacy group, national AID)S ministry leaders, and an African American woman living with AIDS. Teen participants in a summer youth program collaboratively designed and developed a short fotonovela. Copies of this story booklet then were distributed to the African American youth and to African American women in a Bible study group in a low-income neighborhood. After participating in a focus group designed to assess AIDS knowledge, attitudes, and beliefs, participants returned for follow-up sessions where they were encouraged to share personal stories about their AIDS outreach efforts and reactions to the fofonovela.

13








Chapter 4, the analysis chapter, presents a theme analysis of data-texts, and the themes are organized and contextualized using a theoretical framework that synthesizes various behavior change models. Numerous exceptions to this initial framework also are highlighted. This chapter also offers examples that illustrate the meanings, patterns, and contexts in which respondents interpret and discuss AIDS-related issues. The chapter highlights the nature of AIDS dialogue in the African-American church, giving particular attention to the processes by which African-American youth and church-going women engage others in discussion of AIDS issues using afotonovela as a tool.

Chapter 5, the summary and conclusions chapter, discusses the theoretical, methodological, and practical implications of the study, the study's limitations, a summary of key findings, and an agenda for future research. The final chapter also includes a discussion of various barrier and efficacy constructs, as well as implications for future fotonovela interventions targeting African Americans. Theme analysis was used to develop recommendations for a church-based AIDS prevention campaign, and to provide insights into AIDS-related attitudes, including religiosity-based barriers to AIDS prevention. The findings also were used to refine thefotonove1a for future use both as a tool to motivate teens to practice sexual abstinence as well as to foster open dialogue about AIDS prevention issues among youth and between adults and teens.











14













CHAPTER 2
LITERATURE REVIEW

The Need for Culture-Specific Health Behavior Models

The Health Belief Model, Theory of Reasoned Action, Extended Parallel Process Model, and AIDS Risk Reduction Model provide relevant concepts needed to assess and develop a basic AIDS prevention strategy. However, they are static and linear in their view of the health attitude and behavior change process.

Following the logic of these models, African American adolescents confronted with the threat of HIV infection would be expected to rationally assess personal susceptibility, threat severity, costs, benefits, and the efficacy of the prevention advice. Teens also would be expected to rely on past experiences and knowledge, particularly gained from social interaction, as important bases to make these judgments. From this assessment, the teens would make decisions about whether or not to adopt the recommended HIV prevention action.

These models assume that the decision-maker is a rational individualist who can freely receive information and develop a health decision based on interactions with knowledgeable others. However, since individuals do not always make health decisions based on cost-benefit analysis or objective evaluation of various perceptions, they may instead and more likely choose to comply with cultural or social norms. In addition, many people irrationally discount risks and perceive themselves as invulnerable to harm. The




15








perception that AIDS is not a threat often might be explained by the typical adolescents "it won't happen to me" attitude.

Another weakness of these psychosocial models is that they can only account for the amount of variance in health-related behavior change that can be explained by individual health-related attitudes and beliefs. The explained variance is typically 12 percent or lower, possibly because the social and cultural forces that can override rational choice can be stronger predictors of health-related behavior than attitudes and beliefs.

Existing theoretical models also do not fully account for all factors that predict risky behavior or compliance with an AIDS prevention message in every culture. None of these models have My explained or predicted health behavior in all cultures, likely because they are intended to be generically cross-cultural and thus do not include specific cultural norms that have a powerful influence upon individual health decisions.

Thus, new culture-specific models are needed to expand existing models and/or integrate constructs from existing theories, in order to account for normative barriers to action such as traditional social structures and values. Unlike the broad-based behavior change models, a new model could account for behaviors shaped by habit or addiction, behaviors undertaken for non-health reasons (i.e., for attractive appearance, social approval), or behaviors guided by economic or environmental factors. The integrated framework used in the present study attempts to synthesize both individual cognitive and normative components, as well as the factors that predispose individuals to various outcomes.






16










A Strategic Model of AIDS Preventive Behavior Change

The following discussion highlights the rationale and strategies used in developing an integrated theoretical framework for the present study.

A key component of qualitative research design, according to Maxwell (1996), is the conceptual context of a study "the system of concepts, assumptions, expectations, beliefs, and theories that supports and informs your research... This context, or a diagrammatic representation of it, is often called a conceptual framework." Without the construction of a conceptual framework, he argues, the use of existing theory can "often degenerate into a series of 'book reports' on the literature, with no clear connecting thread or argumenf'(p. 26). A researcher should develop a conceptual context or framework prior to data collection by identifying theories, literature, and findings that relate to the phenomena being studied (Maxwell, 1996).

A review of relevant prior research can be used to test or modify theories because it can help a qualitative researcher see if existing theory is supported or challenged by previous studies, as well as generate new theory (Maxwell, 1996). Gilgun (1994) notes that many qualitative researchers "usually do a thorough literature review before beginning their research" in order to "survey the field, develop an understanding of what is known, and identify gaps in knowledge, which may give direction to the research." In addition, qualitative research that does not have a basis in existing literature "does not develop higher order concepts and therefore leaves other researchers with little on which to build" (p. 117).




17








Howe and Eisenhart (1990) assert that the use of prior research "ensures that

qualitative research is rigorous" (p. 2). Similarly, Panitz (1997) argues that standards of rigor include (1) a solid review of existing theory, (2) a presentation of material that either supports accepted theory and/or expands or modifies that theory, and (3) changes to theory that are supported by data.

Miles and Huberman (1994) state that a conceptual framework "explains, either graphically or in narrative form, the main things to be studied the key factors, concepts, or variables and the presumed relationships among them" (p. 18). Concept mapping, a similar tool, was developed by Novak and Gowan (1984), and a third variation, called an integrative diagram, was developed by Strauss (1987). Another similar tool is the influence diagram, proposed by Howard (1989).

A conceptual framework consists of concepts and the relationships among them, and these relationships "are usually represented, respectively, as labeled circles or boxes and as arrows or lines connecting them," and the framework serves "to pull together, and make visible, what your implicit theory actually is, or to clarify an existing theory" (Maxwell, 1996, p. 37). The most productive ways of constructing a conceptual context, Maxwell argues, are:

Often those that integrate different approaches, lines of investigation, or theories
that no one had previously connected ... This framework is something that is
constructed, not found. It incorporates pieces that are borrowed from elsewhere,
but the structure, the overall coherence, is something that you build, not
something that exists ready-made. It is important for you to pay attention to the
existing theories and research that are relevant to what you plan to study, because
these are often key sources for understanding what is going on with these
phenomena. (p. 27)





18








A key distinction is the difference between variance maps and process maps.

Maxwell (1996) notes that variance maps deal with abstract, general concepts and depict how some factors or properties of things (conceptualized as variables) influence others. A process map tells a chronological story, and the categories are presented as specific events rather than as variables.

The Conceptual Framework

The literature review in this chapter is organized using a model designed to

explain the relationships among basic components of health preventive behavior change processes, particularly among African Americans, as well as to show how these concepts can be applied to the development of health campaign strategies. Public health campaigns involve numerous factors, ranging from individual characteristics to social system variables (Sheer & Cline, 1994). The model in this study is used to categorize, delineate, and organize a wide range of variables as they relate to relevant theories and empirical evidence in the health communication literature.

The framework is a variance map that shows the relationships among concepts, as well as the causal network of variables and influences upon AIDS preventive behavior among African Americans. The basic model is a network of eight large domains, with a number of sub-categories and properties within each of these domains.

The model in this study is shown in two versions: basic and descriptive (Figure I and Figure 2). An iteration of the model introduces each section of the literature review. Although the model is general enough to be applied to health prevention campaigns addressing risks other than AIDS, it is expanded in the literature review to address the particular cultural factors that influence AIDS preventive behavior change among 19







African Americans. The logic and physical structure of the model was developed through a synthesis of components from existing theories, concepts, and models.

Michal-Johnson and Bowen (1992) note that the three primary models used in attempts to understand AIDS-related health attitudes and behaviors are Fishbein and Ajzen's (1975) theory of reasoned action, Becker's (1974) health belief model, and Bandura's (1994) social cognitive theory. The theory of reasoned action places more emphasis upon rational decision-making than the health belief model or social cognitive theory, and it is more detailed in specifying relationships among theoretical variables. In addition to these three models, the framework used in this study integrates structural and conceptual components of Ajzen's (1988) Theory of Planned Behavior, Witte's (1996) Extended Parallel Process Model, and the AIDS Risk Reduction Model by Catania, Kegeles, and Coates (1990).

The framework used in this study (shown in Figures 1 and 2) also integrates structural and conceptual components of the following theories:

*Diffusion of Innovation (Rogers, 1995)
*Theory of Planned Behavior (Ajzen, 1988)
*Persuasive Health Messages Framework (Witte, 1995)
*Protection Motivation Theory (Rogers, 1975)
*Input/Output Matrix (McGuire, 1989)
*General Model of Communication (Gerbner, 1956)
*Elaboration Likelihood Model of Persuasion (Petty & Cacioppo, 198 1)
*Transformation Model of Communication (Kreps, 1994)
*Stages of Change model (Prochasta & DiClemente, 1984)

The model is intended to serve as a global view of health decision processes, specifically designed for the integration of unique cultural factors for a specific target audience. While it is not a path model showing correlational linkages, the model shows




20







connections among variables using lines and arrows that illustrate relationships that have been statistically demonstrated in previous health communication studies.

The following discussion provides a summary of each component of the conceptual framework (Figure 1).

Before an individual is exposed to a behavior change message, he or she will be unconsciously conditioned to accept or reject the message depending upon individual predisposing factors and the external factors of his or her environment.

Predisposingfactors are components of a target individual's existing

intrapersonal-level reality prior to exposure to a preventive health message, and these factors are considered to be antecedents to attitudes and behavior. Psychologists generally have identified intelligence, self-esteem, and sex differences as recipient factors that predict the extent that a person can be persuaded (Petty & Cacioppo, 1981).

The factors that predispose an individual toward AIDS preventive behavior are assumed to include personality factors, needs, demographic factors (age, sex, and education), values (i.e., religiosity), prior knowledge about AIDS transmission, prior experience practicing AIDS preventive behaviors (such as condom use or AIDS prevention negotiations with a partner), behavioral risk factors (homosexuality, teen sex, and drug use, as well as cultural norms truancy, motherhood norm, and scarcity of eligible black men that place African Americans at risk), and previous positive health activities such as participation in church-based health interventions.

Environmentalfactors are the external influences upon individual behaviors that are assumed to exist before a person is exposed to a behavior change message. In this study, these factors include social network norms (including norms within the African 21








American community and black church), cultural norms of communication (the Affican American oral tradition), the structure and norms of African American families, media access and use among African Americans, AIDS epidemiology at the national, state, and community levels, and the availability of community resources, with a focus on the evolution of the African American AIDS Task Force.

It is within the predispositional and environmental context that a health message is introduced to the individual, and the manner in which various components of the message are crafted and presented predicts its eventual impact on behavioral outcomes. These components include cues to action, the nature of change agents, homophily and other characteristics of sources appropriate for African American audiences, characteristics of abstinence messages, message strategies including social marketing and community-based health campaign planning, and the selection of channels for targeting African Americans, including thefotonovela as an alternative micro-media channel.

After a person has been exposed to a message, he or she will process it within both cognitive and normative spheres before taking action. In other words, a person's inner thoughts and feelings, as well as his or her innovativeness, roles within social networks, and perceived views of important social referents will predict how the person acts on the message.

Cognitive processes learning, motives, beliefs, and attitudes are predictive of behavior. In the model, these processes are assumed to be the catalysts of behavior change that are influential after an individual has been exposed to a behavior change message, as contrasted with the effects of predisposing factors. The aspects of learning, which include attention, comprehension, social learning, and sexual scripting, are 22








assumed to be dependent upon an individual's cognitive competencies. Thus, motives, attitudes and beliefs would be expected to have little influence on intended behavioral outcomes unless leading has first taken place. Sheer and Cline (1994) note that motives are more cognitively fixed, while attitudes and beliefs are more changeable and thus have less direct influence on behavioral outcomes than motives.

The literature review discusses the theoretical components of learning in light of the study the specific objectives for reaching African American youth with an abstinence-based AIDS prevention message in afotonovela format. This section discusses developmental predictors of attention, processes of reading comprehension, the social learning process, and sexual resistance strategies.

Motives related to health behavior are discussed in light of self-evaluation and social modeling, both components of Bandura's (1994) social cognitive theory. Salient beliefs are discussed in relation to perceived risks and personal relevance, as well as an overview and critique of Becker's (1974) Health Belief Model. The discussion of attitudes focuses on African American attitudes about various health issues, pro-social attitudes promoted by television dramas, and the role of persuasion in community-based AIDS prevention campaigns.

Normative processes are assumed to be the social catalysts of behavior change

that influence individuals after they have been exposed to a behavior change message, as contrasted with the effects of environmental factors. These processes are discussed in light of social network applications in prevention planning, diffusion of innovations theory, opinion leadership, and communication networks, as well as theories about behavior norms, social influence, and individual perceptions about salient referents.


23








Beyond the cognitive and normative processes of interpreting and contextualizing a health message, a nurnber of factors serve to enable a person to comply with the message or serve as barriers to a recommended action.

Enablingjactors include Bandura's (1989) concepts of self-efficacy and response efficacy, and Witte's (1996) process of danger control, as well as source credibility, social support, reinforcement of values through AIDS prevention initiatives in the African American church, and the acquisition of AIDS prevention skills, which is contingent upon educational effectiveness and empowerment.

Potential barriers include racism, black genocide theory, denial, myths and

misinformation, taboos, lack of resources, low literacy, poverty, homelessness, family problems, and depression.

Finally, after each variable exerts its effects upon an individual's decision-making process, he or she is expected to act, even if the chosen action is to do nothing at all. From the perspective of the campaign planner, the behavioral outcome either will be desirable or undesirable.

The descriptive version of the model (Figure 2) includes a corresponding diagram of Rogers' (1995) diffusion of innovations theory, the primary theory guiding this study, in order to illustrate how the behavior change strategy parallels the diffusion process. Details about the diffusion process are discussed in the "normative processes" section of the literature review.

In this study, desirable outcomes include behavioral compliance sexual

abstinence or the postponement of sexual involvement as well as lower-level outcomes such as increased interest in AIDS issues, new awareness or knowledge of AIDS risks, 24








the strengthening of social support networks for open discussion of preventive behaviors, and the sensitization of adults about the needs and pressures faced by adolescents and new strategies for adult-teen communication about those problems.

Undesirable outcomes might include initiation of sexual involvement, continuing sexual involvement, withdrawal from social support networks, reduced interest in AIDS issues, confusion about AIDS transmission, denial of personal risk, or seif-devaluative behaviors, described by Bandura (1994) as the rationalization of self-deplored actions (such as the decision to have sexual intercourse despite internalized religious beliefs that label such behavior as sinful).

INDIVIDUAL PROCESSES









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Predisposing Factors

The "Predisposing Factors" domain of the theoretical framework contains components of 10 different existing health behavior models. The Extended Parallel Process Model (Witte, 1996) contains an Individual Differences component, while the predisposing factors of the Health Belief Model (Becker, 1974) include demographic variables and personal experience as cue to action. The Social Cognitive Theory (Bandura, 1994) classifies knowledge as a "personal factor," and the Stages of Change model (Prochasta & DiClemente, 1984) classifies knowledge about risk as "precontemplation." In the Transformation Model of Communication (Kreps, 1994), "health problem/risk" is categorized as an Antecedent Condition.

The Independent Communication Variables within the "Input" domain of the Input/Output Matrix (McGuire, 1989) include demographics, ability, personality, and lifestyle. The AIDS Risk Reduction Model (Catania, Kegeles, & Coates, 1990) posits that predisposing factors include transmission knowledge, labeling, risk assessment and pre-existing aversive emotions. The Theory of Reasoned Action (Fishbein & Ajzen, 1975) asserts that predisposing factors include personality traits and demographics. Relevant demographics include age, sex, occupation, socioeconomic status, religion, and education.

In the Persuasive Health Messages Framework (Witte, 1995), Receiver Variables and Preferences, which constitute the "audience profile," include demographics (race, gender, socioeconomic status, literacy level, age, employment, primary language), psychographics, habits, customs, key values, preferences, and religious taboos.




27








According to Diffusion of Innovations theory (Rogers, 1995), "Prior Conditions" include previous practice, felt needs/problems, and innovativeness, In addition, the theory posits that the characteristics of the decision-making unit include socioeconomic characteristics and personality variables.

For the sake of clarity, and given that the theoretical framework of the present study was used primarily as an organizing framework, the various affective dimensions (both predisposing and following information exposure) are discussed within the Cognitive Processes section.

The model on the next page, Figure 3, highlights key components of the
"predisposing factors" domain of the conceptual framework and introduces a review of literature about various individual factors that can influence AIDS preventive behavior. Religiosity

The belief in a god or the supernatural, as well as belief in a related dogma, can have a profound impact on behavior (Zimbardo, Ebbesen, & Maslach, 1977). Religiosity has been shown to be a significant predictor of attitudes toward AIDS and toward people living with AIDS (Cowell, 1985; Rudolph, 1989). Individuals who perceive themselves to be active, traditionally conservative Christians tend to conclude that AIDS related messages do not concern them, and they tend to agree with abstinence-based prevention messages without changing risky behaviors (Greene & Parrott, 1993).

Religiosity, which comprises dimensions of involvement and ideology, is a key concept in this study because it is believed that religiosity-related factors may serve as barriers to AIDS dialogue in the black church, as well as attitudinal constructs that can facilitate personal empowerment to practice AIDS preventive behaviors.

28













MIVIDUAL PROCESSES
Predisposing Factors Religiosity Personality Needs
Demographics: age, Gender, education, SES AIDS risk factors
Drug use
Homosexual behaviors
Teen sex
Cultural Factors in HIV Transmission Truancy
Homelessness
Racism
Sex-ratio imbalance
Motherhood norm AIDS prevention knowledge & experience Cognitive Enabling
Processes Factors
MESSAGE DESIGN & OUTCOMES
DELIVERY Normative Potential
Environmental Processes Barriers
Factors I

CULTURAL CONTEXT

FIGURE 3: Predisposing Factors that Influence AIDS Preventive Outcomes

Allport and Ross (1967) assert that religiosity can operate as a "sincere and

adaptive master motive in a believer's life," or it can grow from a self-centered

orientation when a person engages in various religious activities as a means to other ends.

The religious orientation scales developed by Allport and Ross posit four basic religious

orientation types:


29








The social-extrinsic individual considers church the place to form social
relationships.

The personal-extrinsic person tends to use religion for comfort, protection,
relief, or social support.

The residual-extrinsic believes some things are more important than religion.

The intrinsic views religion as the orienting center of life and motivation, and
sees private devotional activity as a genuine expression of religiosity because
it is not practiced for ulterior motives.

Ellison and Gay (1990) identify three dimensions of religious commitment: affiliation (denominational preference), participation (attendance), and private religiosity. Private religious experience, such as frequent prayer or spiritual encounters, can convince people of their own uniqueness through their personal relationship with God, and it can foster self-esteem and a sense of personal efficacy. Prayer also can increase the sense of orderliness in a person's daily life (Antonovsky, 1987) and can promote hope. Zimbardo, Ebbesen, and Maslach (1977) observe that

The personal consequences of faith and prayer are illustrated by the experience of
pilgrims to Lourdes.... Although some physical healing does occur, most of the sick do not get cured. Nevertheless, as a result of the prayers and rituals, almost everyone experiences a psychological improvement and feels more hopeful and
self-confident. (p. 36-37)

Batson and Ventis (1982) developed the Religious Life Inventory, which is based on a three-factor model: religion as means (to other ends: extrinsic), religion as end (in itself intrinsic), and religion as quest (expression of open-minded religious search). The inventory categorizes religious sentiment as external, internal, and interactional; the external scale indicates the degree to which religion represents a means for gaining selfserving social approval, while the internal scale measures the degree to which religion is used to provide firm, clear answers to questions of certainty, strength, and direction. The 30








interactional scale represents the degree to which a person faces existential questions and contradictions open-mindedly.

Religiosity among African Americans

Recent surveys indicate that levels of church attendance and membership in church-related voluntary organizations are higher among blacks than whites (Roof & McKinney, 1987), that church involvement is more closely related to satisfaction in one's life for blacks than for whites (St. George & McNamara, 1984), and that blacks report higher levels of private religious involvement (Roof & McKinney, 1987).

In the National Survey of Black Americans, the first nationally representative

sample of black adults in the U.S., more than 70 percent of 2,107 black adults said they belonged to a church, and 84 percent considered themselves to be religious. Further, 76 percent said religion was very important in their lives when they were growing up, and 77 percent indicated that they believe the church is still a very important influence in their lives (Billingsley, 1992).

Although recent evidence indicates that younger blacks are attracted to apostasy (Nelson, 1988), the younger blacks in the South have remained committed to the church (Taylor, 1988). In analyzing a national survey, Sherkat and Ellison (1991) found that younger blacks are less likely to be members of a neighborhood association. Trout (1989) conducted a survey of church-going and non-church-going black teens, in which she found that most youth were disenchanted with the church. Many youth who do not attend church said they felt the pastors of black churches were hypocritical and did not live up to their call as ministers.




31








In a focus group study of television use among African-American teens, Moore and Waiters (1995) found that most of their religious opinions were related to parental authority and role models and views of religion itself ranged from self-centered to community-focused. Some questioned the necessity of church because their fathers did not attend or because they felt religion went beyond church. Those who were committed to church attendance often said that both male and female family members attended services with them. The teens agreed unanimously that going to church was not a measure of religiosity. While some criticized a minister's ability to interpret the word of God, none expressed criticism of the Bible as the word of God or of the concept of God itself.

Cannon (1988) comments that "in spite of every form of institutional constraint, racism, sexism, and classism, African Americans have been able to exist in another world, a spiritual world, a counterculture within the white-defined world, complete with our own sacred texts, spirituals, and religious practices" (p. 84). Cone (1986) argues that African Americans have taken on the task of creating "a new version of Christianity more consistent with its biblical origins" (p. 486). Murphy (1994) speculates that the black church, "with its direct experience of enslavement, exile, and ghettoization" may have constructed a spirituality "fully consistent with their biblical ancestors," a spirituality that is "a recovery of the spirituality of the Bible, lost through two thousand years of European interpretation" (p. 200).

Southern black religion tends to emphasize "otherworldliness," a simple theology of individual piety and a highly emotional worship style (Ellison & Gay, 1990). Murphy (1994) notes that many affirmations during worship services contain the phrase "I will,"


32








as in "I will pray," "I will rejoice and be glad," "I will go, to see what the end shall be." Murphy comments that this future tense shows that prayer, gladness, and blessings "can only be fulfilled in a world that has not yet arrived" (p. 175).

Many black churches emphasize religious role-taking with a "divine other," in

which people define their own life circumstances in terms of a Biblical figure's situation, then interpret their situation according to what God would expect and want (Pollner, 1989). The movements of worship participants often repeat the actions of biblical figures, such as the gestures of Joshua's army surrounding Jericho or the children of Israel leaving Egypt (Levine, 1977). For those who hear the African-American preacher's sermon "in ordinary consciousness," it is typically a dramatization of biblical stories. But for those "in the spirit," the sermon shows those biblical stories "to be present in the church, in the bodies of the congregants, in the hard and real world of the United States ... they reenact the Biblical dramas of deliverance, of passion and resurrection, and of freedom and fulfillment to come" (Murphy, 1994, p. 198).

A cornerstone of black theology is the belief in the inherent dignity and worth of each individual, grounded in the premise that God hates sin but not sinners. Smith (1985) comments that "for black people the church has been the one place where they have been able to experience unconditional positive regard" (p. 14). These churchgoers "are not only free from the restraints and indignities visited upon them by racist powers, but free to recognize themselves in the company of ancestors and saints" (Murphy, 1994, p. 200).

Religious involvement tends to cushion the harmful effects of adversity on black self-esteem. Murphy (1994) comments that most African Americans:




33








Know the religious insight that comes from their near-universal experience of racial exclusion and prejudice in the United States. The ceaseless attempts to limit and marginalize African Americans have challenged nearly every black
individual to find ever-deeper personal resources of affirmation and compassion.
African Americans have been challenged to become a new people, a "great
nation" in the biblical phrase, and the struggle toward this destiny has given them
a unique and profound understanding of God and his works. (p. 146)

The image of Africa "has been one of the primordial religious images of great significance" for Affican Americans (Long, 1986, p. 176), as shown by the strong orientation of the black church "toward the timeless places and events of the Promised Land" (Murphy, 1994, p. 171).

Fundamentalist churches tend to have stronger interpersonal networks, which provide spiritual and social support (Maton & Rappaport, 1984). The fellowship and networking within the black church can build feelings of self-esteem or personal empowerment. When a church member interacts regularly with other like-minded people, the interaction may reinforce role expectations and role identity (Ellison, 1993).

Perkins (1995) asserts that Christianity is the "inescapable point of reference marking African-American identity" (p. 16 1). In reflecting on her own upbringing, Perkins comments:

The rituals, music, and ethos associated with the Baptist religious practice of my youth provide a sense of connection not just to my own family, but even more profoundly, to
the history of African Americans on this continent. I am deeply moved by the songs (the
gospel chords and rhythms), by the joy of fellowship, and the warm embrace of the
elders. (p. 161)

Murphy (1994) notes that the goal of the individual is to "develop an inner

relationship with the spirit so that one's body and mind might show and share it with others at ceremonies" (p. 19 1). In many black congregations, each member plays a unique part in the worship experience some people "move the spirit by sacred rhythms, swaying in place, singing, clapping, keeping time with the tambourines and sanctioned 34







instruments," while others move through the church, praying with their palms raised and "manifest the spirit through emptying their consciousness of their own personalities" (p. 158). The "ring shout" is a ceremonial form of worship with roots in the African diaspora and in the slave churches of the antebellum South. Participants gather to worship by forming a circle, calling songs, and moving counterclockwise while stamping their feet in rhythm.

African American churchgoers can gain affirmation that their personal conduct and emotions related to everyday events and experiences are reasonable and appropriate, and they can receive emotional support (Ellison, 1993). However, Perkins (1995) points out that

To talk openly and critically (as distinct from negatively) about Christianity is to
risk having to surrender one's membership card in the African American
community.... Disclosure may be punished by ostracism or, even worse, by selfrighteous proselytizing from those with whom we share our feelings" (p. 162163).

Spirituality among African American Women

In a secondary analysis of data from the National Survey of Black Americans,

Billingsley (1992) found that African American women are significantly more likely than black men to cite church as very important in their lives. About 86 percent of these women consider themselves religious (compared with 76 percent of men), 82 percent agreed that it is very important to send children to church (77 percent of men agreed), 80 percent consider church very important now (72 percent of men agreed), and 73 percent said they are members of a church (compared with 59 percent of men).

Further, 76 percent said they attend church at least monthly, compared with 61 percent of men; 84 percent pray daily (versus 68 percent of men); 71 percent watch 35








religious broadcasts weekly (compared with 63 percent of men); and 57 percent read religious books or other materials weekly, compared with 40 percent of men. In interpreting these patterns, Billingley speculates that most black men have a strong set of religious beliefs, but may not convert these into practice as frequently as black women do.

Williams (1995) asserts that African American women have a pervasive and

influential voice in their families and communities, owing the power behind their voices to "our upright spiritual ancestors, to the lessons they taught us through their religious faith and practices, and to the sacred traditions they used to shape wholesome family life that modeled productive, positive action for the future, that inspired us to keep hope alive." (p. 189)

However, while women make up the majority in African American Protestant congregations, they are in the minority in positions of religious leadership (Lincoln & Mamiya, 199 1). Goboldte (1995) argues that the African American church "tends to neglect the spirituality of African American women by legitimating the value of other cultures whose spiritual values may be based on power relationships" (p. 243). The nature of female leadership in African American churches may hinge on the extent that the surrounding community is cosmopolitan. In her ethnographic study of a racially mixed Catholic congregation in Philadelphia, Goboldte found that many African American women filled leadership positions beyond the sphere of conventional women's work to include positions as pastors, elders, and administrators.

Jordan (1991) has described a common attitude among many black women in which a woman is unwilling to "tell her business" to others outside her family because 36







she believes that handling things on her own is a moral imperative. But within the Christian circles of African American sisterhood, the dialogue may be quite different. Dona Marimba Richards, author of Let the Circle Be Unbroken, pointed out that "testifying," or speaking aloud about the day's or week's experiences within a circle of friends, is a spiritual anchor of African American culture:

We would form a circle, each touching those next to us so to physically express our spiritual closeness... We shared the pain of those experiences and received
from the group affirmations of our existences as suffering beings. As we "lay down our burdens," we became lighter. As we testified and listened to others testify, we began to understand ourselves as communal beings, no longer the "individuals" that the slave system tried to make us.... We became, again, a
community. (quoted in Wade-Gayles, 1995, p. 96)

Bettye Parker-Smith, an African-Arnerican writer who grew up in Mississippi, reflected that a group of women gathered in her mother's parlor once a week or whenever a sister was in need of prayer.

I was fascinated by the shifting motion in the women's shoulders, the lifting and
butterfly opening and closing of their hands, and the sporadic shaking of their
heads. I knew from these movements and from the songs they sang that they were
praying and testifying... When I became an adult and understood the meaning of
sisterhood, I realized that the women became stronger individually and
collectively as a result of their spiritual bonding, and the children were the
beneficiaries of their strength. (quoted in Wade-Gayles, 1995, p. 97)

The spiritual bonds among religious African American women collectively could empower them to provide social support and to look out for one another in an effort to avoid the tragic consequences of FHV infection. Religiosity, however, is a complex factor that includes some beliefs that can enable AIDS preventive behavior while other beliefs can serve as barriers to prevention. While an individual's religiosity may influence his or her decisions about sexuality in many ways, the same person may have other risk factors as well. The following section describes several of the risk factors that 37








public health practitioners traditionally have considered in planning HIV prevention initiatives.

Personality Traits

Personality factors categorize individuals in terms of how different people display attitudes and actions toward the same object (Cacioppo & Petty, 1982). Some scholars have identified the personality characteristic of sensation seeking as a fundamental antecedent to attitudes and behaviors related to sexuality (Sheer & Cline, 1994). A sensation-seeking predisposition is the only personality characteristic that has been shown to strongly influence sexual behavior (Lasorsa & Shoemaker, 1988; Weinstein, 1989).

According to the Theory of Reasoned Action (Fishbein & Ajzen, 1975),

personality traits that can influence individual decision-making include introversionextroversion, neuroticism, authoritarianism, and dominance. Maddi (1984) identified eight major personality constructs: locus of control (internal vs. external), need for achievement, need for power, self-disclosure, Machiavellianism, androgyny, sensation seeking, and cognitive complexity. The Structural Analysis of Social Behavior (SASB) model, a behavioral classification system developed by Benjamin (1979) and others, is represented by a series of quadrants that provide oppositional constructs describing the "interpersonal other," "interpersonal self," and the "intrapsychic other to self." A few constructs that likely would predict compliance or non-compliance with AIDS prevention advice include self-protection/self-enhancement, self-oppression, self-monitoring/selfrestraining, spontaneity, self-neglect, assertiveness/self-identity, and deferring/submitting. Statements about how individuals relate to others or how they view 38








themselves accompany each model construct. For example, for self-protection/selfenhancement, the statements include:

Subject (S) comfortably looks after his or her own interests and protects
him/herself

Because S wants to help him/herself, S tries to figure out what is really going
on within him/herself

S practices and works on developing worthwhile skills, ways of being.

One statement for the self-oppressing construct is "S makes him/herself do and be things which are known to be not right for S. S fools him/herself." For self-neglect, a statement is "S is reckless. S carelessly lets him/herself end up in self-destructive situations." For spontaneity, typical statements include: "S lets him/herself drift with the moment. S has no internal direction, goals, or standards" and "S freely, easily, and confidently lets him/herself do whatever comes naturally." For the self-monitoring/selfrestraining concept, typical statements include: "S very carefully watches, holds back, and restrains him/herself 'and "S tries very hard to make him or herself be like an ideal."

In relation to others, an assertive person "speaks up, clearly and firmly states

his/her own separate position" and "has a clear sense of who he/she is" separately from another person. A deferring/submitting person, by contrast, "feels, thinks, does, becomes what he/she things Other wants" and "gives up, helplessly does things Other's way without feelings or views of his/her own." (Benjamin, 1984, p. 13 1-133)

A tendency toward depression has been shown to be a barrier to self-efficacy in practicing AIDS preventive behaviors (Leigh, 1995). Aflican Americans living below the poverty level have the highest rate of depression for any group (Liu & Yu, 1985). The




39








intention to commit suicide is considered a predictor of risky behavior, including sexual behavior and drug use.

Needs

Maslow's (1968) motivation theory defines various behavioral motives in terms of a hierarchy of basic physiological drives and psychological needs. At the bottom of the hierarchy are physiological needs, such as hunger and thirst, and the higher-order needs are safety (security and protection), social (sense of belonging), esteem (selfesteem, recognition, and status), and finally self-actualization needs (self-development and realization).

Among impoverished minorities, concerns about level one needs the adequacy of food, shelter and physical safety tend to supersede any concerns about preventive health measures (Nyarnathi, 1992). Sheer and Cline (1994) identified three types of motives likely to predict sexual behavior among college students: reduction of health risks, related to the need for safety and security; pleasure seeking, a physiological need; and maintaining a good physical or psychological relationship, related to affiliation needs.

Demographics

A defensible attempt to theorize about the predictors of 1HV infection among African Americans, or any population for that matter, requires both synthesis and deconstruction of both complex and contradictory information. In part, this is because the black community is not a monolithic entity nor is human behavior ever effectively or fully explained by a simple model or categorization scheme. Treichler (1988) argues that a more holistic approach includes an analysis of "the intersections of gender, race, and 40








class in relation to an illness profiled in terms of nonintersecting categories" (p. 232). In examining the factors that can predispose an individual to attend to an AIDS prevention message, the following section about demographic variables includes discussion about age, gender, education, and socioeconomic status. Age

AIDS is the number one killer of all American adults aged 25 to 44. Given that the latency period between initial MV infection and the appearance of the clinical symptoms of AIDS can be 10 years or longer, most diagnosed individuals in the 2544 age group probably became infected when they were in the 15 to 34 age range. About 17 percent of the nation's 34 million African Americans are between 15 and 24, and 32 percent are between 25 and 44 (U.S. Bureau of the Census, 1997). The potentially virulent spread of MV among minority youth is attributable to the significant correlation of MV infection with sexually transmitted diseases (USCM, 1990).

Reliance on AIDS case surveillance data has severely underestimated the

seriousness of the health threat to adolescents. AIDS incidence has increased much more rapidly in recent years among younger individuals born in 1960 or later than among older individuals (Rosenberg, 1995), and especially among Affican American adolescents (DiClemente, 1993).

In some minority communities, sexual activity begins as young as age I I or 12 for girls and a few years older for boys. Considering that Affican American teens tend to initiate sexual involvement earlier than white teens, AIDS messages are likely to be most effective if they target Affican American youth before age 12 (St. Lawrence, 1993).




41










Gender

In 1986, the U.S. Centers for Disease Control reclassified a significant number of "unexplained" AIDS cases as having been heterosexually transmitted to and from women (CDC, 1986). Shortly thereafter, public health officials noted that African Americans were the only group in which male and female teens were afflicted with AIDS in approximately the same numbers (National Research Council, 1988).

Treichler (1988) asserts that most dialogue about female FHV risks has given

women "the false belief that they were invulnerable" and often focused on "advising' us' (women) to protect ourselves from 'them' (men)" (p. 197). In addition, the scientific community often has defined the risk "status" of women in terms of their sexual partners rather than in light of their own unsafe behaviors (p. 215).

Not only has AIDS affected African Americans disproportionately in comparison with other ethnic groups, but also public health officials have noted significant gender differences in AIDS rates within the black community.

Although black women account for 13 percent of all women (U.S. Bureau of the Census, 1997), they account for nearly 60 percent of all AIDS cases among women. Black males are nearly five times more likely than white males to get AIDS (CDC, 1996). There are seven times more white males than black males, and black males account for 12 percent of the U.S. male population (U.S. Bureau of the Census, 1997).

Age-based patterns of AIDS rates among African American females and males, as compared with proportions of African Americans in the U.S. population, are shown in Figures 4 and 5 on the following page.


42















65
60

55
50
45 40
35 30 25
20

10 1
5 ~Under 5 5-19 20-24 25-29 30-34 35-44 45-54 55-64 64+ ALL Age Group U % of U.S. male AIDS cases

a % of U.S. male population


FIGURE 4: AIDS Cases among Black Males, Cumulative through June 1997



70 65 60 55 50
45 40 35 30


25
0




kider 5 5-19 20-24 25-29 30-34 35-44 45-54 55-64 64+ ALL Age Group

0 % of U.S. female AIDS cases 03 % of U.S. female population


FIGURE 5: AIDS Cases among African American Females, Cumulative through June 1997





43








African American women are 15 times more likely to be HIV infected than are white non-Hispanic women, and black males are five times more likely to be infected than are white males (CDC, 1996). Among African Americans aged 25 to 44, AIDS accounts for I in every 3 deaths among men and I in 5 deaths in women (CDC, 1996). Among African Americans in their thirties, an estimated I in 33 black men and I in 100 black women were living with HIV infection as of January 1993. Among all American adults aged 18 to 59, the estimated HIV infection rate was I in 213. The estimated incidence of HIV infection has been lowest among white women and has declined markedly during the 1990s among white males, especially those older than 30 years. However, HIV incidence has continued to rise among women and minorities, particularly among black women (Rosenberg, 1995).

Adult women account for an increasing number and percentage of AIDS cases nationAide (Ellerbrock, Bush, Chamberland, & Oxtoby, 1991). In 1987, AIDS was 13 times more common among black women than among white women (Selik, Castro, & Pappaioanou, 1988). Among black females older than 12, 48 percent of the AIDS cases reported between 1981 and June 1996 were infected through injecting drug use, 16 percent through heterosexual contact with an injecting drug user, 16 percent through other heterosexual contact, and 2 percent through sex with a bisexual male.

Among black males older than 12, 39 percent of all AIDS cases between 1981 and June 1996 were infected through homosexual contact, while 36 percent were infected through injecting drug use, 8 percent through homosexual contact and injecting drug use, and 6 percent through heterosexual contact.




44








Education

Lower levels of education among African Americans have contributed to the

higher prevalence of AIDS transmission in the black community (LaSalle, 1990). While the average schooling for white Americans is 12.8 years, the average schooling for African Americans is 11.6 years (Kirsch, Jungeblut, Jenkins, & Kolstad, 1993). African American women are generally better educated than African American men at all levels except the doctoral level (Lassiter, 1995).

Levin (1987) argues that the most powerful determinant of health is socioeconomic status and that by eliminating poverty and low literacy, the greatest amount of health enhancement could be accomplished. Low literacy is a considered a significant barrier to effective FHV prevention education among African Americans (Rotheram-Borus, Koopman, Haignere, & Davies, 199 1; Mays, 1989).

The National Center for Education Statistics groups people into five levels of

English literacy according to their ability to complete prose, document, and quantitative tasks. About 47 percent of Americans 16 or older demonstrate literacy skills in the bottom two levels. Of the 20 percent classified in the lowest literacy level those who can complete only tasks involving brief, uncomplicated texts nearly two-thirds never complete high school. Whites score significantly higher than any of the other nine racialethnic groups (Kirsch, Jungeblut, Jenkins, & Kolstad, 1993). Socioeconomic Status

Poverty and deprivation among African Americans are clearly related to death from AIDS and other diseases, as well as high rates of infant mortality (Oleaton & Johnson, 1995). The increase of HIV infection in the black community has been 45








attributed to economic factors, particularly joblessness (Briggs, 1987) and poverty (LaSalle, 1990). However, Males (1996) offers a contradictory argument, asserting that

When the surplus or deficit of HIV acquisition for each age and ethnic group is
standardized according to each group's surplus or deficit of poverty, the
discrepancy between young and old age groups disappears for both sexes. (p.
1480)

The higher FHV infection rate among black men is not explained by poverty.

When controlling for economic disadvantage, however, the disproportionate rate among black women remains. Males argues that this indicates that

Poverty places women at a higher net risk, perhaps rendering them vulnerable at young ages to sexual violence, prostitution, and sexual contact with older men...
Critical issues in AIDS prevention are not demographic or behavioral, but relate
to reversing the United States' consignment of a uniquely high and rising
proportion of its youth and nonwhites to poverty. (p. 1480)

While race and ethnicity are not causally associated with increased HIV risk, Rosenberg (1996) classifies these factors as "markers for social factors such as low socioeconomic status that are the root causes of the high prevalence rates seen in minorities." Further, income-specific categories of AIDS rates cannot be derived from national AIDS surveillance because such data is not collected. "Even if it were," Rosenberg argues, "inadequacies in available measures of SES and other social factors might preclude a complete explanation of the large excess of AIDS cases among minorities." (p. 1480)

The determinants of teen pregnancy (Frost & Forrest, 1995) and lack of condom use (Roper, 1993) among African American youths are deeply intertwined with poverty and disadvantage. In addition, a constant personal concern about poverty can overshadow perceptions of AIDS risk. For example, in an interview study of sexually



46








active female minority teens (90 percent of whom were black), Overby and Kegeles (1994) found that although most girls were concerned about AIDS, their worries about poverty-related issues were often greater.

Patterns of poverty tend to be age-related. Within each racial category, 21

percent of individuals aged 15 to 24 are impoverished, which is twice the rate of poverty among those aged 25 to 59 (U.S. Bureau of the Census, 1993). Nearly 15 percent of all U.S. residents live below the federal poverty level, defined in 1990 as $13,254 of cash income for a family of four, and 31 percent of these people are Aftican American (U.S. Bureau of the Census, 1997). Poverty affects 32 percent of all black Americans and 36 percent of all black women. About 48 percent of all black female-headed families have incomes below the poverty level, while 75 percent of the 2 million black families in poverty are maintained by women with no husbands present (U.S. Bureau of the Census, 1990).

African Americans living below the poverty level have little or no access to

preventive medical care (Leigh, 1995). Poverty often contributes to poor health because people with low incomes typically have less access to medical care, cannot pay for needed services and medication, and tend to delay seeking care until the condition becomes life-threatening. Poverty also can contribute to crowding living conditions, which can lead to increased exposure to MV (Florida Health Net, 1997).

Among Affican Americans living with AIDS, poverty can predict lower survival times. The mean survival time among blacks diagnosed with AIDS is six months, as compared with 18 to 24 months for whites. For many whites with a higher level of education, a lost job can contribute to a sense of outrage about the disease and motivate them to fight for what is being lost. But African Americans who do not have these 47








advantages may lack this sense of loss. Without the desire to fight AIDS, they may delay in seeking medical care (Friedman, Sotheran, & Abdul-Quader, 1987). Whether a person has AIDS or not, socioeconomic status has been shown to affect one's self-concept and to determine one's sense of powerlessness (Dodson, 198 1). AEDS Risk Factors

According to the AIDS Discrimination Unit of New York City Commission of Human Rights, "it is behavior and not one's race or ethnicity that is the operative risk factor" for HIV infection (quoted in Gleaton & Johnson, 1995, p. 45). The following discussion highlights several behaviors and predisposing conditions that can place African Americans at a greater risk of FHV infection: homosexual behaviors, teen sex, truancy, homelessness, racism, sex-ratio imbalance, motherhood norm, and drug use. Homosexual Behaviors

For many African Americans, the stigma of an HIV-infected family member with a history of drug abuse is not nearly as great as the stigma of explaining that a family member was diagnosed with AIDS as a result of homosexual conduct (Gleaton & Johnson, 1995).

Homosexuality is believed to exist in the black community to the same extent that it exists among other racial groups. Across all racial groups, 13 percent of men and 7 percent of women are exclusively gay or lesbian throughout their lives, and 37 percent of all men report having had at least one homosexual experience. While no significant studies have assessed the incidence patterns of homosexuality among blacks, it has been determined that many black men and women reject the labels used to describe sexual minorities but continue to be sexually active with persons of the same gender. Further, 48








AIDS outreach workers have found that many black women who identify themselves as lesbians engage in prostitution and injecting drugs (Gleaton & Johnson, 1995).

Heterosexual African American women may be more vulnerable than white

women to sexually transmitted HIV infection because a larger proportion of black gay men than white homosexual men report having sex with both men and women 30 percent for black gay men, compared with 13 percent for white gay men (Friedman, 1989). On the other hand, the Multicenter AIDS Cohort Study found that black homosexual men had the lowest risk profile for receptive anal intercourse, use of anonymous sexual partners, and recreational drug use when compared with white and Hispanic homosexual men. Both black and Hispanic gay men more frequently reported a history of sexually transmitted diseases (STDs) than whites (Easterbrook, 1993). Teen Sex

The sex drive of a typical 15- or 16-year-old is about as strong as it will be over the course of a lifetime (Walster & Walster, 1980). National data provided by the Alan Guttmacher Institute (1994) show that 9 percent of 12-year-olds and 16 percent of 13year-olds have had sexual intercourse, and that throughout the 1980s the proportion of teens engaging in sex rose while the age at which they first did so decreased.

Most school-based HIV prevention programs are taught at higher grade levels

(Forrest & Silverman, 1989), neglecting younger teens in middle school and junior high who also have a high prevalence of sexual behaviors that put them at risk for HIV infection (DiClemente, Durbin, Siegel, Krasnovsky, Lazarus, & Comancho, 1992; Durbin, DiClemente, Siegel, Krasnovsky, Lazarus, & Comancho, 1993; Brown, DiClemente, & Beausoleil, 1992).


49








Podschun (1993) contends that the role of sex in these the lives of young African American teens is neither an erotic expression nor a response to romantic love, but rather a part of the "warm body syndrome" or the search for comfort. Many cannot practice safer sex because it is beyond their means to insist on cooperation from their partners.

African American teens commonly have one main partner but also engage in

sexual relations with other casual partners (Bowen & Michal-Johnson, 1990). According to one survey, 80 percent of teen mothers did not consciously want to get pregnant but did so anyway because of a lack of knowledge about contraception or a desire to be liked by a particular boy. When they do get pregnant, poor teenagers are less likely to get an abortion because having a baby carries the possibility of love and purpose (National Research Council, 1988). Because of inadequate contraceptive usage, African American women are twice as likely as white women to experience an unplanned pregnancy (Lassiter, 1995).

A household survey of black and Hispanic youth (Ford & Norris, 1993) showed that young black men reported the earliest initiation of sexual activity and the most partners. In a survey of urban minority high school students (Walter, 1993), 67 percent reported having had sexual intercourse. More than half reported having intercourse during the past year, and of these students, 33 percent had multiple intercourse partners, and 10 percent reported that they previously had been diagnosed with a STD. Age, ethnicity, and contextual factors such as academic failure, substance use, adverse life circumstances, and lack of cues to prevention were strongly associated with AIDS-risk behaviors, while cognitive factors such as knowledge and beliefs about AIDS had little explanatory power.

50








In an interview study of sexually active female minority teens, 90 percent of whom were black, Overby and Kegeles (1994) found that 41 percent of these subjects reported knowing someone with AIDS. The median number of sex partners was three, 55 percent had had a STD in the past, and 77 percent had been pregnant. However, most perceived themselves to be at low personal risk because of a current monogamous relationship, lack of intravenous drug use, and an implicit trust in their partner's safety from IRV infection.

Cultural Factors in HIV Transmission

Truancy: Many school dropouts who are at risk for FUV infection because they are hard to reach with prevention information, and because they tend to be distrustful of adults, they often have lower self-esteem, and are educationally and emotionally impaired (Rotheram-Borus, Koopman, Haignere, & Davies, 199 1).

One cause of truancy and risky behaviors among African American boys is their socialized expectation that men must demonstrate their masculinity in the streets, not at home (Cazenave, 1992). Schultz (1969) commented that African American boys strive to achieve a 'rep' on the street because they perceive that they do not have much status anywhere else, This "rep" is often earned through sexual conquests, toughness, expressive styles in speech, dress, and personal appearance, liquor consumption, and the ability to command respect (Hannerz, 1969),

Homelessness: Crowded living conditions in ghettos and homeless shelters can expose large numbers of people to HIV transmission and AIDS-related illnesses such as tuberculosis (Florida Health Net, 1997). The IRV infection rate among the 1.5 million




51








homeless teens in the U.S. is 2 to 20 times higher than all other adolescent groups (Rotheram-Borus, Koopman, Haignere, & Davies, 199 1).

Runaways are at risk of HIV infection primarily through sexual activity rather than injecting drug use (Stricof, Kennedy, & Nattell, 1991).

The low level of literacy among most homeless people is a significant barrier to effective MIV prevention education. In addition, H-IV prevention messages are often lost on them to more immediate crises. Any AIDS prevention program that does not help them meet basic necessities such as food and shelter is unlikely to succeed (Sondheimer, 1992). Although many runaways are well aware of the dangers of AIDS, these teens are more concerned about day-to-day survival than death in five to 10 years from AIDS (Rotheram-Borus, Koopman, Haignere, & Davies, 199 1).

In the United States, the 1996 point-in-time estimate of the number of homeless people is 760,000 (National Law Center on Homelessness and Poverty, 1996), and an estimated 7 million nearly 3 percent of the total population report they have been homeless at some point in their lives (HUD, 1994).

Racism: In a survey by Herek and Glunt (1993), 51 percent of black respondents

said they believe that the AIDS epidemic is being used to promote hatred of minority groups. Memmui (1968) defines racism as an ideology which assigns character traits to oppressed individuals as an expression of their situation and which promotes passivity among them.

A barrier to AIDS prevention among African Americans, both real and perceived, is the racial discrimination they often encounter when seeking information or other help (Leigh, 1995). Exposure to racism can erode an individual's sense of self worth and self-efficacy. Lanigner (1965) argues that low social status "inhibits the development or maintenance of 52








ego-strength," which involves "adaptive ability, planning for individual survival, conscious control over self, and conscious attempts to control the environment" (p. 366). Lassiter (1995) found that individuals

Vary in their perception and internalization of stressful racial situations, with the
perception and appraisal of a stressful event determined by the person's intelligence,
education, self-esteem, previous experiences, and coping style. (p. 2)

Lack of self-esteem in turn has contributed to the spread of HIV and to unwanted teenage pregnancies (Florida Department of Health, 1997). Among African American mothers, a higher perception of racism has been found to be a predictor of low birth weight and pre-term delivery (Green, 1995).

Sex-Ratio Imbalance: The scarcity of eligible men polarizes the status of being single versus not single and puts pressure on some black women to give in to unsafe sex to maintain a relationship. An African American woman in a relationship with a male partner often has the prestige of being "kept" (Mays & Cochran, 1988).

The lack of single black men is exacerbated by the fact that 23 percent of all black males are incarcerated or under the supervision of the corrections system (Maurer, 1990). Of American black men aged 16, only one in four can expect to reach the age of 25 without being involved in drugs, in prison, or dead (Sepulveda, Fineberg, & Mann, 1992).

The sex-ratio imbalance, the percentage of single adult men compared to the percentage of single adult women, is more prominent for black women than for white women (Mays & Cochran, 1988). Nationally, the ratio of single college-educated black women to similar men is two to one (Staples, 1981). Changes in the sex ratio for various age groups, based on national population data (U.S. Bureau of the Census, 1997) are shown in Figure 6.

53











1.5 -----1.4



0
w1.2
cc E 0
u- 1.1


Under 5 5-19 20-24 25-29 30-34 35-39 45-54 55-64 64+ Overal Age Group
FIGURE 6: Sex-Ratio Imbalance among African Americans



Motherhood Norm: When an African American woman seeks the opportunity to become a parent, her attempts to conceive can put her and her baby at risk of contracting AIDS. Historically, motherhood has been a more valued and meaningful role for the black woman than the role of wife (Bell, 1971). The motherhood norm in the black community also is rooted in a fear of racial genocide because children represent potential cultural survival (Tobin, Clifford, Mustian, & Davis, 1975). This racial genocide belief is the perception that those in authority are systematically trying to eliminate African Americans from society by limiting their opportunities for child bearing, through welfare-based economic sanctions, condom distribution, imprisonment, and other actions perceived to be part of a government conspiracy.

Some African American women choose motherhood out of a sense of

powerlessness (Bauman & Udry, 1972), including restricted opportunities to have a 54








professional career (Nsiah-Jefferson, 1989). The birth of a child may also serve as a social bond to a continuing relationship with a black male, who is considered a precious commodity because of the scarcity of men (Mays & Cochran, 1988). Many black teens who perceive little or no opportunity to improve their status in life may desire a child as something tangible and significant for which they themselves will be responsible (Florida Health Net, 1997).

Drug Use: More than half of all AIDS cases among African Americans are the result of intravenous drug use (LaSalle, 1990). Injecting drug use or contact with a user has been a risk factor in 65 percent of all AIDS cases among black females. Three-quarters of black males who were infected through heterosexual contact contracted AIDS through sex with an injecting drug user. Injecting drug use or contact with a user has been a risk factor in 47 percent of all AIDS cases among black males, compared with 17 percent among white males (CDC, 1996).

Substance use can contribute to risky sexual behaviors because it reduces

inhibitions, impairs judgment, and increases the incidence of unprotected sex. In the U.S., 15 percent of women of childbearing age have problems with alcohol and other drugs, and I I percent of pregnant women use at least one of the following drugs: cocaine, heroin, amphetamines, methadone, PCP, or marijuana.

One third of African-American women report using illicit drugs at some point in their lives, while 7 percent report current use of an illicit drug (Horton, 1992). Nyamathi (1993) reported that non-intravenous drug use and high-risk sexual activity is more prevalent among black women than Latina women. Crack cocaine is a sexual stimulant, and its use often leads to high-risk sexual activities (Fullilove, Fullilove, & Bowser,




55








1990). Within a drug culture, prostitution is often performed either for money to buy narcotics or for the drugs themselves (Stone, 1989).

Kim (1993) found that injecting drug use is significantly associated with sexual risk-taking, and women are more likely than men to have an intravenous drug-using sexual partner. Female intravenous drug users usually have few resources and also must care for children (Wofsy, 1987). If she has a sexual partner, most likely he too is an intravenous drug user (Cohen, Hauer, & Wofsy, 1989) who may fail to provide financial support, and may inflict sexual or physical abuse (Chaffee, 1989). Many female injecting drug users have increased stress and low self-esteem because of the stigmatization that results from the drug use or from the prostitution they must practice to support their habit user (Cohen, Hauer, & Wofsy, 1989).

Intravenous drug use is high on the hierarchy of AIDS risk factors because

needles allow direct exchange of blood from one person's body into the bloodstream of another. In addition to syringes used for intravenous drug use, needles used for tattooing, blood transfusions, insulin injections, vaccinations, acupuncture, and body piercing also can expose a person to HIV if they are not properly cleaned (Gleaton & Johnson, 1995).

AEDS Prevention Knowledge and Experience: AIDS is but one of many crises facing black communities, including other sexually transmitted diseases, substance abuse, unemployment, black-on-black crime, discrimination, unwed pregnancies, and lack of opportunities for educational advancement (Smith, 1995). Despite massive public education campaigns, many people remain confused about how HIV is transmitted. The existence of higher misperceptions about AIDS among African




56








Americans supports the conclusion that existing messages targeted at general populations have not affected most African Americans who are at risk of HIV infection.

People living with AIDS generally are portrayed in the media as either white gay men or street people abandoned by family and friends (Schiller, Crystal, & Lewellen, 1994). This construction of HIV has led to distancing and denial of personal risk by people who don't relate to these "social deviants." For example, African Americans and Latinos are more likely than whites to report that "all gay men have AIDS" (DiClemente, Boyer, & Morales, 1988). Many black men believe they are not at risk for getting FHV as long as they do not engage in sex with a white gay male (Peterson & Marin, 1988). In addition to misperceptions caused by media distortion, low knowledge about AIDS has been linked to religiosity and conservative political convictions (Peruga & Celentano, 1993).

Rotheram-Borus, Koopman, Haignere, & Davies (199 1) found that male

runaways and juvenile delinquents misperceived that blood donation was riskier than blood transfusion, and delinquents were more likely to believe that sex without a condom with someone who does not look sick is safe. Male delinquent runaways were significantly less knowledgeable about AIDS than non-delinquent runaways.

AIDS Prevention Negotiation with a Partner: In an interview study of

predominantly black, sexually active female teens, Overby and Kegeles (1994) found that 65 percent had never discussed actual risk or past behaviors with their partners, and 67 percent said their partner would feel hurt, insulted, angry, or suspicious if he were asked about his AIDS risk factors. Because the black community often encourages women to be subordinate to men, women often are emotionally and economically dependent upon 57








their men and may not be in a position to negotiate AIDS preventive behaviors such as insisting that a sexual partner wear a condom (Worth, 1990).

Prior Condom Use: DiClemente (1992) found that minority junior high students who had a history of three or more sex partners were half as likely to use condoms consistently. Among sexually active female minority teens, 90 percent of whom were black, 98 percent were aware that condoms may prevent AIDS transmission, 64 percent used condoms half the time or less when they had sex, and most who did use condoms reported that they used them primarily for contraception (Overby & Kegeles, 1994).

The AIDS in Multi-Ethnic Neighborhoods Study (Catania, Coates, Kegeles, Fullilove, Peterson, Manin, Siegel, & Hulley, 1992) showed that only 9 percent of minority heterosexual males reported always using condoms, while 48 percent of gay/bisexual men reported always using condoms. Sexual communication and the sexual enjoyment value of condoms were correlates of condom use among all subjects.

Wilson, Kastrinakis, D'Angelo and Getson (1994) found that urban black

adolescent males were more likely to use condoms if they had reached a higher grade level in school, if they had had two or more sexual partners in the past six months, if they had initiated communication about contraception with their sexual partner(s), if they had a desire for STD) prevention when using contraceptives, and if they had received a parental suggestion to use condoms. Black male teens were less likely to use condoms if they had lower levels of knowledge about condom use, if they had a history of impregnating a partner or of having contracted a STD, or if their partner was dissatisfied with condoms. Neither the desire for pregnancy prevention nor the suggestions by friends to use condoms were predictors of condom use. Among urban minority high 58








school students who reported having sex in the past year, 75 percent had never or had inconsistently used condoms (Walter, 1993).

Environmental Factors

In Bandura's (1994) Social Cognitive Theory, "Environmental Factors" are

divided into three domains: physical, institutional, and social. The Persuasive Health Messages Framework (Witte, 1995) classifies the environment as a "transient" factor, and environmental variables include residence and cultural values. The Transformation Model of Communication (Kreps, 1994) includes "quality of life" as an environmental factor. Diffusion of Innovations theory (Rogers, 1995) asserts that the norms of a social system set the stage for the spread of a new idea within a particular social network. In Gerbner's (1956) General Model of Communication, he alluded to environmental factors in the physical and social setting part of his model, which states: "Someone-perceives an event-and reacts-in a situation."

The model shown on the following page, Figure 7, highlights key components of the "environmental factors" domain of the conceptual framework and introduces a review of literature about these factors and their relevance in designing AIDS prevention messages. While normative processes are described in a later section of the literature review, the "environmental factors" section will describe several specific types of norms that characterize and influence the social environment within which an individual makes protective or risky behavioral decisions.








59









INDIVIDUAL PROCESSES
Enabling
Predisposing Cognitive Factors
Factors Processes

MESSAGE
DESIGN & 01JTVnMFQ
DELIVERY

Environmental Factors Normative z
Social network norms Pro esses Potential
Community norms Barriers
Church norms
Communication norms
Family norms

CULTURAL CONTEXT

FIGURE 7: The Role of Environmental Factors in AIDS Prevention



Social network norms

Africa n-American community norms

The black community is not just a geographic grouping or ethnic affiliation of isolated individuals and families, as presented by many sociological studies. Blackwell (1985) defines it as a social system, commenting that:

Within the community, value consensus and congruence exists; a significant
segment of its constituents share norms, sentiments, and expectations... Even
though diversity exists within the community, its members are held together by
adherence to commonly shared values and goals. (p. 14)

Blackwell argues that the black community also is held together by white

oppression and racism, but Billingsley (1992) challenges that view, asserting that black





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religion "exists parallel with but not subservient to white religion" (p. 71). Communitylevel advocacy does appear to be a uniting factor, as shown by the National Survey of Black Americans (1980), in which 90 percent of Affican Americans agreed with the statement that blacks "should work together as a group," 89 percent agreed that "black women shouldwork together," 87 percent agreed that blacks "should work through the present system through political participation," and 74 percent agreed that "black women should fight for both blacks and women."

Geographically, most black families live in neighborhoods where most of their neighbors are also black. In 1989, a national survey showed that 80 percent of African Americans lived in predominantly black neighborhoods (Billingsley, 1992). Parsons (1960) asserts that the geographic dimension of any community is not limited to the set of physical boundaries along its periphery because it can include places where people go to belong to a group. These can include places of entertainment, sources of employment, stores, churches, friends, relatives, streets, and roads.

The term "community" pen-neates the discourse of health planners, frequently

appearing in their talk, mission statements, books, and reports about the future of public health. Despite the prominence of the term, it is extremely rare to find a public health document offering a definition or explanation of community (Wieder & Hartsell, 1996).

Effrat (1974) defines community in terms of the institutions that serve its residents' needs, such as hospitals, churches, family, government, and other organizations. Billingsley (1992) states that the black community is largely defined by four sets of organizations the church, school, business enterprise, and the voluntary organization "which grow out of the Affican-American heritage, identify with it, and 61








serve primarily Affican-American people and families" and which serve to "anchor the community and can be galvanized into collective action when circumstances or leadership commands" (p. 73).

Although many sociologists argue that the black community is not organized, Billingsley contends that "there is an organization, agency, or institution for every conceivable function in the black community today. They are, however, sometimes small and uncoordinated, and uncooperative with others. And they sometimes spring up and dissolve too soon to complete their missions" (p. 73).

Billingsley (1992) identified 12 key systems through which American society influences black families: economic, political, health, housing, educational, welfare, criminal justice, military, transportation, recreation, communications, and religious systems. He classified these systems into four major sectors: government, private business, voluntary nonsectarian, and religious.

Follett (1919) defines community in terms of its processes of interaction,

socialization, shared interests, or common endeavors. Goode (1957) proposed eight characteristics of a community: shared values among its members, role definitions shared by both members and non-members, a common language applied to communal action but only partially understood by outsiders, power over its members, social limits that are reasonably clear, a sense of identity binding its members, continual maintenance of its membership, and production of the next generation through a socialization process.

In a statement to the Congressional Black Caucus, Franklin and Norton (1987) noted that "persistent poverty has eroded but not destroyed the strong, deep value framework that for so long has sustained black people" (p. 4). African Americans cope 62








by banding together to form a network of intimate mutual aid and social interaction with neighbors and kin (Billingsley, 1992). The black community "has always been an agent for its own advancement," and "the self-help tradition is so embedded in the black heritage as to be virtually synonymous with it" (Franklin & Norton, 1987, p. 4).

In a 1989 statement issued by the Joint Center for Political and Economic Studies, Franklin and Norton asserted that African Americans

Have always embraced the central values of the society, augmented those values in response to the unique experiences of slavery and subordination, incorporated
them into a strong religious tradition, and espoused them fervently and
persistently. These values among them, the primacy of family, the importance
of education, and the necessity for individual enterprise and hard work have
been fundamental to black survival. These community values have been matched
by a strong set of civic values, ironic in the face of racial discrimination
espousal of the rights and responsibilities of freedom, commitment to country,
and adherence to the democratic creed. (p. 34)

Many sociologists have defined community attachment or ties in terms of involvement, satisfaction, and community orientation. Attachment measures are typically based on social interaction, such as how well residents feel they fit into the community. Billingsley (1992) notes that most black people, wherever they live, identify with their heritage to a considerable degree; even those who seldom visit black neighborhoods have a potentially powerful connection with black causes and issues.

Goudy (1977) found that people are most satisfied with their community when they have strong primary relationships, when they participate and take pride in the community, and when there is shared decision-making. Community involvement has been measured in terms of connection, manipulation, and attendance (Stamm & FortiniCampbell, 1983), orientation to local facilities, knowing neighbors' names, frequency of neighborly visits (Finnegan & Viswanath, 1988), membership in formal organizations 63








(Litwak, 1960), existence of a personal social network, and how people form friendships (Omari, 1956). Janowitz (1952) found that socioeconomic status is positively related to community involvement.

Church norms

From a systems perspective, the black churches can serve as miniature, dynamic

communities that present an opportunity for developing and implementing health promotion programs (Castro, 1995). The black church has a long and distinguished tradition of leading and caring for its people in times of great suffering, and it often has served as the impetus for education and change in times of crisis through pastoral activism and church mobilization.

When the black slaves came to America, "the new tribe, of which God was the center, was the black church" (Evans, 1995, p. 75). Their hymns and spirituals communicated ideas about salvation, freedom, judgment, punishment, and plans to escape (Lassiter, 1995).

While Frazier (1964) contends that "the black church" is a general term for many diverse ways of expressing the religious experience of African Americans living in the United States, Franklin and Mamiya (1990) define the black church as a network of shared institutions among Protestant Christian denominations, particularly the Methodist and Baptist churches. Washington (1972) includes the smaller, independent Christian churches such as Holiness, Pentecostal, and Spiritual churches, as well as black initiatives within predominantly white denominations such as the Roman Catholic and Episcopal churches. To this list, Hines and Boyd-Franlin (1982) add Jehovah's Witness, Church of God in Christ, Church of Christ, Seventh Day Adventist, Nation of Islam, Prebyterian, and Lutheran.

The black church, which serves as both preserver of the African-American heritage and agent for reform, is leading the Afican-American community's push to influence the future of 64








its families. Every black neighborhood and many non-black ones have black churches as a major institutional presence (Billingsley, 1992).

Billingsley states that the black church is the strongest and most representative

organization in the black community, and that it "embraces traditional African-American values, identifies with both the struggles and achievements of African-American people, and it is institutionalized with an enduring organizational structure and mission" (p. 73). One reason it is difficult to generalize about the power of African-American churches is that they tend to be decentralized and autonomous. Most are doctrinally fundamentalist and socially conservative (Dalton, 1989).

Throughout much of American history, the Southern black church has been the institutional and symbolic center of the black community. Churches have provided locations for meetings and gatherings concerning collective issues and problems, settings for the development of black leadership, and various programs of mutual aid and community uplift (Ellison & Gay, 1990). Murphy (1994) notes that during segregation, the black church functioned as a "full alternative society," offering education, health care, and financial assistance to its members. The black church "often gave members the only avenue toward justice in the wider society, and it provided the network, leadership, and ideology for the quest for civil rights" (p. 156).

Within today's African-American community, the black church represents

independence and respect for its leadership, and offers "the opportunity for self-esteem, self-development, leadership, and relaxation" within a community center and recreational center that encourages "education, business development, and democratic fellowship beyond its members" (Mays & Nicholson, 1969, p. 278).


65








In a 1986 lecture to the Association of Black Foundation Executives, C. Eric

Lincoln commented that the function of the black church historically has included that of "lyceum, conservatory, forum, social service center, political academy, and financial institution" and "has been and is for black America the mother of our culture, the champion of our freedom, the hallmark of our civilization." Nichols (1987) found that a vital congregation "is one in which the redemptive and liberating power of the Gospel is applied with ever-increasing effectiveness to the real needs of people in the context of their personal and social situation in the world" (p. 109).

The Rev. Cecil Murray, pastor of the First AME Church of Los Angeles, commented that "the coming-to-church-for-personal-salvation days are over. Now we are looking not only for personal salvation but for social salvation ... If we don't change the community, the community corrupts the individual" (Schneider, 1992, p. E 1). Murphy (1994) concurs, noting that the "thisworldly" activities of the black church are not divorced from the "other-worldly" ones.

Billingsley (1992) warns that "it is a mistake to think of the black church in

America as simply, or even primarily, a religious institution in the same way the white church might be conceived" (p. 352). In a survey of black congregations, Chaves and Higgins (1992) found that these groups were significantly more active than white congregations in civil rights activity and activities that serve underprivileged segments of the local community, such as community development, meal service, and public education on disease.

Among Southern blacks, religious commitment in the church has served as a gateway for full membership and participation in the black community (Ross & Wheeler, 1971). Because churches historically have been among the few institutions controlled by blacks, participation in 66







church-related activities has offered opportunities for social interaction and social status that were not available in white-dominated society (Lincoln & Mamiya, 1990).

Smith (1985) asserts that the black family and the black church have always drawn on each other for support and nurture, but they must first understand several shared realities before they can effectively develop cooperative strategies for dealing with community problems. These shared realities include "recognition that the black community is a suffering community, a community of extended families, an inclusive community, an adoptionist community, and finally, a hopeftil community" (p. 25-28).

Cultural norms of communication

Oral traditions are long-standing traditions among African Americans (Edwards & Seinkewicz, 1990). African American culture values verbal skills, especially those couched in interactive and narrative frameworks. Oral tradition links speaker to audience, reinforces shared identity, norms, and values, fosters involvement of the audience through the use of metaphors and verbal and nonverbal response patterns (Hecht, Collier, & Ribeau, 1993), and functions as education, a validation of culture, wish fulfillment, and a force for conformity (Bascom, 1954).

Communication behavior patterns often differ between African Americans and white individuals. Kochnian (1981) notes that the African American communication behavior mode tends to be "high-keyed, animated, interpersonal, and confrontational," while the "white middle-class mode tends to be relatively low-keyed, dispassionate, impersonal, characteristically cool, and lacking in affect." (p. 18)

The verbal skills and language competence of the African American oral tradition are learned at early ages. Erickson (1984) describes the tradition of styling" or "show 67







time" in which African American children are encouraged to be assertive and to showcase their verbal skills. Typically, an African American parent tells a child not to do something, and the child gradually intensifies his or her threats to do it anyway. As the child's threats become more and more drastic, the adults reinforce the verbal prowess of the child by saying things like "he so bad" and laughing approvingly and making other comments to positively reinforce the child.

In the classroom, Affican American youth tend to use a narrative form and style that includes a "topic associating" organizational frame that is usually not understood by white teachers (Edwards & Seinkewicz, 1990). In an ethnographic study of a multiethnic college class taught by an African American instructor, Foster (1989) found that the performance mode of both instructor and students was participatory, spontaneous, interactive, and the tone was perceived to be humorous. The instructor used gestures, metaphors, switching between mainstream and Black English, and language that was playful, figurative, and stylistically embellished& In her study of written storytelling among Aftican American youth, Smitherman (1994) observed several key characteristics:

Rhythmic, dramatic, and evocative language.

Cultural references and references to color, race, or ethnicity, even when the topic
does not call for it.

Use of proverbs, aphorisms, and Biblical verses.

A sermonic tone reminiscent of traditional black church rhetoric, especially in
vocabulary, imagery, and metaphors.

Direct address and conversational tone.

Ethriolinguistic idioms, verbal inventiveness, and unique nomenclature.


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Community consciousness, including expressions of concern for the welfare of
the entire community, not just individuals.

Lack of personal distance from topics and subjects.

The oral tradition that originated in the African experience is enacted weekly in pulpits in black churches across the country. Given that the church plays an important role in African American ethnoculture, the conversational style of the black preacher is representative of the community, and sermon themes serve to reinforce community values and rules of appropriate behavior (Hecht, Collier, & Ribeau, 1993).

MacGaffey (1986) asserts that the key factor that distinguishes African from

European theology is literacy or the literary exegesis of texts. In the black church, many texts of tradition are transmitted orally and ceremonially, including songs, prayers, rhythms, gestures, foods, emblems, and clothing (Murphy, 1994). Murphy notes that

By insisting on the oral interpretation of the actions of the spirit, devotees ensure that only sanctioned people will transmit the teachings and that the transmission
will happen only in face-to-face encounters between initiates and novices ... Oral
and ceremonial transmission makes for a smaller, tighter community, which, for all its drawbacks, might have benefits not to be found in communities dependent
on literary exegesis (p. 183).

A culture's use of stories reveals themes and dimensions that identify the key symbols and reveal how social life is interpreted (Philipsen, 1987). Within a person's socially constructed reality, culture is learned through gaining understandings that are handed down in group experience, and it is transmitted through interaction with socializing agents (Lustig & Koester, 1993).

Bellah (1985) states that a "real community" is "one that does not forget its past" and added that




69








In order not to forget that past, a community is involved in retelling its story, its constitutive narrative, and in so doing, it offers examples of the men and women
who have embodied and exemplified the meaning of the community. These
stories of collective history and exemplary individuals are an important part of the
tradition that is so central to a community of memory. (p. 154) Family norms

Dickerson (1994) argues that most past research about African American families has been done using traditional paradigms based on models of the dominant culture. This has resulted in the creation of stereotypes and misconceptions about "the black family."

The typical African American family is an extended kinship network (Staples, 1988), with each household consisting of at least four generations (Martin & Martin, 1978).

From the end of slavery through 1980, most African-American families have been married-couple families. Although more young African-Americans are delaying marriage than in past decades, the value placed on marriage is still so strong that most African-American youths and adults want to be married (Billingsley, 1992). Lewis (1967) argues that there is little need to teach values of marriage and stability to AfricanAmerican youths, but rather they lack the conditions that make it possible to consummate and sustain the marital bond that they already value.

Nearly 15 percent of all black children are informally adopted without legal

documentation, and about 40 percent of Mrican-American families are "extended" in the sense that members of a nuclear family reside with other relatives and/or non-relatives (U.S. Bureau of the Census, 1990). ffill (1977) found that 90 percent of black babies



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bom out of wedlock are reared in three-generational families headed by their grandparents.

A norm of African-American family life is that people do not have to live in the same household in order to function as a family unit. The typical African American family is an extended kinship network (Staples, 1988), with each household consisting of at least four generations (Martin & Martin, 1978). Stack (1974) coined the term "fictive kin," which others call "play mother, brother or sister, aunt, uncle, or cousin." Billingsley (1992) commented that most black children "have so many 'aunts,' 'uncles,' and 'cousins' unrelated to them by blood that they can hardly keep track of them. Whenever they are in need, however, or reach a particular transition in their lives, they can count on assistance from these 'appropriated' family members" (p. 3 1).

Affican-American families have adopted a wide variety of family structures in an effort to resolve conflicting demands of society, as well as the spiritual, physical, economic, social, and psychological demands of family members. Billingsley created a typology of three major structures nuclear, extended, and augmented families as well as 12 different subtypes, depending on gender and marital status of family heads, and the presence or absence of children, other relatives, or non-relatives.

Numerous sociological studies, including Dressler, Haworth-Hoeppner and Pitts (1985), Payton (1982), and Cross (1982), have concluded that the female-headed, singleparent family is not a product of African-American culture or values. Rather, it has resulted from stresses and other forces in the wider society, particularly the struggle with unemployment, racism, and the welfare system.



71








The black single mother norm often has been blamed for the high rates of

delinquency among African American youth. However, the negative behaviors of many Afirican-American teens could be explained by their abandonment of family traditions, including religion, personal conduct codes, sexual codes, dress codes, and language codes. In addition, many of these teens are most susceptible to drug culture and gang life because of an increasingly pervasive street culture. Many black youths between 10 and 14 are just as susceptible as older teens to teen pregnancy and juvenile delinquency (Billingsley, 1992).

More young black males go to jail than to college. In a definitive report on the status of young black males, Gibbs (1988) concluded that they are "an endangered species," and commented that "in American society today, no single group is more vulnerable, more victimized, and more violated than the young black males in the age range of 15 to 24" (p. 219).

By the end of the 1980s, many family specialists, African-American leaders,

public officials, and news media reports began to discuss the "African-American family crisis." Billingsley (1992) comments that "a growing sense of alienation or estrangement' among African-American families "leads to a hopelessness which often borders on despair" (p. 69). In rebuttal to these crisis discussions, Raybon (1987) wrote in Newsweek that:

Day after day, week after week, this message that black America is
dysfunctional and unwhole gets transmitted across the American landscape.
Sadly, as a result, America never learns the truth about what is actually a
wonderful, vibrant, creative community of people. Most black teenagers are not crack addicts. Most black mothers are not on welfare I want America ... to see us in all of our complexity, our subtleness, our artfulness, our enterprise, our specialness, our liveliness, our American-ness. That is the real portrait of black 72







Americans that we are strong people, surviving people, capable people. That
may be the best kept secret in America. (p. 5)

Raybon's statement is supported by a number of studies of black family norms. Royce and Turner (1980) found that black families tend to place strong value on discipline and on teaching children to have self-respect and to be happy and cooperative. Christopherson (1979) found that black family norms also include love for children, acceptance of children born out of wedlock, strong resilience, and adaptability of family coping skills. Gary (1983) found that achieving black families of both single-parent and two-parent structures, as nominated by community leaders, tend to rely on values of strong kinship bonds and positive parent-child relations, as well as strong achievement, religious, intellectual-cultural, and work orientations.

On the other hand, youths who experience abandonment, substance abuse,

domestic violence or sexual abuse at home, the absence of parental figures, destitution within single parent families, or who have parents who are substance abusers or convicted criminals face life stressors that predispose them to high-risk behaviors (Frankenberger & Sukhdial, 1994; Rotheram-Borus, Koopman, Haignere, & Davies, 1991; Sondheimer, 1992).

Young (199 1) found that male teens from single-parent homes tend to engage in higher levels of sexual activity and begin having intercourse at an earlier age than males from twoparent homes. Black female teens from two-parent homes were less likely to be virgins than white female teens, but tended to engage in lower levels of sexual activity than sexually active white female teens from two-parent homes. Similarly, low-income black female teens without a




73







father at home tend to be more sexually active (Keith, McCreary, Collins, Smith, & Bernstein, 1991).

Message Design and Delivery

The "Message Design and Delivery" domain of the theoretical framework

includes components of seven existing theories. Gerbner's (1956) General Model of Communication posits that "someone reacts through some means to make available materials in some form and context conveying content of some consequence." This statement implies that message design and delivery includes utilizes media channels and relies on the administration, distribution, and freedom of access to materials. Process variables include the structure, organization, style and pattern of a message, as well as the communicative setting, sequence of messages, content, and meaning.

A health message usually is designed to persuade an individual to change his or her behavior. The Health Belief Model (Becker, 1974) contains a "Cues to Action" component, which includes campaigns and interpersonal advice. According to the Elaboration Likelihood Model of Persuasion (Petty & Cacioppo, 198 1), persuasion cues include self-presentation, demand characteristics, and source characteristics. The characteristics of a message source, according to the Input/Output Matrix (McGuire, 1989) include number, unanimity, demographics, attractiveness, and credibility. Characteristics of the message itself include the type of appeal, type of information, inclusion/omission, organization, and repetitiveness. Channel variables include modality, directness, and context. Finally, the destination variables of the Input/Output Matrix include immediacy/delay, prevention/cessation, directlimmunization.



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Communication variables of the Transformation Model of Communication

(Kreps, 1994) include message strategies, language used, nonverbal cues, channels, and media. The Persuasive Health Messages Framework (Witte, 1995) posits that message goals include arguments, definition of the target audience, focus (i.e., "What is the threat to be prevented?"), behavior change objectives (i.e., "How will the threat be prevented" and "What recommendation will be advocated?") and cues (cultural values, colloquialisms, best channels, source preferences, literacy level, and customs related to sexual discussions).

Channel factors in Witte's framework are defined by the question, "Where do individuals prefer to get their information about HIV/AIDS prevention?" The cultural appropriateness of a message depends on whether it respects privacy and avoids embarrassment.

The Extended Parallel Process Model (Witte, 1996) distinguishes between the

photographic and written components of threat and efficacy messages. The characteristics of threat messages that can affect their effectiveness include the vividness and neutrality of language, use of examples of susceptibility or severity, use of color vs. black-and-white images, to what extent the source emphasizes the population at risk, the extent that the response efficacy of the recommended behavior is emphasized, whether the message includes role-playing that answers questions, whether it lists typical excuses for non-comphance, whether it emphasizes the ease and benefits of compliance, and whether it refutes false beliefs or low-efficacy beliefs.

The following model, Figure 8, highlights key aspects of the design and delivery of AIDS prevention messages. This domain of the conceptual framework also discusses 75








how individual, cognitive, and social factors can influence the impact of a particular health message, particularly among African Americans. Cues to Action

Cues to action, the stimuli which trigger an individual's decision-making process, include mass media campaigns, interpersonal interactions with peers or experts, nonverbal cues, or personal experience with AIDS, including previous practice of AIDS preventive behavior or the illness of a family member or friend. The "cues to action" concept is a basic component of Becker's (1974) Health Belief Model, which predicts compliance with



INDIVIDUAL PROCESSES

Predisposing MESSAGE Enabling
Factors DESIGN & CognitiveFatr
DELIVERY Processes
Cues to action
Change agents m~n v
Source
Hornophily
>Credibility Normative
Environmental Components ProcessesPoeta
Factors StrategiesPoeta
Social marketing rir4
CULTURAL CONTEX- Channel selection



FIGURE 8: Characteristics of AIDS Prevention Message Design and Delivery



health behavior recommendations. It is particularly difficult to identify effective cues to action for young people because they tend to be inattentive to issues of morbidity and mortality, are being confronted by their emerging sexuality, and are heavily influenced by peer pressures (USCM, 1990).


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Change Agents

Rogers (1995) defines a change agent as a person who "influences clients'

innovation-decisions in a direction deemed desirable by a change agency," uses opinion leaders as his or her "lieutenants" in diffusion campaigns, and who is typically a professional with a university degree in a technical field (p. 27-28). Many change agents believe that an advantageous new idea will sell itself, that its obvious benefits will be widely realized by potential adopters and that it will therefore diffuse rapidly. However, history shows this is rarely the case.

Byrnes (1966) points out that change agents themselves can create resistance to change because of their communication style, through doing such things as:

Giving orders rather than asking what and why people do what they do
Preaching practices rather than teaching how and why
Stressing methods rather than competencies
Talking about rather than demonstrating practices
Being inadequately prepared to teach Source Characteristics

Homophily

Similarity between change agent and target population is an important

determinant in the acceptance of an innovation (Lazarsfeld & Merton, 1964), and conversely, a primary barrier to effective diffusion is dissimilarity between them (Rogers, 1995). Homophily is the degree to which pairs of individuals who interact are similar in certain attributes, such as beliefs, values, education, or social status. Homophilous individuals share common meanings, a mutual sub-cultural language, and are alike in personal and social characteristics.

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Rogers (1995) argues that to some degree, a lack of homophily must exist between individuals in order for any diffusion to occur. If two individuals had an identical technical grasp of an innovation, diffusion could not occur as there would be no new information to exchange.

Lack of homophily between AIDS message designers and African American audiences has resulted in limited effectiveness in reaching black communities. AIDS prevention efforts directed to black communities frequently have been hindered by the assumption that the messages need only be "translations" of public service announcements, pamphlets, and posters originally designed by and for white, middleclass audiences.

Beyond using the colloquialisms of African American sub-groups, messages should demonstrate an understanding of the realities of their everyday lives, as well as how race, ethnic diversity and culture permeate value systems and world view (Gleaton & Johnson, 1995).

In order to reach African Americans with a prevention message, change agents must be culturally competent. In other words, they must draw on community-based values, traditions, customs, and the expertise of knowledgeable people from the African American community.

Cultural competence helps change agents avoid harmful stereotypes and biases, use language and terminology that is meaningful and not offensive, understand the cultural differences and similarities within, among, and between African American subgroups, and focus on the positive characteristics of particular groups (NIDA, 78








1992).

The cultural adaptation model (Michal-Johnson & Bowen, 1992) posits that regardless of whether an AIDS educator is culturally similar to the target audience, he or she must conceptualize the message from the values and experiences of the intended audience, use a verbal style that the audience will find believable and persuasive, and identify with those elements of lived experience that are "normal" and part of everyday events.

Source Credibility

Legitimacy is crucial for community-based health campaigns because it is the

process through which social leaders "give sanction, justification, and the license to act," influencing the rest of the community to adopt desired changes (Rogers & Shoemaker, 1971, p. 280).

According to consistency theories of attitude change, a person who has a negative opinion about an idea but a positive attitude about the endorser will be driven to reduce the tension created by the inconsistency. To reduce this tension, the person must assume that the endorser is not really enthusiastic or knowledgeable or must change his or her attitude toward the idea or endorser. If the audience has strong positive attitudes toward the endorser and the endorser is strongly linked to the idea, the audience will tend to improve its attitudes toward the idea (Batra, Myers, & Aaker, 1996).

Source credibility is enhanced by relationships that are trusting, open, and authentic and is facilitated by frank recognition and valuing of differences (Walker, 199 1). A source must be knowledgeable about the values, assumptions, and identity 79








issues of a target audience in order to achieve credibility (Banks, 1995).

Dimensions of source credibility include power, prestige (from past

achievements, reputation, wealth, political power, or visibility), competence or expertise, trustworthiness, attractiveness, dynamism (Rarick, 1963), and similarity between source and receiver (Rogers, 1962). All things being equal, the greater the physical attractiveness of the source, the more a receiver will like the message and the stronger the persuasive impact will be upon the individual (Batra, Myers, & Aaker, 1996).

Seven kinds of sources tend to be particularly successful in their influence

attempts: commercial authorities, celebrities, connoisseurs, sharers of interest, intimates, people of goodwill, and bearers of tangible evidence (Dichter, 1966). Zimbardo, (1972) observed that parents, teachers, ministers, and counselors

represent some of the most powerful "behavioral engineers" in this society....
They function with the benefits of socially sanctioned labels which conceal
persuasive intent: parents "socialize," teachers "educate," priests "save souls,"
and therapists "cure the mentally ill." (p. 82). Appropriate sources for African Americans

Familiarity with a targeted group is essential in selecting a credible person to

deliver AIDS prevention information. To an African American adolescent, a well-known sports figure may be much more credible than a teacher or doctor (Kaiser, Manning & Balson, 1989). Two kinds of role models are considered especially credible among African Americans: the pioneer, who penetrates an area perceived as closed to blacks, to show it can be done, and the cultural hero, who is often renowned and one of the first blacks to achieve a particular distinction (Manns, 1992). Michal-Johnson & Bowen (1992) found that African



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Americans tend to view personal testimony as a more credible and persuasive piece of evidence than whites do.

Face-to-face interventions among African Americans are likely to promote trust and security if the appropriate sources and messages are used (Bowen & Michal-Johnson, 1989). A key component of any AIDS message is the use of culturally appropriate spokespersons and other information providers. Leigh (1995) notes that culturally competent providers "are perceived by the members of a given culture as being knowledgeable and respectful of their mores, language, and styles of help seeking" (p. 129).

In a video exposure experiment, African American women from housing projects were significantly more sensitized to AIDS, were more likely to have discussed AIDS with friends, to be tested for FHV, and to request condoms at follow-up if they had viewed a public service videotape in which the presenter was African American (Kalichman, 1993). Because African Americans often distrust white health service providers (Bowen & Michal-Johnson 1990; National Commission on AIDS, 1992; Weinman, Smith, & Mumford, 1992; Worth, 1990), the source of the message should be someone who is perceived as credible by them. Message Components

Characteristics of abstinence messages

Abstinence is the most effective method of preventing pregnancy and the transmission of FHV and other sexually transmitted diseases. This is the only FHV prevention behavior recommended by most black churches, given that religious 81








conservatism generally precludes the promotion or discussion of condom use. Cates and Hinman (1992) have criticized exclusive reliance on abstinence-based approaches to HIV prevention as "absolutist."

However, the churches' abstinence message can be part of a broader, communitywide AIDS prevention strategy. While churches promote an abstinence message, AIDS organizations and schools can disseminate a condom promotion message. These dual messages could be integrated into a single community campaign that emphasizes a nonconfusing, rational decision-making approach targeting youth.

Several public health scholars have supported this dual approach. Roper,

Peterson, and Curran (1993) argue that protection of individuals from AIDS will depend on a community's ability to effectively combine abstinence-based and condom promotion strategies. Mays and Cochran (1988) also support this view, contending that abstinencebased church interventions can serve as an important component in multilevel campaigns that fit into the natural context of the community.

The advice to delay sexual involvement is generally more reasonable advice for adolescents than to forbid all sex prior to marriage. Frost and Forrest (1995) note that teens who delay intercourse are more likely to have stable relationships, to make better choices of partners, and to be more skilled at communicating and at negotiating sexual behavior and contraceptive use.

Kirby (1997) argued that abstinence-only programs are especially appropriate for middle school and junior high youths. However, in an evaluation of nearly 80 peerreviewed teen pregnancy prevention programs in the U.S. and other countries, Kirby was 82








unable to determine whether the abstinence-only programs actually delayed intercourse because 99 percent of these programs had significant methodological limitations that could have obscured program impact. These limitations included insufficient sample sizes, lack of long-term follow-up, improper statistical analyses, failure to use random assignment, failure to publish both positive and negative results, lack of behavior change measurement, inappropriate measures of behavior, and failure to use independent evaluators. Kirby argued that rigorous, well-designed research is needed to assess effectiveness of abstinence programsThe "Not Me, Not Now" pregnancy prevention campaign of Monroe County, New York emphasizes the messages that "abstinence makes sense for your future," teen pregnancy has severe consequences, and that "it's OK even cool to say no to sex" (Doyle, 1997).

A pre/post-test survey designed by program coordinators to evaluate the effectiveness of the program showed that a significantly higher proportion of youth said it is OK for people to start having sex when they have a good job and can support themselves and a baby. This reflected an increase of 5 percent over the 22 percent who asserted this view in the first survey. However, there was no change in the proportion who said they would wait until marriage (37 percent) or until they were living with someone (8 percent).

Roper, Peterson, and Curran (1993) argue that adolescents will not be persuaded to postpone sexual activity unless educators can create

A climate supportive of young people who are not having sex and so help to create a
new health-oriented social norm for adolescents and teenagers about sexuality. As
we proceed toward this objective, we must be mindful that many will continue to engage in sexual activity. It is essential that these youngsters receive the message
that they must practice safer sex and use condoms (p. 4).

83








Adolescents who already are sexually active may be less likely than virgins to

postpone sexual involvement as an HIV prevention strategy because compliance with the advice requires behavior change rather than mere behavior maintenance. However, an abstinence message targeting sexually active teens could emphasize the emotional, spiritual, and physical benefits of postponing further sexual involvement.

A number of teen pregnancy prevention programs have shown that an abstinence message reinforced by interpersonal interaction can be an effective component of a comprehensive prevention campaign. In order to succeed, an AIDS prevention program targeting hard-to-reach youth must be comprehensive, intensive, and include one-on-one sessions (Rotheram-Borus, Koopman, Haignere, & Davies, 1991). A review of five rigorously evaluated teen pregnancy prevention programs (Frost & Forrest, 1995) showed that all incorporated an emphasis on abstinence or delay of sexual initiation, training in decision-making and negotiation skills, and education on sexuality and contraception. Of the four programs that measured changes in rates of sexual initiation, all had a significant impact on that outcome, especially when targeting younger teens.

The "SchoollCommunity Program" in South Carolina, based on concepts of adolescent decision-making, self-esteem, communication, and influences on sexual behavior, targets rural, mixed-race, low-income girls. The program recruited clergy, church leaders, and parents to attend mini-courses and used a community newspaper and radio campaign to spread its messages (Vincent, Clearie, & Scbluchter, 1994).

"Postponing Sexual Involvement," an abstinence-based, eighth-grade curriculum in Atlanta based on social influence and social inoculation theories, targets low-income, urban black teens. Eleventh and twelfth grade students lead the teens in activities to help 84








them identify the source of and motivation behind pressures to engage in risky behavior and assist them in developing skills that will help them resist such pressures.

While the "Postponing Sexual Involvement" program strongly emphasizes abstinence, it also includes education about sexuality, contraceptives, and life skills (Howard & McCabe, 1990). "Life skills education" includes instruction about decisionmaking, goal setting, saying no to sex, and negotiating within relationships. The activities often include role-playing exercises in which students actout various situations they might encounter (Frost & Forrest, 1995).

"Teen Talk," a school and community-based curriculum based on the health

belief model and social learning theory, targets low-income boys and girls from mixed racial and ethnic backgrounds. The program includes sessions designed to alter teens' behavior by raising awareness of their own attitudes, beliefs, and knowledge about the probability that they might personally become pregnant or cause a partner to become pregnant, the serious negative consequences of teen parenthood, the personal and interpersonal benefits of delayed sexual activity and consistent, effective contraceptive use, and the psychological, interpersonal and logistical barriers to abstinence and consistent contraceptive use (Eisen & Zellman, 1990).

Of the teens that received the "Postponing Sexual Involvement" or "Teen Talk" curricula, boys were more likely than girls to remain abstinent during the course of the intervention. Wifle this outcome was unexpected, Frost and Forrest (1995) speculate that this may have happened because support for abstinence is seldom given to males in our society. Further, role playing and interactive discussions may have encouraged boys to think about their relationships in new ways (Eisen & Zellman, 1992).

85








Cultural Relevance

Using appropriate cultural symbols in a prevention message is an important strategy for reaching African Americans. While the "America Responds to AIDS" campaign was criticized for its overall culture-free approach, it did include graphics of a church building and a grandmotherly figure wearing a crucifix to symbolize the religious institution as a central but noncontroversial part of the cultural context (Michal-Johnson & Bowen, 1992).

Swanson (1993) criticized the "America Responds to AIDS" public service announcements as being:

A fragmented mix of unfocused communication efforts.... Rather than uniting
members of our American "melting pot" to fight FHV infection and AIDS, the TV and radio spots actually divide the population by reinforcing existing community
stereotypes and excluding the members of already disenfranchised groups from
the fight against the disease. (p.2)

General principles of message effectiveness can be applied in the development of culturally appropriate ADDS prevention campaigns. Banks (1995) argues that message effectiveness is assessed by the degree to which the communication:

Reinforces the self-concept of participants
Affirms cultural identities
Enhances relationships between parties
Accomplishes strategic goals of both parties
Recognizes the contextual nature of meanings
Accepts the diversity of interpretations
Remains open to reinterpretation

In addition, AIDS messages should emphasize how IRV is transmitted in a particular community, in this case the African American community, and how each member of that community can help prevent further transmission.



86







Message Strategies

Social marketing

Social marketing, the application of commercial marketing strategies to the

diffusion of nonprofit products and services, was launched about 45 years ago with the rhetorical question, "Why can't you sell brotherhood like you sell soap?" (Wiebe, 1952). This approach has been applied to AIDS prevention, as well as smoking cessation, safer driving, decreasing infant mortality, family planning, drug abuse prevention, antilittering, and weight loss.

Rogers (1995) notes that social marketing is usually aimed at the poorest and least educated, who are likely the most difficult to reach. Yet change agencies often expect a high level of reach and rate of change as a result of these campaigns,

A barrier to social marketing effectiveness is competition for attention in the public arena. A social condition is problematic only when someone or some group defines it as a problem or threat (Edelman, 1964; Cobb & Elder, 1983). Definitions or frames of social problems compete for acceptance and attention in the public arena and do not reflect objective or non-controversial assessments of conditions (14ilgartner & Bosk, 1988).

The essential elements of a social marketing campaign, according to Rogers (1995) are audience segmentation and formative evaluation research, as well as positioning relative to the intended audience's meanings and use of various communication channels.

Most AIDS prevention social marketing campaigns in the past have promoted condom use, emphasized fear appeals, featured dramatizations of heterosexual 87







relationships, made statements about drug use or infidelity, or provided sources of information about AIDS (Ellerbrock, Lieb, Harrington, Bush, Schoenfisch, Oxtoby, Howell, Rogers, & Witte, 1992).

The usual approach to solving a social problem is to "blame the victim" by engineering ways to change individual behaviors rather than addressing the systemic roots of the problem itself (Dervin, 1980). Audience segmentation is based on the concept of individual behavior change.

Banks (1995) argues that society is always communicated with in segments, as targeted special-interest publics. Grunig and Hunt (1984) contend that relevant publics should be identified by aggregating people into groups on the basis of their perspectives on an issue, rather than merely segmenting a geographic population by race, age, or gender. This kind of segmentation includes assessment of how aware people are of an issue, how relevant they perceive the issue to be to them, and what control they believe they have over changing the issue.

Channel selection

Hertog, Finnegan, and Fan (1996) note that most campaign effects studies have concluded that mass media are more efficient than interpersonal channels for generating simple cognitive outcomes such as awareness and knowledge of simple skills, but interpersonal communication tends to be more effective in inducing attitude or behavioral change. Print channels are more effective in disseminating complicated information, while broadcast channels are better in generating awareness of a campaign and in disseminating simple messages




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