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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 )
City of Gainesville ( local )
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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



2








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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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

Copyright 1999
by
Kristie Alley Swain

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 warn 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 the fotonovela.
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. Bemell
Tripp, another committee member, also generously provided. Ever since we were
graduate students together at the University of Alabama in 1990-91, Bemell 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
IV

Research Award provided by the College of Journalism & Communications, which
helped cover the expense of the focus groups and fotonovela 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 am 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.
v

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
Page
ACKNOWLEDGMENTS iv
LIST OF FIGURES viii
LIST OF TABLES ix
ABSTRACT x
CHAPTERS
1 INTRODUCTION 1
Overview 2
Problem 2
Rationale 6
Objectives 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 Barriers 173
Outcomes 186
Summary of Literature Review 193
3 METHODOLOGY 195
Selection of Method 196
Site Selection 198
Research Questions 213
vi

Participant Observation 214
In-Depth Interviews 215
Recruitment of Key Informants 218
Focus Groups 224
Readability Analysis 240
Informed Consent 243
Data Analysis Procedures 244
Threats to Validity 252
4 RESULTS 258
Predisposing Factors 260
Environmental Factors 290
Message Design and Delivery 300
Cognitive Processes 330
Normative Processes 347
Enabling Factors 365
Potential Barriers 405
Outcomes 448
5 SUMMARY AND CONCLUSIONS 462
Summary 462
Key Findings 465
Detailed Findings 473
Limitations 552
Implications for Future Fotonovela Interventions 554
Future Research 558
REFERENCES 563
APPENDICES
A LONG INTERVIEW PROTOCOLS 637
B FOCUS GROUP PROTOCOLS 647
C EDUCATIONAL MATERIALS 710
D “AFTERNOON DELIGHT’ FOTONO VELA 723
E CODE LIST 728
F INFORMED CONSENT FORMS 731
BIOGRAPHICAL SKETCH 738
Vll

LIST OF FIGURES
Figure Page
1 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
AIDS Preventive Outcomes 260
17 Environmental Factors, Identified by Research Participants, that Influence
AIDS Preventive Outcomes 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
Contexts 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
1 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, African 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.
x

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 framework 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.
xi

CHAPTER 1
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 HIV nor
express concern that their own children and grandchildren might be vulnerable to
the dreaded disease.1
1 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.
1

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 African 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 (HIV), 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
2

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 bom with HIV, and half of all intravenous drug users with AIDS are African
American (HERO, 1994).
The sexual routes of HIV 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. HIV 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 HIV 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).
3

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, 1991).
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
4

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 ADDS 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 HIV
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 HTV
prevention messages has become increasingly recognized by both scholars and public
5

health practitioners (Bayer, 1994). For example, Nyamathi, Leake, Flaskerud, Lewis, and
Bennett (1992) found that presenting basic, culturally-relevant information alone can reduce
high risk behaviors among impoverished African-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 just 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, 1991). 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.
6

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 bom 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,
7

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 created fotonovela
(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 a fotonovela that targets African Americans with a health
promotion message.
8

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 African 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 original fotonovela 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?
9

4. To what extent could this fotonovela change individual attitudes about HIV and
the risks associated with unsafe sex?
5. How effectively could a fotonovela 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 HIV 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
10

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 a fotonovela 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 higher-
level theory, via an integration of variables and other concepts from numerous middle-
range 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
11

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 African
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 turn, 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 a fotonovela 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 fotonovela, conducting readability analysis, providing informed consent,
in evaluating validity threats, and in transcribing, analyzing, and interpreting the data-
texts.
The in-depth interviews included one-on-one discussions with African American
clergy, as well as members of a minority AIDS advocacy group, national AIDS 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 fotonovela.
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 a fotonovela 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 AEDS-related attitudes, including religiosity-based barriers to AIDS
prevention. The findings also were used to refine the fotonovela 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 adolescent's “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 fully 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 argument” (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 (l) 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 1
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, 1981)
• 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.
Predisposing factors 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.
Environmental factors 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 African
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 the fotonovela 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 learning 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 a fotonovela 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 number of factors serve to enable a person to comply with the message or
serve as barriers to a recommended action.
Enabling factors 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 A TPS 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 self-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
Cultural Context
FIGURE 1: A Strategic Model of AIDS Preventive Behavior Change
25

INDIVIDUAL PROCESSES
to
Ov
Predisposing Factors
Personality
Needs
Demographics: Age,
Gender, Education, SES
Religiosity
AIDS risk factors
Drug use
Homosexual behaviors
Teen sex
Truancy
Homelessness
Racism
Sex-ratio imbalance
Motherhood norm
AIDS prevention
knowledge / experience
Environmental Factors
AIDS Epidemiology
Community Resources
Media Access & Uses
Social Network Norms
Community Norms
Church Norms
Communication Norms
Family Structure/ Norms
CULTURAL CONTEXT
Cues to action
Change agents
Source
Homophily
Credibility
Components
Strategies
Social Marketing
Channel Selection
Enabling Factors
Self-Efficacy
Response Efficacy
Danger Control
Social Support
Community Support
Skills Acquisition
Effective Education
Empowerment
Values Reinforcement
Church Intervention
OUTCOMES
Desirable
Undesirable
Figure 2: Conceptual Framework for the Design of Culturally Relevant AIDS Prevention Messages

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 “pre¬
contemplation.” 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

INDIVIDUAL 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
kn *
Enabling
Factors
> OUTCOMES
Potential
Barriers
Factors —
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 self-
serving 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 African 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 (Matón & 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. 161). 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. 191). 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 self-
righteous proselytizing from those with whom we share our feelings” (p. 162-
163).
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, 1991). 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-American 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 HIV 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 introversion-
extroversion, 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/self-
restraining, 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/self-
enhancement, 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/self-
restraining 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. 131-133)
A tendency toward depression has been shown to be a barrier to self-efficacy in
practicing AIDS preventive behaviors (Leigh, 1995). African 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 (self¬
esteem, 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 (Nyamathi, 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 HIV 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 HIV infection and the appearance of the clinical
symptoms of AIDS can be 10 years or longer, most diagnosed individuals in the 25-44
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 HIV among minority youth is attributable to the significant correlation
of HIV 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 bom in 1960 or later than among older
individuals (Rosenberg, 1995), and especially among African American adolescents
(DiClemente, 1993).
In some minority communities, sexual activity begins as young as age 11 or 12 for
girls and a few years older for boys. Considering that African American teens tend to
initiate sexual involvement earlier than white teens, AIDS messages are likely to be most
effective if they target African 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 HIV 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

Under 5 5-19
20-24
25-29
30-34 35-44
Age Group ~
45-54 55-64 64 + ALL
â–  % of U.S. male AIDS cases
â–¡ % of U.S. male population
FIGURE 4: AIDS Cases among Black Males, Cumulative through June 1997
â–  % of U.S. female AIDS cases
â–¡ % of U.S. female population
70
65
60
55
50
45
40
35
30
25
20
15
10
5
0
Under 5 5-19 20-24 25-29 30-34 35-44 45-54 55-64 64+ ALL
Age Group
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 1 in every 3 deaths among men and 1 in 5 deaths in women (CDC, 1996).
Among African Americans in their thirties, an estimated 1 in 33 black men and 1 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 1 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
nationwide (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 A TPS 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 HIV prevention education among African Americans (Rotheram-Borus,
Koopman, Haignere, & Davies, 1991; 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 racial-
ethnic 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 (Gleaton &
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 HIV 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 African 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 HIV (Florida Health Net, 1997).
Among African 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, 1981).
AIDS 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 HIV 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 13-
year-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 HTV
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.
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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 HIV infection.
Cultural Factors in HIV Transmission
Truancy: Many school dropouts who are at risk for HIV 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, 1991).
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 HIV 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, 1991).
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 HIV prevention education. In addition, HIV 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, 1991).
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.
Memmi (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.
Langner (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

Under 5 5-19 20-24 25-29 30-34 35-39 45-54 55-64 64+ Overall
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 11 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).
AIDS 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 HIV 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 (1991) 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, Marin, 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 partners), 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
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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.
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INDIVIDUAL PROCESSES
CULTURAL CONTEXT
FIGURE 7: The Role of Environmental Factors in AIDS Prevention
Social network norms
African-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
60

religion “exists parallel with but not subservient to white religion” (p. 71). Community-
level advocacy does appear to be a uniting factor, as shown by the National Survey of
Black Americans (1980), in which 90 percent of African Americans agreed with the
statement that blacks “should work together as a group,” 89 percent agreed that “black
women should work 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” permeates 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 African-American heritage, identify with it, and
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serve primarily African-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. 3-4)
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 & Fortini-
Campbell, 1983), orientation to local facilities, knowing neighbors’ names, frequency of
neighborly visits (Finnegan & Viswanath, 1988), membership in formal organizations
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(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-Franklin (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 African-American community’s push to influence the future of
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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).
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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. El). Murphy (1994) concurs, noting that the “this-
worldly” 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 hopeful 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. Kochman (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 “stylin’” or “show
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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, African 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 African 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.
• Ethnolinguistic 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
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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 African-
American 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 African-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). Hill (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 “Active
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. 31).
African-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 Dressier, Haworth-Hoeppner and Pitts
(1985), Payton (1982), and Cross (1982), have concluded that the female-headed, single¬
parent 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.
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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
African-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
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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 bom 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 (1991) 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 two-
parent 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
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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, 1981), 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, direct/immunization.
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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 wall 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-compliance,
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
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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
Factors
Environmental
Factors
CULTURAL CONTEXT
MESSAGE
DESIGN &
DELIVERY
Cues to action
Change agents
Source
Homophily
Credibility
Components
Strategies
Social marketing
Channel selection
Media use
Enabling
Factors
OUTCOMES
f Normative \
V Processes J
Rarripr«
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, middle-
class 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,
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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,
1991). A source must be knowledgeable about the values, assumptions, and identity
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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 &
Balsón, 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
80

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 HIV, 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 HIV and other sexually transmitted diseases. This is the only HIV
prevention behavior recommended by most black churches, given that religious
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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, community¬
wide 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 non¬
confusing, 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 abstinence-
based 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 peer-
reviewed teen pregnancy prevention programs in the U.S. and other countries, Kirby was
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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
programs.
The “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).
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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 “School/Community 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, & Schluchter, 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
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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 decision¬
making, goal setting, saying no to sex, and negotiating within relationships. The
activities often include role-playing exercises in which students act'out 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. While 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).
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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 HIV 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 AIDS 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 HTV 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.
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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, anti¬
littering, 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 (Hilgartner &
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
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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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In the Stanford Three-Community Study, one community was treated with a heart
disease prevention campaign using only mass media channels, another with a media
campaign supplemented by face-to-face instruction of high-risk groups, and a third
received no treatment. The strongest campaign effects were seen in the community
where the media were supplemented by interpersonal communication (Maccoby &
Solomon, 1981).
Campaigns are more likely to influence behaviors if they are well conceived,
repeated over time, and reinforced through interpersonal intervention (Levin, 1987).
Media-only health campaigns may be effective in short-term change in knowledge but
usually have little impact on health behaviors that have been ingrained over a lifetime
and which are strongly reinforced by individuals’ lifestyles, reference groups and family
structure (Brown & Einsiedel, 1988).
Freire’s (1968) community action approach is philosophically similar to the two-
way symmetrical model cited in the public relations literature. Grunig and Hunt (1984)
posit that this model is one of four that have become standard approaches to campaign
development:
• Press agentry model, which aims propagandistic information in one-way
dissemination to a constituency to achieve interest, awareness, or motivation.
• Public information model, which assumes truthful information is communicated
in a one-way process but without persuasive intent (McQuail, 1993).
• Two-way asymmetrical model, which assumes persuasion, but the communicator
collects information about the audience up front or as feedback.
• Two-way symmetrical model, in which the communicator and audience share
initiative and power. The audience accepts ultimate responsibility for driving an
intervention and provides formative input and feedback so that the communicator
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can conduct continuous research in order to develop a campaign based on mutual
needs and benefits (Grunig & Grunig, 1992).
Appropriate channels for African Americans
Intervention strategies may not effectively reach high-risk individuals in the black
community unless they incorporate nontraditional media and face-to-face delivery strategies.
For campaigns targeting African American teens, these individuals can be most effectively
reached at such locations as street comers, homes, churches, housing projects, shopping malls,
community recreation halls, rap concerts, arcades, public agencies, group homes, court-related
facilities, hospitals, and clinics (Stryker, Coates, DeCarlo, Haynes-Sanstad, Shriver, & Makadon,
1995).
In addition, outdoor media may be effective in reaching those who have limited access to
television or newspapers. Transit posters at places where teens congregate can provide toll-free
numbers for relevant health and community service organizations. Aside from multimedia
campaigns, past interventions incorporating interpersonal intervention strategies have included
HIV antibody testing with pre-test and post-test counseling, syringe exchange, street outreach,
condom handouts to prostitutes and drug users, and other forms of peer education (Stryker,
1995).
Another strategy in developing an interpersonal component for a community A TPS
prevention campaign targeting African Americans is to encourage individuals to obtain
information about AIDS and risky behaviors from doctors or public health workers. Coverdale
(1990) found that 92 percent of physicians who provide primary care for minorities believe they
should educate their patients about AIDS, but in actuality these doctors reported giving advice to
only 11 percent of their male patients and 14 percent of their female patients. A local A TPS
90

prevention program could include a workshop for physicians in which they learn communication
skills that could make them feel more comfortable discussing sexual issues with minority
patients.
Fotonovela as alternative campaign channel: The fotonovela, a Latin American
soap opera or serial story script presented with photographs in a comic-book format, can
be adapted for use as an innovative, culturally appropriate health promotion tool to target
a variety of audiences. Flora and Flora (1978) define a fotonovela as “a love story told in
photographs with balloon captions presenting the dialogue,” and these booklets “both
shape and are shaped by the dominant values” of the audience members (p. 135).
Fotonovelas have become a highly effective means of disseminating a variety of
educational messages to Hispanic audiences throughout Mexico, Latin America, and the
U.S. (Conner, 1991). The fotonovela is a micro-media channel, as are brochures, comic
books, posters, lapel pins, and T-shirts. Micro-media channels, a component of micro-
marketing strategies, do not disseminate a message or materials through media
organizations, as contrasted with mass media channels such as newspapers, radio,
magazines, and television.
In describing the use of photonovels in Peace Corps projects in third-world
countries, Weaks (1976) asserts that the photonovel
has permitted access where other media have failed; it has filled in the gaps
where more traditional, and often more expensive media have introduced ideas
but without great and lasting impact. It is more important as a means of
information dissemination and as a catalyst for audience participation, (p. i)
The fotonovela was long unnoticed as a campaign channel, partly because of “the
profusion of poorly designed and executed posters, pamphlets and brochures that have
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bombarded the public in the past” (Weaks, 1976, p. 2). During the early 1970s, the Peace
Corps tried to reach isolated peoples in Ecuador using flipcharts, posters, and filmstrips.
However, the organization abandoned these methods, after trials, in favor of the
photonovel “because of its ability to communicate a detailed message through words and
vision, while entertaining at the same time” (Weaks, 1976, p. iv).
Televised public service announcements have been used massively in the service
of various public health goals, including AIDS prevention (Lorch, 1994). However,
many PSAs fail to reach individuals because they are aired too infrequently, outside
prime time, or on noncommercial stations; many are directed at unidentifiable audience
segments; and most do not account for the attitudes, values, and norms that affect
exposure to PSA messages (Flay & Sobel, 1983). Compared with traditional broadcast-
format public service announcements, educational fotonovelas have many advantages.
According to Weaks (1976) and others, fotonovelas typically are:
1. Less expensive to produce than radio, television, or film productions.
2. More likely to remain in the readers’ possession and less likely to be discarded.
3. More effectively disseminated to a target audience because of their greater
potential to circulate within existing community networks.
4. Better able to explain information in detail, emphasize key points, and outline
procedures.
5. More culturally sensitive and culturally relevant.
6. More realistic because the photographs help the reader more readily identify with
the characters.
7. More likely to be in demand among those who read similar materials for
entertainment.
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8. More fun to read because pictorial content, simple dialogue, and an interesting
story create an atmosphere conducive to learning.
9. More effective in creating and maintaining norms, through social modeling and
interpersonal reinforcement of the message within communication networks.
10. More appealing to lower-literacy individuals because the language is more
readable, familiar, and comprehensible. Rather than feeling pressured to learn,
the reader can absorb information without conscious effort.
11. Better able to “sell ideas” because the story shows readers the “how” and “why”
of an idea and illustrates how he or she may benefit as an individual.
12. Better designed, particularly when audience members help in producing them.
13. Effective in conjunction with other media in a communications campaign because
it can fill in informative details too lengthy to include in radio, TV, or posters.
14. More user-friendly in that electronic equipment such as a television, radio,
computer, or film projector is not needed and because audience members can
read it at their convenience.
When used as an educational tool,fotonovelas also have several disadvantages
when compared with other media (Weaks, 1976, p. 4):
1. The content is static because it is more difficult to change without costly
adjustments.
2. Close teamwork is required, which means that writers, photographers, actors, and
printers must be cooperative.
3. Thousands of copies must be printed so that the cost per booklet is not prohibitive
for free or low-cost distribution.
4. They are not accessible to non-literate audiences or to individuals with poor
eyesight, even though they are appropriate for semi-literate readers and can be
read aloud to those who cannot read.
The literary fotonovela originated as an entertainment form in North Africa and
Europe and was introduced into Latin America during the 1940s (Conner, 1991). The
early Mexican fotonovelas retold the action of a melodramatic love story with
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photographic stills of popular movies and dialogue contained in balloons (Flora & Flora,
1978). In a fotonovela, “captioned photos present male-female relations in the melding
of visual exactness and audio imagination” (Flora, 1980, p. 524).
By the 1970s, 23 weekly fotonovela titles - with as many as 350,000 issues of a
single title printed - were distributed in more than 7,000 newsstands in Mexico (Hemer,
1979). A popular version of the fotonovela in Europe, the French photoroman,
originated in the mid-1950s as an offshoot of the general women’s magazine and often
presented each dramatic serial in a pocket-size format for three to six months (Nye,
1977).
In Mexico, the audience members for fotonovelas are usually semi-literate,
working class women. Surveys offotonovela readers indicate that the vast majority has
few appliances and is, therefore, assumed to be in the lower socioeconomic classes
(Habert, 1974). The traditional fotonovela sold in Latin America may particularly appeal
to women from lower socioeconomic backgrounds because the narrative reinforces long-
accepted sexual mores. Acosta (1973) identified six types of female characters portrayed
in fotonovelas: (1) erotic objects, (2) voracious devourers of men, (3) virginal girlfriends
and fiances, (4) chaste faithful wives, (5) saintly mothers, and (6) meddling mothers-in-
law. In their analysis of 62 Spanish-language fotonovelas, Carrillo and Lyson (1983)
found five major themes: marital/premarital morality, beneficent fate, conflict in family
relationships, sexual taboos, and social success stories.
Women are not the exclusive readers of romantic fotonovelas, however. In a
content analysis of 200 pen pal request letters published in a Mexican fotonovela, Flora
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(1980) found that most letters were from adolescent boys and girls, and a third were from
males.
Fotonovela Design and Delivery: A fotonovela has greater potential to empower
target audience members to reduce their health risks if it is culturally appropriate,
effective, and affordable (Ricardo, 1996). Effective fotonovelas typically feature
“cultural sensitivity, relevant contexts, powerful role models, and an entertainment
format” (Ricardo, 1996) and are appropriately geared to the culture, ethnicity, race,
gender, language, and class status of the learners (Rudd & Comings, 1994).
The effectiveness of a fotonovela depends in part upon its production and
aesthetic value. If a reader can visually see that a fotonovela is about his people, and
especially if he has rarely seen stories written about his people, he likely will read the
fotonovela on the basis of visual content even if the message is of no interest to him
(Weaks, 1976). Baetens (1989) asserts that
Since the photographic novel belongs to two distinct artistic domains, it must be
submitted to a plurality of judgments: It lends itself to a literary appreciation and,
moreover, it does not escape from a photographic evaluation, (p. 286)
From a purist’s point of view, however, fotonovela photography may not be truly
artistic. Baetens observes that the photo novel is “fake,” in that
Its producers fail to watch and wait for the miraculous instant in which “true”
photographs are taken. The shift from the single photograph to a constructed
series of images, together with all the artifices that result from staging, montage,
and editing necessarily disqualify the genre in view of the dominant photographic
ideology, (p. 287)
Nye (1977) noted that most fotonovelas use cinematic-style photography,
including
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A careful blend of close-up, medium, and long shot... emphasizing the
dramatics of the posed situations.... In effect, the arrangement of pictures on the
page is intended to resemble a succession of movie stills, each advancing the
action a step. (p. 746)
Weaks (1976) argues that the visual content of a fotonovela is more likely to hold
a reader’s attention if the photographs reflect three types of viewpoints in the way that
they compose various scenes:
• The establishing photo shows the environment in which the action occurs
(i.e., room, house, or landscape). Tells the “where” of the story.
• The close-up, which closely frames a character’s face or object of interest.
Tells the “who” or “how” of the story.
• The medium close-up shows the immediate situation. The emphasis shifts
from the subject to its activity, which may involve more than one person.
Tells the “what” of the story.
Another dimension offotonovela effectiveness is its readability, including its
ability to appeal to a reader’s interest. Nye (1977) found that the dialogue is usually
simple, with limited vocabulary and short sentences. The settings are places “where
people meet and things happen” (p. 746). A unique characteristic of many fotonovelas is
their pocketsize format, which “aids readership of this ‘deviant’ material, which can be
easily concealed in newspaper or schoolbook” (Flora, 1980, 525).
Weaks (1976) recommends that a fotonovela writer:
• Create a plot that is easily understood by the audience.
• Avoid using “sophisticated gimmicks such as flashbacks or leaps through
time.”
• Keep the cast to a minimum of those needed to carry the plot to a conclusion
and convey the message (usually three to five characters).
• Clarify scene changes.
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• Set the dialogue apart from photographs by using balloons and/or narrative
inserts.
• Use appropriate colloquial expressions and other dialect.
• Pre-test the narrative if any material might be scandalous or otherwise
sensitive (p. 9-10).
A major cost-saving aspect of a fotonovela intervention is that it can be
implemented by community volunteers or other non-professionals. Fotonovela delivery
methods should be interactive and varied, depending on the characteristics of the target
population (Gromley, 1996).
A fotonovela can serve “as a cultural bridge between an impersonal, unfamiliar,
and often alienating environment and the more familiar heritage of the readers” (Carrillo
& Lyson, 1983, p. 59). It also can serve “as a convenient mechanism to establish and
maintain a common set of norms and values” among members of a large segment of a
population (Acosta, 1973, p. 29).
One way of creating and maintaining norms among targeted readers is to involve
audience members in developing a fotonovela. In Ecuador, researchers involved learners
in developing fotonovelas in order to stimulate discussion and to help participants
discover themselves as the agents of change (Center for International Education, 1975).
Similarly, the Chiapas Photography Project, a Mayan cultural cooperative started
in 1992, teaches natives of highland Chiapas, Mexico, to produce fotonovela
presentations of their plays and other works about their ancestry and everyday lives. For
example, one shepherd in the artists’ cooperative recorded and illustrated 47 traditional
rules and beliefs that guide the eating and health habits of her people,
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So that the roots of our ancestral culture [can] be known by the new generation,
above all by the children, because they are those who suffer most from the
cultural changes of our people. (Nifong, 1994)
Overall, the purpose of the Chiapas project is
To make available to indigenous artists the technical resources they need to
express freely their creativity. No artistic or cultural guidance is provided that
might influence in any way the photographers’ work (America, 1994).
On Dec. 22, 1997, para-military men massacred 45 Mayans in Chiapas, Mexico,
as the villagers gathered in worship at church. Like the Africans brought to America, the
Chiapas people are the victims of ethnic genocide. However, their expressions of
creativity, tradition, and heritage within their fotonovelas may truly be, as Freire (1961)
envisioned, a “pedagogy of the oppressed” and a lasting vestige of their culture.
Ricardo (1996) found that the most influential aspect of a novela, as an
educational tool, is that readers often engage in interpersonal dialogue about the story.
The social interest generated by the characters, photos, and story promotes conversation
among those who read, hear, or see the novelas. As participants disseminate
fotonovelas, the educational impact is bolstered through social interaction (Gromley,
1996). Detectable, positive effects of a fotonovela, including behavior change, usually
require three to four weeks (Ricardo, 1996).
Through in-depth interviews with Latin American adolescents, Flora (1980) found
that most begin reading fotonovelas at around ages 9 or 10, and those who spend the most
time reading them are 14 or 15. Flora observed that fotonovela reading among
adolescents is often a group function, in which
Friends will get together with a pile offotonovelas and read them as they trade
back and forth. A social invitation may consist of “Come over and read
fotonovelas " Like watching television, little interaction occurs for most readers.
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But doing it together creates a non-verbal sharing of a series of important values,
especially those relating to interpersonal relationships, the relative importance of
romantic versus other problems, and the method through which problem solution
is achieved. Thus writing to fotonovelas can be seen as a continuation of the
social process offotonovela reading (p. 530).
In Latin America, most working-class neighborhoods have at least one
“entrepreneurial” woman with a rental library offotonovelas (Flora & Flora, 1978). In
Ecuador, many “lunch hour libraries” rent fotonovelas by the hour, and “the service is so
popular that one sees a city park blanketed with lounging workers, each with a
photonovel in hand” (Weaks, 1976, p. 1). Flora and Flora (1978) observed that “within a
household, all family members are likely to read a purchased volume, and both blood and
fictive kin borrow the fotonovela frequently” (p. 136). Weaks (1976) notes that a
fotonovela “is guarded as a possession worthy of great care” (p. 2).
Fotonovela as Health Education Tool: The use of drama has been shown to
improve the outcomes of health education and communication skills among nursing
students (Riseboroughyh, 1993). Fotonovelas, as well as radionovelas and telenovelas,
have been used in the United States and in Latin American countries to communicate
health information to the public on such topics as AIDS, diabetes, and substance abuse,
as well as other social issues that are not directly health related (Gromley, 1996). The
earliest educational photonovels in Ecuador, produced by the Peace Corps, addressed
environmental sanitation, pre- and post-natal nutrition, malaria control, and family
planning (Weaks, 1976).
To reach Long Island’s Spanish-speaking population with a campaign to combat
drunken driving, several counseling and educational agencies teamed to produce a
bilingual fotonovela titled “¿a Pesadilla” (The Nightmare), also used as a classroom text
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(Business Wire, 1995). Safeway grocery stores and the California Highway Patrol
recently used bilingual folonovelas to disseminate information about child lead poisoning
prevention (Business Wire, 1995). The city of Santa Ana, California, won a national
award for producing a fotonovela and accompanying video in three languages titled
“Good Home, Good Neighbors” to help recent immigrants learn the “do’s” and “don’ts”
of their new city (Henry, 1995).
Century Council, a Los Angeles-based alcohol abuse program funded by the
alcohol industry, created a fotonovela titled “Si Toma, No Manaje” (If You Drink, Don’t
Drive) to educate Hispanics about drunk driving. The fotonovela was one component in
a campaign that also included PSAs, posters, buttons, and materials encouraging alcohol
vendors to check I.D.s to prevent underage purchases (Alcoholism & Drug Abuse Week,
1992). Similarly, the California Highway Patrol created a drunk-driwing fotonovela and
accompanying video telenovela titled “El Protector,” featuring a superhero portrayed as
A calm, benevolent figure with an understated macho presence,... a CHP officer
dressed in a black leather jacket and sunglasses, wearing a mustache and slicked-
back hair - or whatever fashion statement is considered cool at the time
(Regalado & Bustillo, 1993).
Many folonovelas also have been developed to educate Hispanic patients about
various illnesses and treatments. For example, folonovelas with such titles as “Qe le pasa
a abuelito?” (What’s Happening to Grandfather?) and “Unidos en la Lucha” (United in
the Fight) have been developed to educate Hispanics about Alzheimer’s disease (Aging,
1992). A number of American drug companies have developed folonovelas targeting
Hispanic patients. Burroughs Wellcome, a company that produces retroviral drugs for
HIV-positive patients, converted a traditional physician’s flip chart into a culturally
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relevant fotonovela containing Spanish-language testimonials and custom-tailored
illustrations. The company interviewed patients, physicians, and AIDS service
organization counselors, all of whom were Hispanic. In addition, the company involved
these participants in every step of the process of creating the materials (Lipton & Lipton,
1995).
Pratt Pharmaceuticals and Roerig Inc. developed a series of bilingual fotonovelas
titled "Su Salud Su Futuro ” (Your Health, Your Future) to educate patients about
treatments for diabetes, hypertension, and depression. The companies supply the
fotonovelas free of charge to physicians, who then may distribute the materials to
appropriate patients. Pratt and Roerig used the fotonovela format as a tool
To reach the mass undiagnosed Hispanic market with a message on the risk
factors and warning signs of diabetes.... (and) to deliver the educational
message in an interesting, friendly, and approachable manner (Lipton & Lipton,
1995).
The only known targets of previous AIDS prevention fotonovela interventions are
low-literacy Hispanics, particularly migrant farm workers. A number offotonovelas
targeting these individuals have been disseminated by outreach workers, health clinics,
and churches. For example, as part of an informal AIDS clinic in the heart of the Latino
community in Santa Ana, clients received HIV prevention fotonovelas geared to lower
literacy audiences (Reyes, 1993).
In the first published evaluation of an AIDS fotonovela intervention, Conner
(1991) examined changes in knowledge, attitudes and behavior as the result of a
California intervention targeting young male, Mexican migrant workers. "Tres Hombres
sin Fronteras ” (“Three Men without Borders”) told a story of three farm workers who
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left their families in Mexico to work in the fields of the United States. The program
involved two types of formats: a fotonovela consisting of an eight-page, tabloid-sized
booklet and a 15-segment radionovela (five minutes each segment). The fotonovela also
includes a mini -fotonovela, “Marco Aprende como Protegerse” (“Marco Learns How to
Protect Himself’), which explains how to use, dispose of, and obtain a condom and
which includes several condoms for practice and use.
The fotonovela and radionovela tell the story of three men who leave their
families to cross the Mexico-U.S. border and work in the agricultural fields. After work,
they meet prostitutes who inform them about AIDS risk and how to prevent it by using
condoms. The worker who refuses to use condoms discovers that his wife and baby, who
remained in Mexico, are sick and infected with HIV. The worker who learns to use
condoms and the one who abstains from sex remain healthy. Folk and modem medical
personnel play roles in the story as AIDS information disseminators. Conner asked farm
workers to assess the acceptability, appropriateness, cultural sensitivity, and clarity of the
content. Pre-and post-intervention interviews of 52 men, as well as 37 men in a control
group, were used to assess the effectiveness of the novelas. The pre-test included an
assessment of AIDS knowledge. More than 80 percent read the fotonovela, and 68
percent correctly identified messages contained in each of the three fotonovela frames
tested. When asked if they could protect themselves against HIV, almost twice as many
men (90 percent) said “yes” after the intervention than before exposure to it. In addition,
a significant increase in condom use was reported.
Ricardo (1996) found that the use offotonovelas within this population resulted
in faster behavior change than the use of radionovelas aired as a serial in multiple
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segments. Fotonovelas also have been more effective than traditional brochures. In
measuring readership of a locally produced AIDS prevention fotonovela compared to a
more traditionally formatted and illustrated booklet, Mickiewicz (1991) found that the
local fotonovela was more effective in increasing farm workers’ AIDS-related knowledge
and in changing their attitudes and practices toward less risky sexual behavior.
Ricardo (1996) developed a health promotion fotonovela that targeted Latina
women in migrant and seasonal farm worker populations who were enrolled in prenatal
care programs. Ricardo found that these women tended to have difficulties adopting risk
reduction strategies because they lacked access to relevant information and medical care,
a migratory lifestyle, and various cultural and spiritual barriers. The fotonovela scripts
were designed to reduce behavioral risks, including lack of knowledge of sexually
transmitted diseases and HIV/AIDS, low perceived risk regarding HIV because of limited
information, cultural myths, and illiteracy. Among migrant farm workers, exposure to
novelas resulted in increased requests for condoms and increased interest in HIV issues
among participants. Ricardo (1996) argued that the effective novelas were designed to
• Increase understanding among migrant women about the risk of HIV
transmission.
• Increase condom use, which was the primary behavior change goal.
• Increase individual self-efficacy.
• Provide information in a way that low-literacy individuals can comprehend it.
• Create an information-sharing norm among members of the target population.
• Facilitate community participation in and ownership of effective intervention
strategies.
• Provide positive role models to women.
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• Establish effective partnerships with community organizations to create and
disseminate novelas.
Opportunities for an African American AIDS fotonovela: A major challenge in
developing effective AIDS prevention interventions among African Americans is
overcoming barriers of low literacy skills and cross-cultural communications. To be
culturally sensitive, specialized AIDS interventions for African Americans should use
language familiar to the recipients and use visual messages (Wofsy, 1987).
Gromley (1996) found that African American focus group participants identified
soap operas and other dramatic presentations as effective methods of education. This
interest in drama, combined with the strong tradition of storytelling in African American
culture, creates a strong rationale for the use offotonovelas in AIDS prevention efforts.
An example of a program that draws upon the African American oral tradition is a STD
prevention intervention designed by Solomon and DeJong (1986). They designed soap
opera videos for the CDC that specifically targeted inner city black men who used STD
clinics.
If the emotional appeal of traditional fotonovelas were culturally adapted for
African Americans, it might boost their popularity in the black community. Carrillo and
Lyson (1983) observed that most Latin American fotonovelas
Offer an escape into both a cultural and linguistic milieu that is familiar and
reassuring and into a fantasy world that provides the reader with vicarious sexual
titillation. (p. 59)
In conducting focus group interviews with African Americans, Gromley (1996)
found that a short leaflet or poster is more culturally appropriate for targeting the black
community than the much longer, book-length fotonovela used to target Hispanics. This
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observation also is supported by research about pro-social television. Paulson (1974)
found that the short segment format of television programming is generally more effective in
promoting pro-social behaviors among African American youth than a longer format,
possibly because an individual’s attention span may be influenced by the short formats used
in most television programming.
Many AIDS prevention interventions that have not specifically used a fotonovela
have nevertheless utilized drama as an important component of outreach to youth. For
example, as part of an urban AIDS intervention program, Rotheram-Borus, Koopman,
Haignere, and Davies (1991) invited runaway minority teens at public shelters to
participate in video and art workshops. The youths developed soap opera dramatizations,
public service announcements, commercials, and raps about HTV prevention.
Similarly, in developing the “Not Me, Not Now” abstinence-based pregnancy
prevention program for youth, Monroe County, New York, interviewed minority youth
about their feelings and perceptions about sexual activity, their parents, future plans, and
dreams, then used these comments as the basis of television and radio scripts. This
strategy allowed the PSA designers to make the stories relevant and the language natural
and authentic (Doyle, 1997).
The fotonovela framework: Analyzing the plots offotonovelas can illuminate the
social meaning of the stories presented, show what the characters generally do, and
reveal prescriptive norms of proper and improper behavior and aspirations. Following
Wright’s (1975) structuralist method of textual analysis, Flora and Flora (1978) identified
two types of plots in 90 percent of 78 selected fotonovelas: “individual love rewarded”
and “mutual love rewarded.” In both these plots, “it is the state of loving, not necessarily
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a specific action, which takes control of the situation and brings about the solution to the
specific problem” (p. 140), and both plots “stress passivity, mobility-adaptation, and
individualism in support of the status quo” (p. 149). Regardless of the plot type, the
fotonovela's narrative structure
Is such that no matter what the theme, individual sources of problems and
individual solutions are stressed.... Vital plot devices must resolve the
individual crises of lovers, not the structural conditions surrounding the couple...
The survival (offotonovelas) depends upon mirroring the values that support that
type of system. (Flora & Flora, 1978, p. 141,149)
Romantic emotion is the core of the photo novel narrative. To quote Barthes
(1982), the principal characteristic of the genre is a “silliness as touching as it is
traumatizing” (p. 59). While love is the “common, persistent, inexhaustible ingredient”
of the photo novel, the booklet often features such “real-life” themes as: “true love
doesn’t run smooth, life is filled with traps, a good man is hard to find,... people make
mistakes, happiness doesn’t come easily, don’t expect too much” (p. 745, 747).
Regardless of which face of love the story presents, “virtue eventually wins, sin is
punished (or forgiven under the proper circumstances), the rewards of fidelity are
certain” (Nye, 1977, p. 747).
Similarly, in her analysis of Mexican and Colombian fotonovelas, Flora (1980)
found that 30 percent start with the characters knowing each other, but without mutual
love, and 40 percent begin with the romantic attachment established and mutual. The
remaining 30 percent open with the initial meeting of the lovers, “and these depend
almost exclusively on love at first sight, which often occurs in the first frames, without
development of either character” (p. 529).
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All humans have a basic need for storytelling, for organizing their experiences
into tales of important happenings. Genishi (1994) further asserts that
Within and through stories, we fashion our relationships with others, joining with
them, separating from them, expressing in ways subtle and not so subtle our
feelings about the people around us.... Stories are an important tool for
proclaiming ourselves as cultural beings.... We evidence cultural membership
both through our ways of crafting stories and in the very content of our tales. ...
Stories have the potential for empowering unheard voices, (pp. 2-4)
In explaining his idea of participation frameworks, Goffman (1981) posited three
possible positions a person might take in any communication exchange:
1. The principal, whose values and position on an issue are established in the text.
2. The author, who creates the content of the communication text.
3. The animator, who physically performs the communication act.
In addition, Schiffrin (1990) suggested a fourth position, the idea offigure, the
character whose image is constructed in the text. Banks (1995) argues that one person
could function in all four participation positions simultaneously.
In a fotonovela intervention, the principal could be the change agent. That person
or organization could provide the basic framework, resources, and creative leadership for
a fotonovela collaboration project, as well as the health statistics and other pieces of
factual information to be included in the narrative. Weaks (1976) warns that “confusion
among the producers about the goals of a photonovel will result in confusion among the
readers,” and he further recommends that a fotonovela's scope be limited to one clearly
defined theme because “attempts to combine two unrelated messages ... will probably
result in the dilution of both messages” (p. 7).
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In the context of an AIDS prevention intervention, the fotonovela author would be
both collaborative content creator and member of the target audience. While an author
does not play a visible role within the narrative of the fotonovela itself, as he or she is not
depicted in the dialogue or photos, the readers engage in cognitive involvement with the
narrative.
Given that the fotonovela combines elements of the comic book and motion
picture, it “creates an interpersonal experience between the reader and the image, much
as exists between the audience and the film” (Weaks, 1976, p. 1).
A variety of symbols are created by the author and embedded in both the narrative
and photos of a fotonovela story. According to symbolic interactionism theory, these
symbols obtain their meaning from interaction in a social environment, and these
meanings may differ according to time and place. Briggs and Wagner (1979) assert that
an effective story contains several key elements, including: characterization, dialogue,
colorful and descriptive language, transitions, suspense, emotional appeal, clear plot, few
digressions, and a conclusion.
An author defines the tone, language, and style of the dialogue script, as well as
the issue framing and characterization. The conceptual development of a health
promotion fotonovela thus should be grounded in the attitudes, knowledge, and beliefs of
target population members as reflected in their views, behaviors, and their dramatic
writings.
The animator, who physically performs the communication act could be assumed
to be the network of target audience members who read, discuss, and disseminate a
fotonovela to promote dialogue about a particular health issue. Weaks (1976)
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recommends that fotonovela producers construct a detailed portrait of the audience that
includes: sex, age, ethnicity, educational level, visual literacy, customs and preferences,
preconceived ideas about the subject, places where the photonovel is likely to be read,
likely methods of distribution, and the number of individuals that can be reached (p. 7).
According to Briggs and Wagner (1979) a person can benefit in many ways from
reading and telling stories. They assert that storytelling:
• Promotes high ideals: The stories can “satisfy human desires for recognition,
love, beauty, and courage ... (and) fortify persons faced by adverse
circumstances and assist them to cling to their ideals.”
• Helps reduce tensions: “A “transfer” of feeling may occur when the hero or
heroine of the story manages to solve her dilemma and thereby provide,
vicariously, a tension-relieving solution. It is comforting ... to discover that story
characters also have fears and problems for which solutions may be found. As a
result of this association, (the reader) might develop an improved self-concept.”
• Stimulates the imagination: Imagination can assist a reader in self-reflection.
William Wordsworth wrote that “Imagination, which in truth, is but another name
for absolute power and clearest insight, amplitude of mind, and reason in her
most exalted mood.”
• Entertains: “Stories can assist to produce social consciousness, group
cooperation, and laughter.”
• Assists in the learning process: “Storytelling is an excellent means of enlivening
instruction and making it both enjoyable and more meaningful. ”
• Improves communicative ability: Reading and telling stories can help individuals
“recognize worthwhile ideas, organize thoughts and feelings,... (and) become
more independent, confident, and creative.” (Briggs & Wagner, 1979, p. 10-12)
The figure, the fourth type of participation framework, is the set of characters in
the fotonovela narrative. The basic types of characters can be classified according to the
ideological basis of the narratives. Flora and Flora (1978) identified three functional
categories of Latin American literary fotonovelas:
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(1) Disintegration-integration, which “serves to break primary ties and integrate
workers and peasants into an urban lifestyle” (p. 135). These fotonovelas tend
to have highly mobile characters, reinforce traditional values and legalistic
morality, emphasize trust in fate and love, and highlight incidents central to
the lives of the protagonists (p. 142).
(2) Total-escape, which “provides a mechanism of escape from real problems”
(p. 135). These fotonovelas feature a “Cinderella” theme, in which a poor but
well-bred girl marries a handsome and older millionaire. This dream is
achieved “only when the heroine is willing to let her own happiness be
sacrificed for the sake of others” (p. 145).
(3) Consumer-oriented, which “encourages consumption of middle-class items”
(p. 135). Even though “career is a dirty word” for most of the upper-class
heroines in these fotonovelas, the stories nevertheless promote the “off-chance
that the myth of social mobility actually becomes a reality” for the readers
(p. 146). '
General media use among African Americans
Longshore (1990) contends that examining the media most likely to reach an
intended audience is a key task in the development of prevention messages. An
evaluation of mass media use patterns among African Americans could indicate how
targeted individuals might react to an ADDS prevention fotonovela and whether they
would be motivated to read it, based on their other media consumption patterns.
Small regional media outlets play a major role in developing community
cohesiveness. Playing the role of social leader, local media unite community members
by “providing them with common causes to support and by helping to create a set of
personal and public standards, values, and modes of behavior for its audience” (Tripp,
1994, p. 164).
A survey of African Americans by the National Commission on A TPS (1992)
showed that 77 percent believed the most popular source of HTV/AIDS information was
television, followed by newspapers (45 percent), magazines (40 percent), and radio (30
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percent). However, radio may be best for reaching African American adolescents
(Bowen Young African Americans are heavy users of radio and television, possibly
because many are isolated from other sources of information. African American children
also may feel isolated from the mainstream and turn to radio and television to get a
glimpse of the rest of the world (Brown, Childers, Bauman, «fe Koch, 1990). Among
black youth, 53 percent said they read at least one magazine, particularly Ebony and
Sports Illustrated, and most of the youths who read magazines were female. When
compared with whites, black youth watch television 15 hours more per week and listen to
the radio more than four hours more per week (Klein, Brown, Childers, Oliveri, Porter, &
Dykers, 1993).
Although African American youth do not read the newspaper as many times
during the week as white youth, they spend more time with the newspaper when they do
read it (Cobb began in the late 1970s have contributed to increased readership among African
Americans, particularly among young adults and teens (Stone, 1994; Windhauser Stone, 1981).
Most television and radio use studies typically conclude that African Americans
of all ages watch more television than whites and those from other ethnic groups (Perry,
1996). This may be partly due to a lack of newspaper distribution in predominantly
African American neighborhoods. Although African Americans in general read the
newspaper less often than whites (Stevenson, 1977; Stone, 1978), and those over 35 read
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more than those who are younger (Perry, 1996), readership is higher among African
Americans age 18 to 34 than among whites the same age (Stone, 1994).
Cognitive Processes
The cognitive processes domain of the theoretical model in the present study
includes four major components: learning, attitudes, motives, and beliefs. These
concepts are grounded in 11 theories in the existing behavioral psychology literature.
The two major cognitive domains of the Theory of Reasoned Action (Fishbein &
Ajzen, 1975) include intention and attitude toward the behavior. The Extended Parallel
Process Model (Witte, 1996) posits that message processing consists of cognitive
appraisal and emotional arousal. The cognitive processes within the Stages of Change
model (Prochasta & DiClemente, 1984) include contemplation and preparation.
According to the Input/Output Matrix (McGuire, 1989), the response steps that mediate
persuasion include exposure to the communication, attending, comprehending/leaming,
liking/becoming interested, decoding on basis of decision, memory storage of content,
and information search and retrieval.
The model shown on the next page, Figure 9, highlights key components of the
“cognitive processes” domain of the conceptual framework and introduces a review of
literature about these factors and about how individuals, particularly African American
youth, tend to process AIDS prevention messages.
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Cognitive Processes
Learning
Attention
Comprehension
Social learning
Sexual scripting
Motives
Beliefs
Health beliefs
Perceived risk
Attitudes
Relevance
About AIDS
Predisposing
Enabling
Factors
Factors
BEHAVIOR
CHANGE
MESSAGE
OUTCOMES
Environmental
Factors
( Normative \
V Processes J
Potential
Barriers
FIGURE 9: Cognitive Processes that Influence
Individual AIDS Preventive Behavior
Learning Processes
Reading comprehension
Given that many African American youth initiate sexual activity, alcohol or drug
use, and other risky behaviors early in life, it is imperative to seek understanding of what
messages are most appropriate at various stages of a child's development. For example,
prevention messages often require teens to process complex information, which may be
difficult for younger children at the concrete operational stage of cognitive development
(Boyer & Kegeles, 1991).
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Among people of all ages, reading is a complex physical and cognitive activity in
which a reader is attracted to symbols, sees them, and interprets them. Researchers
theorize that most readers use an interactive model that combines characteristics of both
top-down and bottom-up processing. Top-down processing holds that readers use their
schemata or prior knowledge to conceptually re-organize and create new meaning from
information presented in a text. Bottom-up processing, a lower-level reading skill, builds
understanding by identifying features of each word and relating these features to relevant
schemata (Zimmerman, 1993).
Reading at school differs from other reading tasks because students expect to be
tested or evaluated on what they have gleaned from texts. When reading on the job,
workers read only enough to learn how to do a specific task. In developing a fotonovela
targeting youth, it is assumed that their primary reading goal would be entertainment and
that these readers would not be motivated to process complex information because they
do not expect to be tested on what they have learned.
Printed materials should be written at an age-appropriate reading level because an
individual must be able to comprehend a message before he or she can attend to it. The two
types of “attentional processes” within Social Cognitive Theory (Bandura, 1994) are modeled
events and observer attributes. The ability to process information, according to the Elaboration
Likelihood Model of Persuasion (Petty & Cacioppo, 1981), depends on message
comprehensibility, issue familiarity, appropriate schema, distraction, and fear arousal. Further,
the nature of cognitive processing depends on the person’s initial attitude, the quality of the
argument, and whether favorable or unfavorable thoughts predominate. Self-presentation
motives and evaluation apprehension are the primary persuasion cues.
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In a comparison of pre- and post-test analysis of an AIDS prevention program designed
for African American youth, Darlington and Mitchell (1993) found that older youth, aged 15 to
19, did not learn as much or pay as much attention to the content as younger youth, aged 5 to 14.
Social learning
Social learning theory, developed by Bandura (1977), has been used to explain causes
of self-directed change in the individual, and how new response tendencies can be learned by
modeling an observed behavior. Studies that have applied social learning theory include
research about AIDS communication (Reardon, 1989), television violence (Tan, 1986),
safety-belt promotion (Geller, 1989), venereal disease education (Greenberg & Gantz, 1989),
cardiovascular disease prevention (Flora, Maccoby & Farquhar, 1989), and fatal aggression
(Phillips, 1986).
Social learning theory helps explain behavior that considers both environmental
forces and internal dispositions to be primary determinants of action. The social learning
process has five basic steps: (1) availability of an event to be modeled, (2) attention to the
event, (3) retention, (4) performance of the act, and (5) repetition of the act, depending on the
degree of reinforcement through external, vicarious, or self-initiated rewards (Bandura,
1994).
Individuals tend to pay attention to events that are distinctive, positive, simple,
prevalent, and useful. The degree of learning depends on such variables as attention
span, arousal level, perceptual set, and acquired preferences. The Theory of Planned
Behavior (Ajzen, 1988) asserts that perceived facilitation encompasses perceived
behavioral control and attitude toward the behavior, and these perceptions in turn lead to
intent.
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Retention involves symbolic coding, cognitive organization, symbolic rehearsal, and
enactive rehearsal. An individual's ability to learn and his or her existing cognitive structures
determine whether the event is remembered. Whether an individual engages in a behavior
depends on how accurately he or she remembers the event, observation of enactments by self
or others, and the accuracy of feedback from others or self (Bandura, 1977).
Social learning theory posits that behaviors that are rewarded will be performed,
while behaviors that are punished will remain dormant. The extent to which a behavior is
rewarded in the individual's everyday social environment largely determines whether the act
will be performed. Once social learning has taken place, the individual becomes accustomed
to the stimulus or message. Cline (1975) argues that daily exposure to any stimulus for three
consecutive weeks is likely to lead to habituation. Individual differences are also important
predictors of habituation effects (Ceniti & Malamuth, 1984).
Sexual scripting
Learning about ways that people cognitively represent sexual action sequences
can shed light on the communication barriers to practicing safer sex (Edgar, Freimuth, &
Hammond, 1988). Several scholars have identified a variety of resistance strategies from
which a person could choose. In a study of influence behavior among friends, Manusov
(1989) found examples of 28 different resistance tactics, which were grouped into four
general categories: direct, challenging, avoidance, and distributive.
McCormick (1979) argued that people use the same tactics to request sex that
they use for refusing sexual advances. These tactics include reward, coercion, logic,
information, moralizing, and relationship conceptualizing. Both males and females are
more likely to rely on direct rather than indirect techniques when resisting sexual
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advances, and a woman’s use of nonverbal or other indirect resistance messages
frequently results in misunderstanding. Abbey and Melby (1986) found that males tend
to view nonverbal cues in a more sexual manner than females. Byers (1988) and
Christopher (1988) both argue that many females are not direct enough in
communicating resistance and may need to express their desires more definitively.
Direct females typically refuse a male’s sexual advances by simply saying “no”
without explanation, saying “no” with an accompanying excuse unrelated to the
relationship (for example, “I’m expecting company”), or saying “no” with an explanation
that the couple was not close enough to engage in the behavior. Most men say they
would stop their advances if given one of these responses, and men with liberal views are
more willing to comply than males with conservative views (Byers & Wilson, 1985).
Attempts at sexual resistance are carefully planned (McCormick & Jesser, 1983),
following a script often learned from one’s own peer group (McCormick, Brannigan, &
LaPlante, 1984), typically learned by adolescence (McCormick, 1987), and usually
governed by sex role stereotypes (Peplau, Rubin, & Hill, 1977). The script allows an
individual to “define the situation, name the actors, and plot the behavior” (Gagnon &
Simon, 1973, p. 19).
These “sexual scripts” give a person information about how participants in the
“play” are expected to act the likely sequence of events, and the scripts are frequently
strong. Despite the strength of the script, however, some ambiguity inevitably remains
that requires the individual to fill in the gaps; thus, competency with sexual
communication may be the result of learning how to gear a generic script to a particular
partner and situation (McCormick, 1987). When scripts are tightly defined, changes in a
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person’s sexual compliance behavior are often more difficult (Grauerholz & Serpe,
1985).
Peplau (1977) contends that in the standard heterosexual script, males are
expected to be the initiator and to get as far as possible, while the female’s role is to set
the limits on sexual interaction while simultaneously preserving a good reputation.
Grauerholz and Serpe (1985) found that females reported feeling more
comfortable in resisting sexual intercourse and less at ease in initiating sex. Females
most commonly used persuasive strategies to avoid intercourse with an aroused date
(LaPlante, 1980), as well as to initiate intercourse (Perper & Weis, 1987).
Stereotypes about African American heterosexual behaviors include the “hot
black mamma” and the “black stud” images (Gleaton & Johnson, 1995). However, when
black and white youth are compared, blacks tend to have less stereotypical views of sex
roles (Gold & St. Ange, 1974) and more androgynous attitudes (Johnson, 1977) which
have been attributed to the sex-role socialization provided by black mothers (Harrison,
1992). In many black families, the first-born, whether boy or girl, is expected to become
a nurse-child to a younger child (Young, 1970), and a “mothering” is highly valued,
whether the person is male or female (Lewis, 1975).
Motives
Motives are an important category of cognitive factors. The AIDS Risk Reduction
Model (Catania, Kegeles, & Coates, 1990) includes a “commitment” component, while
the “motivational processes” of Social Cognitive Theory (Bandura, 1994) include
external incentives, vicarious incentives, and self-incentives. The Elaboration Likelihood
Model of Persuasion (Petty & Cacioppo, 1981) posits that an individual can be motivated
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to process information because of issue involvement, relevance commitment, dissonance
arousal, and a need for recognition.
Bandura’s (1994) social cognitive theory posits that people are knowers,
performers, and self-reactors with a capacity for self-direction. An incentive for personal
accomplishment is assumed to be the anticipated self-satisfaction gained from fulfilling
valued standards - not from the standards themselves but from the fact that others could
evaluate the behavior.
While media images of risky behavior can reinforce or establish adolescents’
perceptions of their social environment (Klein, 1993), images of risk-reducing behavior
may play a role in the development of healthy behaviors by providing behavioral scripts
or schemas for these health-related activities (Waczak, 1991).
Bandura (1986) posits that behaviors are learned from observation when they are
repeated, simple, vicariously or directly reinforced, and when the individual feels
competent in performing them. Social cognitive theory defines the cognitive and
motivational processes required for a person to adopt behaviors from observation.
Modeling, a component of Bandura's (1990) social-cognitive theory of self
efficacy, encourages a person to imitate the behavior of another respected person.
Individuals can be persuaded to engage in a modeled behavior through self-efficacy,
involvement, reasoning, fear, or illusion created by positive spin.
Bandura (1990) asserts that “to be most effective, health communications should
instill in people the belief that they have the capability to alter their health habits.”
Devine and Hirt (1989) argue that social modeling theory is appropriate for the
development of an AIDS campaign with an interpersonal emphasis. An AIDS message
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based on the modeling concept could use a spokesperson who would address a specific
audience and fit an appropriate social role while delivering a prevention message.
Social learning by watching others is not merely a process of behavioral mimicry,
but involves highly functional and skillful patterns of behavior. In abstract modeling,
observers can apply the general rule that governs the specific judgments or actions shown
by others. Once they learn the rule, they can use it to judge or generate new instances of
behavior that go beyond what they have seen or heard. People acquire standards for
categorizing and judging events, linguistic skills of communication, thinking skills on
how to gain and use knowledge, and personal standards for regulating one’s motivation
and conduct (Bandura, 1986).
An observer can learn thinking skills much more easily when models verbalize
their thoughts aloud as they engage in problem-solving activities (Meichenbaum, 1984).
Bandura identified several ways that individuals can be persuaded to engage in a modeled
behavior, including self-efficacy, involvement, reasoning, fear, and illusion (positive spin).
Adolescents tend to assume the best solution to a problem is the most self-centered
option, which raises the question of whether unselfish solutions and delayed gratification can
be modeled effectively for teens (Johnston, 1983).
Individuals are more motivated to talk to others about a health campaign when
some personal satisfaction or reward is associated with the behavior. Dichter (1966)
argues that the motivations to talk fall into four categories, each associated with various
kinds of involvement:
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• Product involvement, in which people want to talk about distinctly pleasurable or
unpleasurable things because talk serves to relive the pleasure the speaker has
obtained and dissipate the excitement aroused by using the product.
• Self-involvement, in which the speaker seeks confirmation of the wisdom of his or
her decision from peers as a way to reduce dissonance, gain attention, show
connoisseurship, to enhance feelings of being first with something, having inside
information, suggesting status, spreading the gospel, seeking confirmation of
one’s own judgment, or asserting superiority.
• Other involvement, in which the major motive is the need and intent to help
others and share with and enjoy the benefits of the product. Sharing the product
can serve to express sentiments of neighborliness, care, friendship, and love.
• Message involvement, in which the campaign’s message becomes the focus of
conversations.
Health beliefs
Among many African Americans, illness is believed to result from disharmony or
conflicts in some area of a person’s life (Cherry & Newman-Giger, 1991). Beliefs about
health vary among African Americans,
Depending on the degree of adherence to traditional ideas, geographic location,
education, scientific orientation, and socioeconomic status. Nevertheless, the
Africentric heritage has caused most African Americans to retain a holistic
philosophy of health, perceiving mind and body as inseparable and the total
person in interaction with the environment. (Lassiter, 1995, p. 8)
After conducting extensive public health studies of low-income blacks, Snow
(1983) offered many insights into their health beliefs that could be relevant to the design
of an AIDS prevention campaign. Lassiter (1995) summarized Snow’s conclusions:
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Some African Americans believe in a twofold classification for the causes of
illness, natural or unnatural, with the designation determining where the
individual will seek health care. The unnatural causes are due to forces like
“worriation” (worry), everyday stress, evil influences, or sorcery.... Some
African American clients are suspicious of too many blood tests because
blood is a substance that can be used in witchcraft.
• Some believe that the failure to worship God through prayer or church
attendance could cause a natural illness.
• Low-income African Americans use a large variety of home remedies,
traditional healing practices, and over-the-counter drugs, (p. 8-9)
In a study of health protective behaviors practiced by 407 elderly black women
living in rural North Carolina, Wilson-Ford (1992) found that prayer was the most
common method used for the treatment of illness. The researchers identified the
following behaviors among the women, listed in order of priority:
1. Eat nutritious food.
2. Pray / believe in God.
3. Use home remedies and over-the-counter drugs.
4. Sleep / rest.
5. Ignore / forget until condition becomes disabling.
6. Reduce stress.
7. Monitor weight and use of salt and sugar.
8. Avoid alcohol and smoking.
9. Contact health care system, (p. 28)
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Several theoretical models have been developed to predict an individual’s
compliance with health advice. Health beliefs are essential in any persuasion framework
for AIDS prevention messages. Perceived threat and perceived efficacy can lead to either
defensive or protection motivation, according to the Extended Parallel Process Model
(Witte, 1996), and these cognitive processes are mediated by fear. Rogers (1975)
Protection Motivation Theory suggests that the more fearful an individual feels, the more
likely he or she will perceive a health risk as severe.
The oldest of the health behavior change models is the Health Belief Model, first
developed in the early 1950s by a group of social psychologists at the U.S. Public Health
Service. The model is a risk-perception framework that explains and predicts why
individuals do or do not engage in a wide variety of health-related actions. It “grew out of
the widespread failure of people to take actions to prevent asymptomatic diseases”
(Conner, 1992, p. 4). The model asserts that perceived susceptibility, seriousness, and
threat predict an individual’s readiness to undertake a recommended compliance
behavior. These factors are mediated by concern or salience about health matters in
general, willingness to seek and accept health advice, intention to comply, and positive
health activities already a part of the person’s life.
The Health Belief Model has been used to predict individual compliance with a
variety of health behavior recommendations, including dental checkups, immunizations,
cessation of smoking, and condom use to prevent HIV infection (Catania, Kegeles &
Coates, 1990; Emmons, 1986; McKusick, Horstman & Coates, 1985). Most studies
testing Becker’s (1974) Health Belief Model have involved behaviors that are less life-
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threatening and involve less complex responses than those arising in the case of AIDS
(Montgomery, Joseph, Becker, Ostrow, Kessler, & Kirscht, 1989).
Becker’s original model includes the following belief dimensions:
• Perceived susceptibility: feelings of personal vulnerability to a condition and
one's perception of the risk of contracting a condition.
• Perceived severity: feelings about the seriousness of contracting an illness,
including evaluations of medical or clinical consequences (i.e., death,
disability, or pain) and possible social consequences (i.e., effects of the
condition on work, family life, and social relations).
• Perceived benefits: beliefs regarding the effectiveness of actions available in
reducing the disease threat.
• Perceived barriers: psychological constraints such as perceptions that a
prescribed behavior may be too expensive, dangerous, unpleasant, difficult,
inconvenient, or time-consuming.
In a meta-analysis of Health Belief Model studies, Janz and Becker (1984) found
that barriers are the most significant predictors of health behavior, followed by benefits,
susceptibility, and severity. Many other health promotion studies have supported this
conclusion. For example, in studying a breast self-examination (BSE) intervention for
nurses, Agars and McMurray (1993) found that perceived barriers at pre-test and
perceived susceptibility at follow-up were predictive of BSE practice. A reminder to
practice BSE was significantly associated with an effective BSE technique.
In 1975, Becker and Maiman reformulated the Health Belief Model by adding
two belief variables to Becker’s (1974) model:
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• Health-related motivations, including salience of health matters in general,
willingness to seek and accept medical direction, intention to comply, and
positive health activities.
• Value of illness threat reduction, including an individual's estimate of the
extent of possible interferences with social rules.
Many AIDS prevention strategies incorporate elements of the Health Belief Model,
including perceived vulnerability to AIDS, efficacy to control exposure to AIDS, and
proximal threat of AIDS. In a study of 909 homosexuals in Chicago, AIDS knowledge,
perceived susceptibility, perceived efficacy of preventive behavior, barriers to action and
perceived social norms predicted HIV-preventive practices (Emmons, Joseph, Kessler,
Wortman, Montgomery & Ostrow, 1986). However, the behavior change variance
explained by these variables was modest, ranging from 7 to 12 percent for the five
measures. Aiken, West, Woodward and Reno (1994) found that Health Belief Model
constructs accounted for 16 percent of compliance with mammography screening
recommendations among white, middle-class women 35 and older, while physician input
accounted for 25 percent of the compliance. A possible reason that the Health Belief
Model does not robustly explain AIDS preventive behavior is that it fails to account for
peer-group influence (Freimuth, 1992).
Perceived risk
Providing information and reasons for changing behavior is necessary but rarely
sufficient to cause people to change risky health behaviors. AIDS knowledge alone has been
repeatedly shown to be an insufficient precondition of behavior change. However, the
responses to knowledge questions indicated that they have received both accurate and
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inaccurate information about the transmission of HIV. Therefore, an information campaign about
AIDS transmission is needed as a precursor to effective behavior-change messages.
Attitudes
Personal relevance: Perceptions of the risk of contracting AIDS from unsafe sex
may not affect a person’s behavior unless the risk is personalized (Edgar, Friemuth, &
Hammond, 1988). The extent that people believe they are personally at risk of becoming
HIV infected is related to their risky behavior.
A related factor linked to risky behavior is optimistic bias, the belief that one’s own risk is
less than the risk faced by others, particularly others who are perceived as more vulnerable
(Weinstein, 1989). Similarly, Cline and Freeman (1988) found that college students perceive their
partners as safer if the partners are of similar socioeconomic status. Optimism is greatest for risks
with which individuals have little personal experience, and personal experience is a powerful stimulus to
action. Since personal experience is much more vivid than statistical information about risks, direct
experience with the consequences of AIDS would reduce a person's optimism about his or her
invulnerability to the disease (Weinstein, 1989).
Attitudes about AIDS among African Americans: Greenwald (1989) defines an
attitude as a human evaluative reaction about an object. Concerning attitudes about AIDS,
Overby and Kegeles (1994) found that 41 percent of predominantly black, sexually active
female teens reported having personally known someone with AIDS. About 48 percent were
very worried about getting AIDS, while 56 percent were very worried about someone they
knew getting AIDS. Nearly three-quarters estimated their chance of getting AIDS to be very
low or nonexistent, a belief caused by an attitude that the ability to choose partners carefully
is more important than the cumulative effect of past relationships.
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Three-quarters of the teens who had a regular boyfriend reported little or no worry
about acquiring AIDS from him, and the same number agreed that if “guys know you are
taking the pill, they don’t want to bother with a condom.” About a quarter felt they had little
control over whether a condom was used during the last time they had sex.
Pro-social attitudes: Because research has not been published about the attitudinal
effects offotonovelas compared with other media, research about pro-social attitudes towards
television programming may be useful in illuminating the probable effects of narrative modeling
in fotonovelas. The fotonovela is similar to television programming in that it offers an illustrated
narrative format that simulates the frame-by-frame drama of television.
Although many messages about behavioral skills are not amenable to dramatic
presentation on television, the narrative format of television programming has been shown to
promote pro-social behaviors among older children because they can comprehend more complex
messages (Johnston & Ettema, 1982). In contrast with pro-social content, the protagonists
depicted in most other television programs seldom suffer adverse consequences of their
behaviors, despite their grossly distorted experience with crime, violence, or illness (Brown
& Hendee, 1989; Strasburger, 1990).
Stein and Friedrich (1972) found that viewing pro-social television content led to
increased pro-social behavior exclusively in lower socioeconomic status children. When these
subjects were trained through role-playing to be helpful to friends, those who had viewed pro¬
social television were more helpful. Television appeared to predispose them to pro-social
behavior by providing a model or schema.
Lovelace and Huston (1983) identified three modeling strategies for conveying pro-social
messages: model only the pro-social behavior to be promoted, present models who encounter
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difficulties when exhibiting pro-social behavior, and create and resolve the difficulties
encountered by the pro-social model.
Johnston and Ettema (1982) reported that overt messages in a pro-social television
program are usually not recalled because the messages tend to "turn off' the audience. The extent
to which a behavior is rewarded in the individual's everyday social environment largely
determines whether the act will be performed. The researchers also developed a specific formula
for effectively promoting pro-social behaviors that includes standardized plot in which characters
engage in non-stereotypical behaviors, encounter difficulties in doing so, overcome difficulties by
mastering non-stereotypical behavior, and in the end are rewarded for doing so.
Seeing people react emotionally activates emotion-arousing thoughts and imagery in
observers, and these observers can acquire lasting reactions, attitudes, and behavioral
tendencies toward persons, places, or things that have been associated with vicarious
emotional experiences. They learn to like the things that gratified models, fear what
frightened them, and learn to exercise control over the things that are feared (Bandura, 1994).
Normative Processes
The Normative Processes domain of the theoretical framework in the present study
includes concepts borrowed from six different existing social psychology theories and
behavior change models. The “social influences” domain of the AIDS Risk Reduction Model
(Catania, Kegeles, & Coates, 1990) consists of social support and norms, and these factors
are assumed to affect risk behavior at every stage of the behavior change process.
The Stages of Change model (Prochasta & DiClemente, 1984) posits that social
behaviors influence an individual’s contemplation about a recommended behavior, and the
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person then will prepare to take compliant action as a result of social reinforcement of the
behavior.
The Theory of Planned Behavior (Ajzen, 1988) asserts that normative beliefs
influence subjective norms. Subjective norms, in turn, influence an individual’s intention to
comply with a recommendation, according to the Theory of Reasoned Action (Fishbein &
Ajzen, 1975). Reflexively, the extent that subjective norms influence intention depends upon
the relative importance of normative considerations. The Theory of Reasoned Action defines
normative considerations as a person’s beliefs that specific referents (individuals or groups)
think he or she should or should not perform a recommended behavior. These beliefs are
mediated by the person’s motivation to comply with the referents.
The Persuasive Health Messages Framework (Witte, 1995) further clarified this
definition by including approval/disapproval of salient referents, metaperceptions of
referents’ view of the individual’s HIV risk, and metaperceptions of referents’ beliefs about
what happens to people when they are infected with the virus. Given that a cultural custom is
a type of norm, Witte’s framework also asserts that customs related to sexual discussion are
important cues to address in a persuasive message.
The “modifying factors” that mediate cost-benefit analysis, perceived threat,
susceptibility, and severity, as posited by the Health Belief Model (Becker, 1974), include
source of advice and social pressure. Interpersonal interaction with a health advice source,
such as a doctor, also can mediate the decision-making process. Length and depth, as well as
mutuality of expectation, are dimensions of this interaction.
The model shown on the next page, Figure 10, highlights key components of the
“normative processes” domain of the conceptual framework and introduces a review of
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literature about these factors and about how individuals, particularly African American youth,
tend to respond to AIDS prevention messages in various social contexts.
INDIVIDUAL PROCESSES
Cognitive
Processes
Normative Processes
Network approach
Diffusion process
Opinion leadership
Communication networks
Norms
Behavior norms
Popular norms
Prescriptive norms
Social influence
Predisposing
Factors
MESSAGE
DESIGN &
DELIVERY
Enabling
Factors
Environmental
Factors
CULTURAL CONTEXT
Potential
Barriers
OUTCOMES
FIGURE 10: Normative Processes that Influence
Individual AIDS Preventive Behavior
The Network Approach
Marketing research has gradually moved from treating buyers and sellers as isolated
actors toward focusing upon dyadic exchange (Bagozzi, 1978).
The network approach also has been useful in constructing mass media messages
about AIDS prevention. Given that a target audience should not always be treated as an
aggregate of separate individuals, several successful campaigns have aimed health messages
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at friends and family to prevent drunken driving and hypertension among men (Rogers &
Kincaid, 1980).
Fisher and Misovich (1989) found that individuals involved in a social network in
which AIDS prevention behavior was a value consistent with the network's belief system
demonstrated more AIDS prevention behavior, greater perceived knowledge about AIDS,
greater actual knowledge about AIDS, increased belief in the efficacy of preventive
behaviors, and higher levels of intended AIDS prevention behavior.
The World Health Organization promotes an “ecologic” view of health promotion
by defining it as “a mediating strategy between people and their environments,
synthesizing personal choice and social responsibility in health” (WHO, 1986).
Diffusion strategies may be logically developed from such an ecologic
perspective, as seen in many of the best known community-based health promotion
efforts such as the North Karelia Project in Finland (Puska, 1985), the Minnesota Heart
Health Program (Carlaw, 1984), and the Stanford Three Community Study (Maccoby,
1977).
Given that these applications are macro-level and broad-based, with communities
and organizations as the primary targets for interventions rather than individuals, the
strategies emphasize linkages, mediation, and coordination among systems and
organizations (Portnoy, Anderson & Eriksen, 1989).
In a study of community linkages in East Harlem, Indyk and Belville (1995)
found that information exchanges, resource sharing, continuing education for health
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care providers, and service coordination must be established between and among community
organizations and the medical community in order to effectively prevent and treat HIV/AIDS.
The diffusion process
Diffusion of innovations theory can serve as a foundation for AIDS prevention
strategies through the development of new community norms.
Freimuth (1992) noted that the content of AIDS campaign messages in the United
States has expanded the boundaries of community acceptability. For example, public
discussions about HIV and AIDS has moved from the use of euphemisms such as "body
fluids" to more explicit language such as the words “blood,” “vaginal secretions,” and
“semen.”
Ross and Carson (1988) found that many people frequently seek the advice of
friends about the steps needed to reduce risk for AIDS. The “Not Me, Not Now”
pregnancy prevention campaign for minority youth trains teens to deliver an abstinence
message to their peers in the community (Doyle, 1997).
The design of the Mpowerment Project in San Francisco included a process in
which young gay men encourage each other about the need to practice safer sex so that
safer sex becomes the mutually accepted norm (CAPS, 1996). Peer support has been a
major predictor of risk reduction among gay men, while lack of peer support tends to
predict lack of success in recommended behavior change. Further, the beliefs that one’s
friends already have made precautionary changes and that these changes will be well
accepted predict compliance with AIDS risk reduction recommendations (Kelly, 1990;
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Kelly, 1991). Theoretical models of AIDS prevention and intervention recommentations
developed for homosexual male populations, such as the Mpowerment Project, may be
generalizable to African American adolescents’ sexual behavior (Reitman, 1996).
According to Rogers (1995), diffusion of innovations is the process of
communicating about new ideas through channels over time among the members of a
particular social system. An innovation is an idea, practice, or object perceived as new by
an individual. Rather than adopting a new idea on the basis of “obvious” benefit, users
are assumed to receive and implement the idea within an appropriate cultural context.
Thus, an idea is spread more quickly when it is compatible with the norms and values of
the social system. The more homogenous the social system, the faster the diffusion rate
and the higher the maximum penetration.
Diffusion of innovations theory is used to explain how new ideas spread from
their sources to potential receivers and thus create social change, to help close the gap
between what is known and what is effectively put to use, to determine the factors
affecting the adoption of innovations, and to predict why very few innovations actually
spread, while most are forgotten.
Bandura’s (1994) social cognitive theory posits three processes of the social
diffusion of new behavior patterns: acquisition of knowledge about innovative behaviors,
adoption of these behaviors in practice, and social networks through which they spread and
are supported. Symbolic modeling, such as the case in which behaviors are promoted by the
mass media, usually functions as the principal conveyer of innovations to widely dispersed
areas.
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Goals of diffusion research include the assessment of relative risk or perceived
risk of innovation adoption for the receivers, bringing about overt behavioral change
(adoption or rejection of new ideas), creating awareness and knowledge of a new idea
through use of mass media channels, changing attitudes toward innovations through
interpersonal channels, and shortening the time lag between the introduction of a new
idea and its widespread adoption.
Given that social change can occur at both individual and societal levels,
sociologists generally consider change at the individual level to be the result of diffusion,
adoption, modernization, acculturation, learning, or socialization. Change at the societal
level is assumed to involve such processes as development, specialization, integration,
and adaptation.
Rogers and Shoemaker (1971) define social change as “the process by which
alteration occurs in the structure and function of a social system.” Social change, they
argue, occurs when the structure or function of a social system is altered. It occurs either
when people invent a new idea that then spreads within the system, called immanent
change, or when external sources introduce a new idea, called contact change.
Depending on whether the recognition of the need for change is internal or
external, contact change can be selective or directed. Selective contact change occurs
when people are exposed to external influences and adopt or reject a new idea from that
source on the basis of their needs. Exposure is spontaneous or accidental, and the
receivers are left to choose, interpret, and adopt or reject the new idea. When social
change is directed or planned, outsiders intentionally seek to introduce new ideas in order
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to achieve goals they have defined. In response to a planned diffusion, individuals
typically are persuaded, reject the idea, or offer a customary response.
Rogers and Shoemaker propose three sequential steps of social change: invention,
a process by which new ideas are created and developed, diffusion, a process by which
new ideas are communicated to the members of a social system, and consequences, the
changes that occur within a social system as a result of the adoption or rejection of the
new idea. Triandis (1972) argues that from a social psychological perspective, social
change involves a new set of social relationships and social behaviors that is more likely
to lead to rewards.
Lippitt (1973) defines transmitted social change as evolutionary change that
occurs without deliberate guidance, whereas transformed or planned social change
occurs when individuals, groups, or organizations change themselves or others through
conscious actions or decisions. Health promotion programs are typically instances of
planned social change, designed to facilitate individual changes in health-related
attitudes and behaviors.
The function of an innovation is how the new idea contributes to a community’s
way of life, and the meaning of an innovation is the subjective perception of the
innovation by the social system members. Rogers and Shoemaker (1971) argue that the
consequences of an innovation can be dysfunctional if the direct or indirect effects are
undesirable, and can be manifest or latent, depending on whether or not the changes are
recognized and intended by the social system members.
Byrnes (1966) argues that people may resist adoption of an innovation for many
reasons: fear of the consequences of change, traditional orientations, lack of knowledge,
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lack of resources, failure to look ahead, satisfaction with existing practices, or the belief
that nothing will be gained from change. Byrnes emphasizes that a target audience must
be approached in language they understand, in terms that are relevant to their experiences
and desires, and by people they trust and respect.
Kolbe and Iverson (1981) argue that effective planned social change depends on
the desirability, perceived promise and feasibility of an innovation, its possible positive
and negative consequences, and the resources, means, constraints and other
environmental factors that affect its implementation.
Rogers (1995) proposes five key characteristics of innovations:
• Relative advantage, the unique benefits provided by an innovation and the degree
to which an innovation is perceived as better than the idea it supersedes, which
may be measured in economic terms, usefulness, payoff time, social prestige
factors, convenience, or satisfaction.
• Comparability, the degree to which an innovation is perceived as being consistent
with the existing values, past experiences, and needs of the receivers. An idea that
is incompatible with values or norms will not be adopted as rapidly as one that is
compatible. Zaltman and Duncan (1977) referred to this concept as
compatibility, and further specified that it reflects the degree to which an
innovation is congruent with the technical, psychological, sociological, and
cultural attributes of the situation in which it is to be used.
• Complexity, the degree to which an innovation is perceived as difficult to
understand and use. Zaltman and Duncan (1977) referred to this concept as
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communicability, and additionally specified that it includes the ease with which
information about an innovation can be disseminated.
• Trialability, the degree to which an innovation may be experimented with on a
limited basis or “installment plan.” This dimension also refers to the ease with
which an innovation may be discontinued and the permanent consequences of
having tried the innovation. Zaltman and Duncan (1977) refer to this concept as
divisibility.
• Observability, which is the degree to which the results of an innovation are
visible to others.
In expanding Rogers’ conceptual framework, Zaltman and Duncan (1977)
proposed five additional dimensions of an innovation that can predict its potential for
diffusion:
• Impact on social relations, including its positive influence and ability to facilitate
relations.
• Time required to introduce or implement an innovation.
• Risk and uncertainty, including both personal and institutional risk inherent to
introducing the innovation and uncertainty about its consequences.
• Commitment required to adopt and implement the innovation, usually associated
with the magnitude of the innovation’s impact.
• Capacity for successive modification, which prevents the innovation from
becoming dated. Dube (1958) pointed out that an innovation is rarely accepted in
the form in which it is presented to the community because a process of screening
occurs as it passes from one type of “teacher” to another.
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Rogers (1995) suggests a sequential, linear process: After an individual gains
knowledge about an innovation, another person who is not yet aware of the new idea
learns about the innovation from the first person through some communication channel
connecting the two individuals. After a person gains awareness about a new idea, this
exposure sparks interest in gaining further knowledge about the innovation. The person
then begins to evaluate the idea and forms a general favorable or unfavorable attitude
toward the innovation. Finally, the person initiates a small-scale trial of the innovation
which leads to its adoption or rejection.
Rogers posits five stages of adoption: knowledge, persuasion, decision,
implementation, and confirmation. The success of the last four stages depends on the
extent that individuals interact interpersonally within a network.
1. Knowledge occurs when a person or decision-making unit learns of an
innovation’s existence and gains some understanding of how it works. During
this stage, a person “mainly seeks information that reduces uncertainty about the
cause-effect relationships involved in the innovation’s capacity to solve an
individual’s problem” (Rogers, 1995, p. 21), and mass media channels can
effectively transmit this kind of information.
2. Persuasion involves the formation of favorable or unfavorable attitudes toward an
innovation. A person tends to become a decision-maker and active information
seeker through psychological involvement with the innovation and through
evaluation of possible consequences. In a survey of Swedish midwives’
awareness, attitudes, and use of selected research findings, Berggren (1996) found
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that the midwives were in the persuasion stage as indicated by their desire to use
research when the findings recommend better care for mothers and babies. As
shown by this study, an individual in the persuasion stage tends to network with
peers or near-peers to determine an innovation’s advantages and disadvantages in
his or her own situation.
3. During the decision stage, people become involved in interpersonal activities
leading them to choose between adopting or not adopting the innovation. Rogers
posits three types of decisions: a decision independent of decisions made by
others; a collective decision, made by members of a social system through
consensus; or a decision based on an authority forced upon individuals by
someone in a superordinate power position.
4. The fourth stage involves implementing, or using, the innovation. Byrnes (1966)
found five principal reasons Philippine farmers adopted new practices: seen and
proven effectiveness, novelty of the practice, ease of doing the practice,
availability of needed resources, influence of neighbors and friends, influence of
extension workers, and the compatibility of the practice with the farmers’ needs
and goals. Rogers noted that implementation often leads to re-invention of an
innovation.
5. The final stage is confirmation, in which people seek interpersonal reinforcement
of their decision to adopt or not adopt the innovation. If people are exposed to
conflicting messages, they may reverse their decision. Havlicek (1980) found
four phenomena associated with the likelihood of maintenance, or continuance of
an innovation: involvement of community members in planning, training, and
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development of materials, assistance to implementers, cooperation, and
communications about what the innovation was accomplishing.
In a survey of knowledge, awareness, and adoption of AIDS curricula among
Dutch secondary school teachers, Paulussen (1995) found that knowledge acquisition
was largely dependent on diffusion networks within schools, while transition from
awareness to adoption appeared to be mediated by perceived instrumentality, subjective
norms, perceived colleague behavior, and teachers’ sexual morality.
Opinion leadership
Rogers (1995) notes that interpersonal channels involving face-to-face exchange
are more effective than mass media channels in persuading an individual to accept a new
idea, especially if the interpersonal channel links two or more people who are
homophilous.
Rogers contends that an innovation is often initiated by a relatively small segment
of opinion leaders in the population. Others are influenced after an innovation is visibly
modeled and accepted by natural opinion leaders. People are most likely to adopt new
behaviors based on favorable evaluations of the innovation conveyed to them by similar,
respected others. Community change comes about through a process of informal
communication and modeling by peers within their interpersonal networks. DiClemente
(1993) notes that the use of peer educators as behavior-change agents is the most
underutilized ADDS prevention strategy. Peer educators have been used effectively to prevent
and reduce teens’ use of substances such as tobacco (Telch, 1990), alcohol (Perry & Grant,
1988), and marijuana (Klepp, 1986). Peer-led interventions in clinics have enhanced HTV
knowledge and decreased risk behaviors (Slap, 1991).
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Trained peer educators may be more credible, they communicate in a language more
likely to be understood, and they can serve as positive role models (DiClemente, 1993).
Further, they may be more effective at facilitating acquisition of social skills, such as sexual
negotiation or assertiveness (Hein, 1991; Stone & Perry, 1990).
Rogers (1995) posits five basic types of adopters:
1. Innovators, the first in their system to adopt a new idea. They are venturesome,
active information seekers who have a high degree of mass media exposure, can
cope with higher levels of uncertainty about an innovation than others, can
understand and apply complex technical knowledge, control substantial financial
resources to help absorb possible loss, and whose interpersonal networks extend
over a wide area, reaching outside their local system.
2. Early adopters, the respected localites or local missionaries, tend to be opinion
leaders and role models and are the individuals “to check in with” before using a
new idea. This person has higher social status, and continues to earn the esteem
of colleagues by maintaining a central position in the communication network,
making judicious innovation decisions and conveying subjective evaluations of
the innovation to peers.
3. Early majority, the person who adopts a new idea just before the average member
of the system does, tends to deliberate for some time before adopting, and who
interacts frequently with peers, but seldom holds a position of opinion leadership.
Early majority adopters make up a third of the members of a system and provide
interconnectedness in the system’s interpersonal networks.
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4. Ixite majority, another third of the members of a system who skeptically and
cautiously adopt new ideas just after the average person does, because of
increasing peer pressure. Because of their relatively scarce resources, they will
not feel safe to adopt until most uncertainty has been removed. An exception to
this pattern was discovered by Cancian (1981), who found that individuals with
low or middle socioeconomic status tend to be more innovative than high-middle
SES individuals because they stand to gain more and lose less.
5. Laggards, the last in a social system to adopt an innovation, possess almost no
opinion leadership and tend to cling to tradition. They tend to be suspicious of
innovations and change agents, and their resistance often results from a
precarious economic situation.
Rogers (1995) defines opinion leadership as “the degree to which an individual is
able to influence other individuals’ attitudes or overt behavior informally in a desired
way with relative frequency” (p. 27). Opinion leadership is not a function of formal
position or status, but is earned and maintained by a person’s technical competence,
social accessibility, and conformity to a system’s norms. The most innovative member of
a system usually is not considered an opinion leader because he or she is often perceived
as deviant and thus has lower credibility with the average members.
Katz and Lazarsfeld (1955) define opinion leadership as an “almost invisible,
certainly inconspicuous form of leadership at the person-to-person level of ordinary,
intimate, informal, everyday contact” (p. 138). Deutschmann and Danielson (1960)
contend that opinion leadership frequently involves both relay and reinforcement
functions. Rogers (1995) notes that opinion leaders can lose respect if they deviate too
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far from the existing norms of a system or if they are perceived as too much like
professional change agents. This one reason that peer educators tend to be more
effective in changing social norms than outside change agents.
Communication networks
Rogers (1995) defines a communication network as “interconnected individuals
who are linked by patterned flows of information” (p. 27). These networks of
relationships include occupational colleagues, organizational members, kinships, and
friendships, and these social clusters range from loosely knit to densely interconnected.
In coining his phrase, “intersection of social circles,” Simmel (1964) indicated that each
individual is unique in that his or her pattern of group affiliations is never exactly the
same as that of any other individual.
Fischer (1977) contends that network links represent potential influences on
individual behavior, as well as individual influence upon the larger system. These
scholars argue that
Society affects us largely through tugs on strands of our networks - shaping our
attitudes, providing opportunities, making demands on us, and so forth. And it is
by tugging at those same strands that we make our individual impacts on society -
influencing other people’s opinions, obtaining favors from “insiders,” forming
action groups, (p. viii)
Granovetter (1983) found that innovations are more extensively diffused within
cohesive groups through weak but multiple social ties. Deutschmann (1962) found that
horizontal (peer) conversation is more common than vertical conversation, and face-to-
face local messages flow more frequently within groups than between groups.
In investigating the role of friendship cliques on teen drinking behavior,
Alexander (1964) found that most of a clique’s members were either all drinkers or all
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teetotalers. In the rare case of a non-drinking member of a drinking clique, or vice versa,
the person was less connected sociometically than were the others.
Given that no single social network in a community serves all purposes, different
innovations engage different networks (Bandura, 1994). In the African American
community, for example, abstinence behaviors can be more effectively diffused within
the church and within extended family networks and neighborhoods, while condom use
practices can be diffused through other organizations within the African American
community, such as non-religious youth groups and schools.
Deutsch (1968) argues that “learning nets and societies do not grow best by
simplifying or rigidly supporting their parts or members, but rather with the complexity
and freedom of these members, so long as they succeed in maintaining or increasing
mutual communication” (p. 399). Similarly, Rogers and Kincaid (1980) argue that
communication in real-life, natural settings can be understood better “if it is not broken
up into a sequence of source-message-channel-receiver acts, but rather examined as
complete cycles of communication in which two or more participants mutually share
information with one another in order to achieve some common purpose, like mutual
understanding and/or collective action” (p. 31).
Rogers and Kincaid’s (1980) convergence model of communication, based on a
cybernetic explanation of human behavior from a systems perspective, is holistic, focuses
on links rather than individuals, and concentrates on the relationships between parts and
on interactions of a system with its environment. This model is contrasted with the
dominant psychological paradigm in communication research, which focuses on the
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individual as the unit of analysis and defines social problems in terms of individual
blame rather than system blame.
Rogers and Kincaid argue that when information is shared by two or more
individuals, information processing may lead to collective action, as the result of mutual
understanding and mutual agreement. Four combinations are possible: mutual
understanding with agreement, mutual understanding with disagreement, mutual
misunderstanding with agreement, or mutual misunderstanding with disagreement.
The Bass (1969) forecasting model of marketing posits that potential adopters of
an innovation are influenced by a combination of mass media and interpersonal word-of-
mouth channels. The two-step flow theory of communication, proposed by Lazarsfeld,
Berelson, and Gaudet (1948), was developed through a study of voter decision making in
the 1940 presidential campaign. They contended that “ideas often flow from radio and
print to the opinion leaders and from them to the less active sections of the population.”
They found that mass media had less direct influence than other people and that these
opinion leaders were identified as those who tried to convince others of their own
opinions or who were sought out by others for their opinions.
Katz (1957) emphasized that a two-step flow depends on interpersonal relations
functioning as communication networks and as sources of social pressure or support.
Greenberg (1963) noted that interpersonal channels are used in two-step diffusion
primarily for reinforcing existing opinions, rather than for creating or converting
attitudes.
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Community AIDS prevention networks
The study of communication networks can be useful in the development of
community-based AIDS prevention campaigns. Communities act as agents of the dominant
culture and as “systems of exchange and influence relationships” to “transmit values and
norms that symbolically circumscribe some behavioral choices and encourage others”
(Finnegan, Bracht & Viswanath, 1989, p. 56).
Eisenstadt and Shachar (1986) argue that community-based campaigns should be
based on the rationale that social and cultural influences are important factors in learning and
adopting behavior patterns and that these influences are experienced by individuals through
social aggregates and networks that make up communities.
When a community is mobilized to act as a change agent, it lends legitimacy to norms
for desirable behavior and makes the social and physical environment more conducive for
individuals to act upon recommendations. This mobilization is accomplished through
engaging networks of public and private organizations and special interest groups to channel
their resources - time, money, personnel, goods, and services - in coordinated activity in a
broad range of interpersonal, group, and mass communication strategies (Crosby, Kelly, &
Schaefer, 1986). Warren (1963) and Eisenstadt and Shachar (1986) proposed six key
concepts in the development of community-based campaign strategies:
• Complexity - the size and specialization of functions.
• Linkage and relationships - the interaction of formal organizations.
• Power and influence - control over resources, coordination, centralization or
dispersion.
• Dependence-autonomy and formality of various social relationships
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• Community identity
• Social integration or cohesion
Behavior norms
Rogers (1995) defines norms as
The established behavior patterns for members of a social system . . . (that) define
a range of tolerable behavior and serve as a guide or standard for the members’
behavior. . . . (and) tell an individual what behavior is expected (p. 26).
Norms can operate at the level of a nation, a religious community, an
organization, or a local system like a neighborhood. The use of norms to promote or
inhibit individual action has long been considered a powerful weapon of social control,
often as powerful as laws (Noelle-Neumann, 1974). Cialdini (1989) asserts that
individuals tend to act according to the dictates of the type of norm that is currently focal,
even when other types of norms might dictate contrary conduct.
The more compatible an innovation is with prevailing social norms and value
systems, the greater its adoptability (Rogers & Shoemaker, 1971). HIV prevention
programs that change community norms are essential for impact effectiveness (Gorman
& Mallon, 1989). Impact effectiveness is a function of the number of people impacted in
a given time period.
Youth who have bonded with societal norms and standards are less likely to
engage in risky behaviors. Those who are alienated from the dominant values and norms
of their family, school, and community tend to exhibit low religiosity, rebelliousness,
high tolerance of deviance, and a strong need for independence. Prevention efforts
targeting these youth should provide opportunities, skills, and rewards for positive social
involvement so they will have a stake in society and feel connected to it (Hawkins, 1990).
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Another strategy for reinforcing social norms to prevent harmful behavior is
inoculation, in which bolstering existing resistance attitudes among younger adolescents
renders them less vulnerable to the onset of sexual intercourse and subsequent slippage
caused by experimentation and growing tolerance toward sex (Bernstein & McAlister,
1976).
Development of an AIDS prevention strategy in the black church could consider
cultural norms, belief systems, communication style, views of personal control, existing
and potential social networks, and the role of social influence. An intervention strategy
could help members of a social network gradually redefine the norms of social decorum
until increased openness in discussing AIDS issues can be initiated on an interpersonal
level.
Macneil (1980) found significant differences in the extent to which norms predict
individual versus interpersonal or organizational behaviors. While the norms that prompt
non-relational behaviors tend to revolve around a person’s pursuit of individual goals,
relational behaviors are based on reciprocity and mutual benefits for the good of the
relationship or shared goals. Relational norms theory suggests that members of a
religious community could work together toward a mutually beneficial goal, educating
others about ADDS risk.
The Extended Behavioral Intention Model developed by Fishbein (1967) proposes
that behavioral intentions can be based on a person’s own attitude toward a behavior as
well as a subjective norm. This may be a relevant concept in developing interventions
for the black church, given that many religious teachings encourage introspection as well
as meta-perceptions about the morality of behaviors.
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To the extent that a person's value or behavior conflicts with a group-based belief,
it will be more strongly challenged through social influence. Conversely, if a value or
behavior is consistent with a central belief in a group's assumptive system, it will be
supported more vigorously than if it were consistent with a non-central belief (Nadler &
Fisher, 1988).
Popular norms
Cialdini and Petty (1981) argue that human behavior is motivated by both
prescriptive norms and popular norms. Popular norms involve perceptions of which
behaviors are typically or customarily performed.
Bandura’s social modeling theory suggests that watching someone else engage in
a behavior can focus the viewer on the issue of what other people do in a similar
situation. However, Cialdini argues that while a public service announcement might
portray an unhealthy behavior with the intent of discouraging individuals from engaging
in that unhealthy behavior, an underlying and undercutting message might inadvertently
portray the unhealthy behavior as acceptable or consistent with popular norms.
Prescriptive norms
Prescriptive norms involve perceptions of which behaviors are societally
sanctioned or customarily approved. Descriptive norms can be either popular or
prescriptive, as they motivate individuals to simply “follow the leader” by imitating the
leader’s actions.
Descriptive norms are used as an information processing shortcut in decision
making. For example, many advertisers strive to show that many customers think a
product is desirable rather than trying to convince an audience that the product is good
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(Venkatesan, 1966). In a series of nine field experiments, Cialdini (1989) found a
positive relationship between the number of pieces of litter in the environment and the
percentage of people who littered.
Social influence
Social influence has been found to be an important determinant of population risk
behaviors in studies of health promotion campaigns about smoking (HHS, 1989), family
planning (Rogers, 1973), and AIDS prevention among gay men (McKusick, 1987; Kelly,
1990).
Peer support, a function of social influence, can play an important role in
changing or maintaining a person's beliefs or attitudes. Deutsch and Gerard (1955)
define two types of social influence, normative and informational, which explain how
others can influence an individual’s opinions and behaviors. While a normative social
influence is an influence to conform with the positive expectations of others, an
informational social influence prompts individuals to accept information obtained from
others as evidence about reality (p.629).
Internal personal influence is the decision-making effect of mental processes that
involve people or groups. Bearden, Netemeyer, and Teel (1989) assert that informational
reference group effects occur when low-knowledge individuals seek information from
others they consider to be credible experts. Normative influence occurs when a person
identifies with a group to enhance his or her self-image and ego or to comply with a
group’s norms to gain rewards or avoid punishments.
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Robertson (1971) found that personal influence is more likely to operate in
situations where the decision is riskier, the idea is not easily testable, the individual is
more involved in the choice, or the financial or emotional investment is high.
Lessig and Park (1978) define reference groups as actual or imaginary
institutions, individuals or groups having significant relevance on a target individual’s
evaluations, aspirations, or behavior. Reference groups can be used as standards of
comparison for self-appraisal, those considered to be informative experts, or those used
as a source of norms, standards, and attitudes. A reference group can be a large social
grouping, such as ethnic group, social class, or subculture.
Batra, Myers and Aaker (1996) note that an individual does not have to be a
member of a reference group for the influence to occur. They note that external
influences can lead to personal decision making based on explicit social interactions,
such as a situation where two or more people are involved. A person might seek to
include friends, family, or neighbors in his or her decision-making process or otherwise
refer to the proposed idea in the course of conversations and social interactions.
Rogers (1995) asserts that mass media and other impersonal sources of influence
are typically most important during the early stages of awareness and interest, and word-
of-mouth and personal influence tend to be most important in the later stages of
evaluation, trial, and adoption.
Gatignon and Robertson (1991) found that advertising can have its greatest
influence on diffusion when the level of cognitive processing is low, whereas personal
influence will be greatest when there is a large amount of cognitive activity. Thus,
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personal influence is more important for information seeking and mass media are more
important for information giving.
Settle and Alreck (1989) contend that individuals “play out” social roles that are
either sought and acquired voluntarily or ascribed to them by society. Most people look
to reference groups, either actual or depicted in the media, to learn how to play their
roles. When people are uncertain about what to do in a social situation, they turn to
others for guidance.
Individuals differ in the extent of their susceptibility to social and group influence
(Bearden, Netemeyer, & Teel, 1989). Those who are more easily persuaded by reference
group influences tend to be more extroverted, more likely to engage in social
interactions, and more affected by the opinions of friends, neighbors, role models, and
others. Park and Lessig (1977) found that younger people are more susceptible to
reference group influence partially because they tend to have lower knowledge, lower
self-confidence in decision making, more social contacts, greater social visibility, and to
be undergoing more intense identity-seeking and socialization processes.
Batra, Myers and Aaker (1996) note that advertisers rely heavily on group
influence and often try to appeal to a consumer’s needs for group identification,
belongingness, and adherence to social and community norms. They define word-of-
mouth advertising as “a form of personal influence in which information is passed along
or diffused through a social system from one person to the next” (p. 346). Television
commercials and public service announcements that use “slice-of-life” appeals often
show a person demonstrating benefits to another, thus simulating a personal influence
process.
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Salient referents
Fishbein and Ajzen’s (1975) theory of reasoned action incorporates concepts of
beliefs about referents’ behavior, attitudes toward people and institutions, intention,
personality traits, demographic variables, subjective norms, and personal behavior. The
theory is based on the idea that the most immediate determinant of a person’s behavior is
what the person intends to do. The intention to perform or not perform a particular
behavior is a function of the person’s attitude toward the behavior and the person’s
subjective norm - the general perception of whether important others desire the
performance or nonperformance of the behavior.
The theory of reasoned action describes how a person processes social influence,
positing that a person’s attitude is a function of both the weighted evaluation of each
belief combined with the weighted strength with which each belief is held. Further, an
individual’s subjective norm is a function of the normative beliefs that the person
ascribes to particular salient others and his or her motivation to comply with these others
(O’Keefe, 1990). Although the model assumes that the individual is a rational decision
maker, it does emphasize that attitudes and beliefs are largely influenced by culture and
lead to specific actions within a cultural context.
The theory of reasoned action can be useful in explaining how people weigh costs
and benefits when making AIDS prevention decisions. Aoki (1989) argues that the
theory emphasizes changing beliefs about the "direct personal consequences of adopting
or ignoring protective behavior" and implies that community norms must be affected first
in order to integrate such behavior into the subjective standards of the community as a
whole (p.301).
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It also emphasizes that false beliefs, such as the idea that only white gay men get
AIDS, must be changed before any significant behavior change can occur. Two
important interpersonal components of the theory of reasoned action are the expectations
of significant others and the importance of conformity. Taking into account these
concepts, rooted in African American culture, would increase the applicability of the
theory of reasoned action to AIDS prevention strategies within that community.
Parental influence
In a survey of 751 never-married inner-city black youths and their mothers or
caretakers, Jaccard, Dittus, and Gordon (1996) found that adolescent perceptions of
maternal disapproval of premarital sex and satisfaction with the mother-child relationship
were significantly related to abstinence from adolescent sexual activity and to less-
frequent sexual intercourse and more consistent use of contraceptives among sexually
active youths. Teens who reported a low level of satisfaction with their mother were
more than twice as likely as those highly satisfied with their relationship to be having
sexual intercourse. Discussions about birth control were associated with an increased
likelihood that teens were sexually active.
A number of other studies also have suggested that parental attitudes toward
premarital sexual intercourse may influence the sexual activity and contraceptive
behavior of teens. Miller (1986) found that parents who exercise low levels of
supervision over the dating activities of their teens are more likely to have teens who
engage in sexual risk behavior. Moore, Peterson and Furstenberg (1986) found that
parent-teen communication about sex was related to lower levels of adolescent sexual
behavior for young women from more traditional families but not for those from less
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traditional families. Treboux and Busch-Rossnagel (1990) found that general parental
attitudes toward premarital sex were predictive of adolescent premarital sexual attitudes,
which were in turn related to adolescent sexual behavior. Scott (1993) found a
relationship between sexual activity and the quality of the mother-daughter relationship
among African Americans.
Crawford (1993) found that African American mothers who possessed more
formal education reported greater levels of parent-child communication, and those who
possessed higher levels of self-esteem indicated that they discussed sexual topics with
their children more than parents with lower self-esteem.
The Johns Hopkins University Center for Communication Programs conducted a
survey-based evaluation study of the Campaign for Our Children teen pregnancy program
in Maryland, in which it found that 75 percent of youths said the program helped them
talk with their parents about sexuality, family life, dating, and other related issues. The
national average for this kind of parent-child communication is 20 percent, according to
the Maryland Governor’s Council on Adolescent Pregnancy (CFOC, 1997). In a related
evaluation study of the “Not Me, Not Now” pregnancy prevention campaign of Monroe
County, N.Y., no significant changes were found in the likelihood that a student would
talk to their parents about a personal relationship or sex as a result of the campaign,
although 37 percent said it was somewhat likely and 20 percent said it was very likely or
extremely likely that they would engage in this kind of dialogue.
Jaccard, Dittus, and Gordon (1996) note three key advantages of having parents or
other family members educating teens about sex:
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1. It permits the presentation of information in a context consistent with parents’
values.
2. Parents can tailor the timing and content of information to the specific life
circumstances, maturity, and personality of their child.
3. Parents can be sensitive to the entire family context, such as sibling relationships
and daily stressors.
Enabling Factors
The Enabling Factors domain of the theoretical framework includes various
conditions that can facilitate compliance with an AIDS prevention message. The
definitions of these factors and their interaction with other variables in the persuasion
process are discussed within each component of the Enabling Factors literature review.
The enabling factors of the Health Belief Model (Becker, 1974) include prior
experience with the action or regimen, prior experience with the illness, and perceived
benefits. The Persuasive Health Messages Framework (Witte, 1995) additionally
suggests that family values be reinforced in an AIDS prevention message.
Diffusion of Innovations theory (Rogers, 1995) asserts that an individual is more
likely to be persuaded to adopt a new idea if the person can assess its compatibility with
his or her existing situation, its observability and trialability among others, and its
relative advantage (as compared with other alternatives).
The Theory of Planned Behavior (Ajzen, 1988) labels enabling factors as
“perceived facilitation,” and this facilitation leads to perceived behavioral control (self-
efficacy) and finally to the intention to change. Similarly, the Theory of Reasoned
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Action (Fishbein & Ajzen, 1975) asserts that an individual decides whether to comply
with health advice based on beliefs that the behavior will lead to certain outcomes.
Protection Motivation Theory (Rogers, 1975) posits that perceived response
efficacy is influenced by a fear appeal. The individual’s belief in the efficacy of his or
her ability to cope with a threat (self-efficacy) is a cognitive mediating response that can
lead to attitude change and the intent to adopt a recommended response. The Extended
Parallel Process Model (Witte, 1996) posits that self-efficacy and response efficacy leads
to protection motivation if the individual exercises danger control rather than fear
control, because danger control leads to adaptive change.
The AIDS Risk Reduction Model (Catania, Kegeles, & Coates, 1990) asserts that
the perceived benefits of making changes are a function of perceived response efficacy.
The higher the response efficacy, the greater the commitment to change. The ARRM
also posits that the acquisition of communication skills enables an individual to enact an
AIDS prevention recommendation.
McGuire’s (1989) Input/Output Matrix asserts that the response steps needed to
mediate persuasion include skill acquisition (learning how to perform the behavior) and
social reinforcement of the desired acts. Similarly, the enabling factors within the Social
Cognitive Theory framework (Bandura, 1994) include skills, knowledge, outcome
expectations, self-efficacy, and personal goals.
The enabling skills posited by the Stages of Change model (Prochasta &
DiClemente, 1984) include environmental restructuring, planning, and problem solving.
When an individual prepares to act, he or she must set proximal goals in order to adopt a
new behavior. Once individuals adopt a new behavior, they must have enough self-
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efficacy to overcome setbacks, sufficient skills to prevent relapse, and the intent to
monitor their own progress and extend their personal goals.
The model shown on the next page, Figure 11, highlights key components of the
“enabling factors” domain of the conceptual framework and introduces a review of
literature about the factors that enable individuals, particularly African American youth,
to comply with AIDS prevention recommendations.
Self-Efficacy
Behavior change campaigns can facilitate behavior change by improving individuals’
self-efficacy, or by removing perceived barriers (Bandura, 1977). Perceived self-efficacy is
an individual's judgment about how well he or she can organize and execute a specific
cognitive, social, or behavioral skill in a variety of circumstances. For example, a person
articulating a self-efficacy belief might say that “I am able to postpone sexual involvement to
prevent my getting AIDS.”
Self-efficacy can be developed through strategy training, which often is
accomplished by encouraging individuals to imitate a respected person. If a person's
perceived self-efficacy could be measured, future behavior might be predicted more
accurately (Bandura, 1977). Self-efficacy supports change in a variety of behaviors,
including the decisions to engage in sexual activity.
Preventive health practices are better promoted by heightening self-efficacy than by
elevating fear (Beck & Lund, 1981). Both the preexisting and induced level of perceived
self-efficacy influence the likelihood of the adoption and social diffusion of health practices
(Maibach, Flora & Nass, 1991).
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FIGURE 11: Factors that Enable an Individual to Comply with
AIDS Prevention Advice
In black culture, validation by peers serves to enhance self-esteem and self-efficacy.
While some studies have associated the African American child with low self-esteem,
Staples (1988) found that these children are not likely to suffer from low self-esteem because
of many supportive influences, including religion, reference groups, group identification, and
positive experiences in the extended family. Similarly, Verkuyten (1988) found that most
African American adolescents have healthy self-esteem because these youngsters tend to
focus more on the perceived judgments of family members and other significant others than
on the opinions of society.
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Manns (1992) notes several nuances of validation used by both family members and
non-relatives within the African American community:
• Positive defining, in which a significant other articulates a direct positive
definition of the individual, in order to build up the person’s sense of importance
and worth.
• Heritage reminding, in which a significant other advises the individual of his or
her racial background, to promote a sense of pride in black roots and the need to
appreciate it.
• Achievement socialization, in which a significant other establishes or mandates an
achievement atmosphere or stipulates specific goals.
• Teaching, in which a significant other instructs the individual about skills, strategies,
or philosophies. The black elderly often use a “maxim” as a teaching tool in
interactions with younger family members (Martin & Martin, 1978).
• Nurturing, in which a significant other offers emotional support and love.
Response Efficacy
Response efficacy involves beliefs about the effectiveness of a recommended
response in deterring the threat (Witte, 1996). For example, a person articulating a response
efficacy belief might say, “Postponing sexual involvement will prevent my getting AIDS.”
From the viewpoint of protection motivation theory, response efficacy is a form of
coping appraisal that is positively related to the persuasiveness of threat appeals (Kimura,
1997). Witte (1996) found that when individuals believe a health recommendation will
really work, they are likely to be motivated to control the danger posed by the health threat if
they also believe that they are susceptible to the threat and that the threat is severe. However,
even when individuals have high perceived susceptibility and high perceived severity, they
are likely to reject a health recommendation if they also have low perceived response
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efficacy. This failure to comply often is rooted in defensive avoidance or denial of the
threat, which are both forms of fear control.
Most AIDS prevention studies of response efficacy have examined psychosocial
correlates of condom use. For example, Roper (1994) found that assertions that minimize
the potential efficacy of condoms may be self-fulfilling prophecies because individuals may
use condoms less consistently if they do not believe them to be effective.
Some studies have shown a strong connection between self-efficacy and response
efficacy, while other studies have not found this link. De Wit (1994) found that individuals
who believe they are capable of putting on a condom themselves were less likely to
experience condom failure than those who found this difficult. However, Malow (1994)
found that response efficacy was not associated with self-efficacy in a survey of heterosexual,
cocaine-dependent African American men. Although the men who used condoms (62
percent of the subjects) reported significantly higher levels of self-efficacy, condom use
skills, and sexual communication with sexual partners than did those who did not use
condoms, the condom users were not more or less likely than the non-users to believe that
condoms are effective.
Danger Control
Danger control is a component of the Extended Parallel Process Model,
developed by Witte (1996). Danger control involves a cognitive process eliciting
protection motivation, and it occurs when individuals believe they can avert a significant
and relevant threat through self-protective changes (Witte, 1996). When people are
involved in danger control, they think of strategies to avert a threat, and their beliefs,
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attitudes, intentions, and/or behavior change are more likely to comply with relevant
health advice. A threat can motivate people to strengthen arguments that underpin their
resistance attitudes and thus resist subsequent pressure to engage in risky behavior
(Anderson & McGuire, 1965).
Danger control responses are the result of high perceived self-efficacy or high
perceived response efficacy, while fear control responses occur when an individual has low
perceived efficacy. Danger control thus is more likely to lead to compliance with a health
recommendation than fear control, as fear control elicits negative coping responses such as
defensive avoidance, denial, derogation of the issue or message, or perceived manipulative
intent (Witte, 1996). Fear appeals have been found to be ineffective when perceptions of
threat are high and efficacy beliefs are low (Kleinot & Rogers, 1982; Rogers & Mewbom,
1976).
Social Support
Dichter (1966) asserts that a listener must receive some satisfaction or reward
from an interaction with a speaker. Therefore, the person who recommends something
needs to be interested in the listener and his or her well-being, the speaker’s experience
with and knowledge must be convincing, and there must be mutual trust between them.
This empathy and trust are components of social support, generally defined as the
existence and availability of others on whom people can rely and who let them know that
they value and care about them (Sarason, Levine, Basham, & Sarason, 1983). Social
support facilitates psychological adjustment and well-being in general (House, Landis, &
Umberson, 1988) and leads people to feel that there are others they can turn to in times
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of need who will provide satisfactory support. Cohen and Wills (1985) assert that social
support can serve five functions:
1. Positively contribute to feelings of self-esteem and acceptance by letting
individuals know that they are valued, worthy, and accepted, regardless of their
problems or deficiencies.
2. Counteract feelings of helplessness, low self-esteem, and other destructive
thoughts and thus reduce perceived barriers and enhance perceived self-efficacy.
Albrecht and Adelman (1987) identify four kinds of supportive messages that
enhance personal control: messages that increase the desirability of achievable
goals, and those that emphasize acquisition of problem-solving and
communication skills, tangible assistance, and acceptance or assurance.
3. Serve an informational function by helping individuals interpret, comprehend,
and cope with a behavior change recommendation in functional ways.
4. Fulfill needs for social companionship and affiliation, and contribute to feelings
of “belongingness.”
5. Provide individuals with the material resources and services they need to change
their behavior.
A form of social support that is essential in the network diffusion of HTV
prevention information is advice. Goldsmith and Fitch (1997) note that advice can
provide expert opinion on how to solve a problem, another point of view in making a
decision, or assistance in laying out options. The authors identify three dilemmas of
seeking, receiving, and giving advice: advice may be seen as helpful and caring or as
butting in or criticism of the recipient’s competence; it may or may not be experienced as
honest or supportive; or, seeking or receiving advice may either make the receiver appear
less autonomous and competent or it may enact respect and gratitude while the
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recipient reserves the right to make his or her own decision. Further, advice can function
to reassure someone by making a problem appear manageable.
AIDS educators can play a role in developing and reinforcing social support and
supportive messages. Michal-Johnson and Bowen (1992) suggest that when respect,
trust, and empowerment guide their efforts, educators can help individuals gain
communication skills that will enable them to change their lifestyles without fear of
negative judgment.
Community support for AIDS prevention
At a 1987 national conference about African American health, Reed Tuckson,
commissioner of health for the District of Columbia, predicted in a speech that the AIDS
epidemic in the black community
Will give us the opportunity for a fundamental restructuring.... The threat that
AIDS represents is so severe, so serious, that it will force us to change how we
behave as a civilized, or, in this case, an uncivilized society.... We will be
forced to make changes in our sense of who we are (Quoted in Billingsley, 1992,
p. 168).
The minority adolescents who are hardest hit with HIV infection and who are hardest to
reach are minority teens who drop out of school, run away from home, engage in prostitution, or
who are homosexual. The challenge to motivate these teens to change their behaviors rests with
community-based organizations that can reach out to teens on the streets, in the housing projects,
and in juvenile detention centers (Bowen & Michal-Johnson, 1990).
Oyemade and Brandon-Monye (1990) assert that prevention programs are most
successful when their efforts target minority youth and when communities and families
provide full support for these efforts. In addressing AIDS and other problems in the
black community, Bell and Jenkins (1990) urge development of a community-level
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education and awareness campaign to “increase the black community’s awareness of the
problem and increase black ownership of it” (p. 148). They recommend that community-
based programs strive to enhance racial identity and solidarity, encourage values, a sense
of direction, and high self-esteem among black youths, and recruit more privileged blacks
to help those in greater danger.
Acquisition of AIDS prevention skills
In a review of school-based AIDS prevention programs, Kirby and DiClemente
(1993) found that effective programs have seven common characteristics:
• Use social learning theory, cognitive behavioral theory, or social influence theory
as a foundation for program development.
• Maintain a narrow focus on reducing sexual risk-taking behaviors.
• Use active learning methods of instruction.
• Include activities that address social and/or media influences and pressures to
have sex.
• Focus on and reinforce clear and appropriate values against unprotected sex
(postponing sex, avoiding unprotected intercourse, or avoiding high-risk
partners).
• Provide modeling and practice of communication or negotiation skills.
• Tailor programs to be developmental^ appropriate and culturally relevant.
Successful non-school-based AIDS interventions targeting African American
male teens (Jemmott, Jemmott, & Fong, 1992), minority runaway teens (Rotheram-
Borus, Koopman, Haignere, & Davies, 1991) and teenage girls (Slap, Plotkin, Khalid,
Michelman, & Forke, 1991) also contain many of the key components of an effective
intervention, as identified by Kirby and DiClemente. Schinke (1992), for example,
designed and tested an interactive videodisk that included culturally sensitive AIDS
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intervention vignettes for African American and Hispanic youth, as well as an
accompanying curriculum.
Doyle (1997) notes that the essential components of the “Not Me, Not Now”
pregnancy prevention program include a “kids teaching kids” approach, teaching parents
and their children communication skills for discussing personal issues and sex, and the
promotion of resistance skills that enable teens to handle peer and social pressure.
Empowerment
Much of the sociological research in the past has portrayed African Americans as
passive and powerless or as victims of white racism and slum pathologies. However,
many recent studies have contradicted these stereotypes by conveying a sense of active
involvement and by supporting the view that African Americans are an empowered
people who are engaged in struggle, living their lives with dignity, and shaping their own
futures (Goings, 1996).
Smith (1996) argues that black empowerment is the product disciplined self-
reliance and compassion for the well-being of all African Americans.
Frame and Williams (1996) argue that reconnecting African Americans to their
powerful spiritual traditions may be a crucial catalyst for personal empowerment because
African American spirituality plays an important role in shaping self-identity and in
producing social change. They posit three components of African American spirituality
unique to that culture: the prominence of the African American church, the importance of
liberation and freedom as Biblical themes, and the centrality of music including
indigenous African rhythms, Negro Spirituals, blues, soul, jazz, and rap. Moore (1991)
argues that the African-American church always has been a source of empowerment
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because it has helped forge an identity for a people removed from their homeland and
offers mutual assistance, a center for social change, and a place where shared needs and
hopes can be expressed.
Neighbors (1995) argue that the African American tradition of community-based
self-help can help individuals reject self-blame, take personal responsibility for their
health, and develop collective action. Bolstering self-esteem is a basic empowerment
method, given that persons of lower self esteem are less resistant to peer pressure, and
higher levels of self-esteem can serve to attenuate or potentiate the effectiveness of AIDS
prevention strategies (Botvin, 1982; Flay, 1985). In developing a cancer prevention
awareness program targeting black audiences, the National Cancer Institute
recommended that messages should emphasize empowerment and self-esteem in order to
be effective (OCC, 1983). Similarly, Ford (1996) used an empowerment-centered,
church-based approach to educate African American adults about asthma.
Gleaton and Johnson (1995) define empowerment as “a long term process
involving the stimulation of awareness and active participation of the concerned parties”
(p. iv). In his classic critique of the dominant philosophical paradigm of education,
Paulo Freire (1968) points to the dangers of equating teaching with telling, with assuming
that students are empty vessels, and of separating learning from action. Freire supports
the idea of an empowering process of education that emphasizes the collective action,
decision making, and full participation of learners.
Freire views education as a tool for liberation, which takes place when the
oppressed see their situation as a reality that they can affect and transform. He uses a
“banking” metaphor to describe the traditional process of a teacher “depositing”
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knowledge into passive students, which leads to dependence and a fragmented view of
reality. By contrast, Freire’s “problem posing” approach breaks down the teacher-student
dichotomy to establish a situation of equality, dialogue, mutual communication, and
praxis, the process of action-reflection-action.
Freire’s co-intentional approach called upon educators to promote commitment to
change by identifying the levels of individual awareness within a target community:
• Magic awareness, in which people are fatalistic because they believe events and
forces shaping their lives are myth or magic-related.
• Naive awareness, in which individuals have limited knowledge about what shapes
their lives but strive to adapt to the system that controls those conditions.
• Critical awareness, in which people examine and question the causes of their
problems, observe and reason about them, and attempt to change the system that
is creating or reinforcing them.
Freire argues that a “culture circle,” a group of learners whose facilitator
structures the discussion, can promote critical awareness and reflection about their own
reality and the constraints put on their lives. In their studies of health promotion
strategies for African Americans and other minorities, Braithwaite and Lythcott (1989)
note that Freire’s approach shifts the locus of control from experts to participants.
Given that individuals can be easily confused by large volumes of material
offered in a multimedia AIDS campaign (Hastings, Eadie & Scott, 1990), and that the
term “AIDS prevention” implies the unrealistic goal of no new HIV infections, the
principle of harm reduction may offer a more practical and empowering approach to
AIDS education (CAPS, 1993).
Also known as “secondary prevention” or “risk minimization,” harm reduction
philosophically dovetails with the problem-posing education approach by recognizing
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that individuals are the experts about their own behavior, and their ability to function
with their behavior must be defined by them. It requires that options be presented in a
holistic, non-judgmental, non-coercive way, respectful of individuals’ competence to
make choices and changes in their lives. The primary goal is to educate individuals to
become more conscious of their risky behavior, increase their self-esteem and self-
efficacy, and then provide them with tools and resources with which they can reduce
their risk (CAPS, 1993).
Reinforcement of religious values
Many studies have shown a link between religiosity and health behavior. While
some have shown religiosity to be an intervening barrier to compliance (i.e.,
homophobia) and a direct predictor of noncompliance (i.e., refusal to use condoms or
discuss safer sex), others have shown it to be related to good health, self-care, and well¬
being.
Among both African American men and women who are 18 and older,
organizational religiosity is strongly correlated with life satisfaction and well-being, even
when controlling for various socio-demographic variables (Levin, Taylor, & Chatters,
1995). McIntosh and Danigelis (1995) found that formal religious participation
decreases negative affect among older black women. When the black church helps
protect individuals from the negative effects of various problematic circumstances, this
spiritual, emotional, and material support in turn can lower their risk of hypertension and
many other health problems (Dressier, 1996).
In studying family planning needs among inner-city homeless women, Shuler
(1994) found that 92 percent of the women reported one or more religious practices, such
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as praying, attending worship services, or reading religious materials. Nearly half of the
women who prayed also used less alcohol and/or street drugs, had fewer perceived
worries, and fewer depressive symptoms. Similarly, frequency of church attendance
among black men reduces the frequency of smoking and daily drinking (Brown & Gary,
1994). Among minority women, religiosity is a predictor of compliance with the
recommendation to use mammography screening (Miller & Champion, 1993).
Religious commitment among adolescents tends to diminish the propensity to
engage in sexual intercourse and delay the age for onset of sexual intercourse (Nicholas
& Durrheim, 1995; Dunne, 1994). Similarly, Caetano and Hines (1995) found that
African American men who are more religious are less likely to engage in unsafe sex.
Numerous churches have implemented health programs (Boario, 1993), many
which are African American (Tuggle, 1995) and many which view health as a holistic
interplay of body, mind, and spirit (Miskelly, 1995). Nurse ministries, for example,
promote the Gospel through health education, health counseling, patient advocacy,
referrals, support groups, and volunteer training (Salewski, 1993; Adams, 1993;
Newsome, 1994).
Participation in church activities also can expose individuals directly to health
advice, information, and resources. African American churches have served as effective
settings for the national “Healthy People 2000” initiative that encourages people to
consume five or more servings of fruits and vegetables every day (Havas, Heimendinger,
Damron, Nicklas, Cowan, Beresford, Sorensen, Buller, Bishop, & Baranowski, 1995).
Similarly, in an inner-city, church-based cervical cancer control program for black and
Hispanic women, 96 percent of the targeted women in 24 congregations participated in
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the education and screening program. The program was based on a social influence
model of training of lay health leaders to serve as messengers, recruiters, and organizers
(Davis, Bustamante, Brown, Wolde-Tsadik, Savage, Cheng, & Howland, 1994).
In implementing a church-based smoking cessation program for inner-city
African Americans, Stillman (1993) built trust by recruiting ministers and lay volunteers
to mediate culturally specific interventions and conduct health screenings. African
American men who participated in a prostate cancer screening program demonstrated
significant improvements in knowledge and self-efficacy after completing a church-based
intervention conducted by trained lay educators who previously had been treated for the
disease (Boehm, 1995).
The church can provide needed support for those attempting to reduce their risk
of getting AIDS. Although AIDS interventions in the black church must be sensitively
and carefully crafted, the church can assist in creating a community-level atmosphere
that supports AIDS prevention norms and reinforces school-based prevention messages
(Coates, 1990; Kelly & Murphy, 1992).
Some black ministers have begun to address AIDS more directly and prominently,
preaching messages of compassion and charity toward those who are ill (Goldman,
1989). Despite a theological emphasis upon abstinence in most churches, some facets of
African ancestry may offer inroads to a more open discussion of sexuality in a spiritual
context that may include safer sex advice, depending upon the theological conservativism
of the church. The quest for African American liberation, Goboldte (1995) argues,
focuses on Affocentrism, “the reclamation of African-centered cultural perspectives and
ethos” (p. 242). Walker-Alexander, an African American writer, commented that
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There is an earthiness to our spirituality and sexuality that comes from our
African ancestry.... that we expressed in uninhibited movement in dance and
song. . . . Sexuality is a strong force in creativity. It works with my spirituality,
not apart from it (Quoted in Buckner, 1995, p. 226-227).
The disintegration of community networks often leads to “community meltdown”
- increasing crime, intensifying drug abuse, and indiscriminate and frequent sexual
activity, particularly among youth. The black church also can assist in “community
recrystallization” efforts, which are needed to facilitate AIDS education efforts (Wallace,
1993). Franklin and Norton’s (1987) strategic framework for community-based problem
solving implies that black churches could take the lead in defining new and continuing
problems related to the local AIDS situation, in communicating the urgency of those
problems to congregations and to the community, and in prescribing and initiating
solutions.
Black churches that engage in community outreach differ in several respects from
those that do not (Billingsley, 1992). Churches that are more likely to sponsor outreach
programs include those which have larger memberships, been established in the
community longer, higher numbers of paid clergy and other staff, higher level of
education of the senior minister, ownership of facilities, facilities which are made
available for non-religious activities, a senior minister who perceives the role of his
church to be serving both members and community, and a senior minister who is active
in community activities. Regression analysis shows that the black churches most likely
to initiate community health outreach programs are those which have larger
congregations and which have a more highly educated minister (Thomas, 1994).
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Within its existing value structure, the black church can provide support groups
for people living with AIDS who are non-white and non-gay. Some black churches have
spent years developing AIDS ministries because the disease has affected members of
their congregations (McGhee, 1992). Weitz (1989) notes that HIV positive, heterosexual
African American women are far less likely to have networks of fellow sufferers to
whom they can turn for advice and information.
The church can provide needed support for those who are directly affected by
HTV, including caretakers, orphaned children, and the ill. The congregation can provide
tangible and emotional resources for people living with AIDS that other institutions
within the community cannot, and it can help people living with AIDS improve their
health by providing social support, an environment for prayer and worship, and the
inspiration to believe in miracles. Carson (1993) found positive relationships between
hardiness of long-term survivors of AIDS and their perceptions of spiritual health and
participation in prayer and meditation. Hall (1994) found that people coping with end-
stage AIDS maintain hope through involvement in work or vocations, support of family
and friends, miracles, and religion.
Potential Barriers
The Potential Barriers domain of the theoretical framework includes factors that
can inhibit an individual from adopting a behavior recommended by an AIDS prevention
message. The barriers dimension of the AIDS Risk Reduction Model (Catania, Kegeles,
& Coates, 1990) includes aversive emotions (i.e., persistent anxiety about being at risk),
and aversive emotions are assumed to come into play at the labeling, commitment, and
enactment stages of behavioral change. The Extended Parallel Process Model (Witte,
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1996) identifies fear and defensive motivation as maladaptive changes in the fear control
process.
Diffusion of Innovations theory (Rogers, 1995) identifies perceived complexity as a
key factor that can inhibit adoption of a new idea. The perceived barriers domain of the
Health Belief Model (Becker, 1974) is part of the cost-benefit analysis assumed to
characterize the health behavior change process. The likelihood that a person will comply
with a particular health advice message is thus determined by a rational equation: perceived
benefits minus perceived barriers.
Barriers to compliance within the Theory of Reasoned Action (Fishbein & Ajzen,
1975) include lack of intention to perform the behavior, negative attitudes toward institutions
and toward the behavior itself, lack of motivation to comply with specific referents who think
the individual should perform the behavior, and conversely, the belief that specific referents
think the individual should not perform the behavior. The Persuasive Health Messages
Framework (Witte, 1995) asserts that barriers to self-efficacy include beliefs that the
behavior
• Is performed infrequently by others (especially among those with the same
demographic profile).
• Is associated with immorality or disease.
• Is inconvenient.
• Reduces pleasure, virility, or desirability.
• May be seen as an admission that one is at risk of contracting HIV.
• Is not needed because the individual perceives him/herself to have low
susceptibility to the risk.
• Is forbidden or otherwise discouraged by the church or other referent groups.
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The model shown below, Figure 12, highlights key components of the “potential
barriers” domain of die conceptual framework and introduces a review of literature about
factors that can discourage or otherwise hinder an individual from complying with an AIDS
prevention recommendation.
Lack of Self-Efficacy
Individuals’ perceptions of barriers are strong predictors of their resistance to
adopting safer sexual practices (Aspinwall, 1991). Perceived barriers diat inhibit various
kinds of recommended behavior changes include costs (Price, Colvin & Smith, 1993),
forgetfulness, unpleasantness, inconvenience, perceptions about one’s inability to control
sexual drives (Zimmerman, 1994), complexity, danger, duration, and potential negative
impact of prescribed behavior on the lives of close others (Becker, 1974).
Individual processes
FIGURE 12: Barriers to Individual Compliance with AIDS Prevention Advice
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Grunig’s (1983) situational theory posits that people who have heightened
perceptions of barriers also are likely to seek less information and exhibit more defensive
responses to challenging information than those with lower perceptions of barriers.
However, Rimal and Flora (1996) found that enhancing self-efficacy does not always
lower perceived barriers, as is generally assumed, because the acquisition of coping skills
does not necessarily result in accomplishments.
The possibility of loss tends to loom cognitively larger than the potential for gain
in the minds of most individuals (Tversky & Kahneman, 1974). The decision to enact a
health behavior is much more susceptible to influences of losses than the decision to
enact other kinds of behaviors (Rimal & Flora, 1996).
The most important barriers to achieving the desired cognitive, behavioral, and
psychological outcomes in AIDS prevention among African Americans are failures to
address the concerns that they perceive to be most serious, their lack of risk reduction
skills, lack of resources, and lack of self-esteem and perceived control (Wofsy, 1987).
Other barriers may include poverty, low literacy, and lack of access to health care. For
example, the Blacks Educating Blacks About Sexual Health Issues program identified
critical need youths as those who live below the poverty level, function below the normal
academic grade level, have inadequate health insurance, and lack health care services
(USCM, 1990).
Dalton (1989) contends that the attitudinal barriers to AIDS education among
African Americans are rooted in five causes:
1. A societal sense of blaming African Americans for bringing the disease to
America.
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2. Deep-seated suspicion and mistrust of any whites who express a sudden interest
in them.
3. Homophobia, which can promote denial of homosexuality and bisexuality.
4. The phenomenon of drug abuse in the black community.
5. Tremendous resentment at being dictated to.
Black genocide theory
Stevenson and White (1994) found that a major barrier to effective AIDS outreach in
minority communities is a distrust of majority culture institutions. Dalton (1989) noted that
many African-Americans view the AIDS epidemic as genocide aimed at blacks. Many
African Americans view the government’s promotion of condom use as a way of limiting
the growth of the black community (Spector, 1991).
Another black genocide belief is the conspiracy theory that HIV is a manmade
weapon of racial warfare. This belief is rooted in distrust and suspicions surrounding the
Tuskegee study of untreated syphilis in black males conducted 1932-1972 (Thomas &
Quinn, 1991). During the 1970s, many blacks called the use of contraceptives a form of
ethnic genocide promulgated by whites because they viewed the ability to reproduce as a
powerful tool in the fight for liberation (Mays & Cochran, 1988). A New York Times/CBS
telephone poll conducted in 1990 found that 10 percent of black respondents said that the
AIDS virus was deliberately created in a laboratory to infect black people, and another 19
percent felt that the theory might possibly be true (DeParle, 1990).
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Stevenson (1994) asserts that black genocide theory is rooted in the African
American community's distrust of science. In a survey by Herek and Glunt (1993), 67
percent of African Americans, compared with 34 percent of whites, agreed that the U.S.
government is not telling the whole story about AIDS. This distrust is based on two primary
factors: that historically, mainstream societal institutions have systematically attacked the
sexuality of African Americans for purposes of subjugation and control, and that assumptions of
inferiority underlie “helping strategies” for African Americans (Stevenson, 1994).
Jemmott and Jones (1993) argue that the “legacy of racism” in the black community can
cause African American individuals to distrust researchers
Who seek to recruit them for studies and government officials and health authorities who
provide AIDS-related information and recommendations.... Ethnic minority individuals
may believe that they are being used as guinea pigs in experiments to try out procedures
that would not be tried on whites (p. 216).
In a survey of participants in the 1990 Southern Christian Leadership Conference,
Rosin (1995) found that more than one-third agreed that AIDS is a form of genocide
against blacks, while more than a third believed that HTV was produced in a germ-
warfare lab. Rosin observed that “suspicion and mistrust of mainstream medical
institutions make it difficult to mount a communal response” to the AIDS epidemic in the
black community (p. 21).
The “test tube” theory advocates the notion that the U.S. government developed
HTV in a laboratory as a germ warfare weapon against foreign countries. AIDS was
assumed to be the result of these errant U.S. germ warfare experiments. The theory
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first emerged in 1986 in the Soviet press. AIDS experts have dismissed this notion, and
Washington has accused the Soviets of waging a “disinformation campaign” (Time.
1986).
The theory also hinges on the June 9, 1969, Congressional Record, which
reported that Dr. D. M. McArtor, then Deputy Director of Research and Technology for
the Department of Defense, appeared before the House Subcommittee on Appropriations
to request funding for a project to produce a synthetic biological agent for which humans
have not yet acquired a natural immunity. McArtor asked for $10 million dollars to
produce the agent over the next five to ten years. According to the plan for the
development of this germ agent, the most important characteristic of the new disease
would be “that it might be refractory [resistant] to the immunological and therapeutic
processes upon which we depend to maintain our relative freedom from infectious
disease.” AIDS first appeared in the U.S. as a public health risk 10 years later.
Another “test tube” theory is a popularization of the “stealth virus” theory, which
suggests that polio vaccines during the 1950s and 1960s were contaminated with a HTV-
like virus that can reside within the body without being detected by the immune system.
A partial sequence of this “stealth” virus is similar to the simian cytomegalovirus
(SCMV), which has been found in the African Green monkey. African Green monkey
kidney cells are used in the production of live oral polio vaccine. Some researchers
believe that the “stealth” virus mutated into HIV (NIP, 1998).
While the “stealth virus” theory has not been confirmed through laboratory tests,
the CDC did detect another monkey virus, Simian virus 40 (SV 40), in lots of injectable
polio vaccines used prior to 1961. SV 40 has no relationship to HIV or simian
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immunodeficiency virus (SIV, the virus that causes AIDS in monkeys), but the virus has
caused cancer in laboratory animals. Since 1961, polio vaccine manufacturers have been
required by the Food and Drug Administration to test for SV 40, even though studies in
the U.S. and Sweden have shown no increased rates of cancer among humans who would
have received polio vaccine between 1954 and 1962 (NIP, 1998).
Other theories about the origin of AIDS suggest that the disease made its initial
lethal intrusion into the human population in Africa through contact with monkeys. The
“green monkey” theory is well known because many geneticists have found wild African
green monkeys to be naturally infected with SIV, a retrovirus related to HIV (Fukasawa,
Miura, Hasegawa, Morikawa, Tsujimoto, Miki, Kitamura & Hayami, 1988). In some
monkey species, SIV can induce an AIDS-like syndrome characterized by the early
presence of viruses in the blood, frequent decrease in blood platelets, severe depletion of
lymph tissues, opportunistic infections, and brain inflammation. It has caused death in
70 percent of monkeys within a year after infection (Hirsch, Dapolito, Johnson, Elkins,
London, Montali, Goldstein, & Brown, 1995). Some scientists have speculated that
humans could have become infected initially through monkey bites, eating tainted meat,
or bestiality. The virus then may have been passed on to other humans via sexual contact
and possibly by rituals involving tattooing or scarring of the skin.
AIDS services to African Americans likely will be unsuccessful if this distrust goes
unrecognized. In addition, Thomas and Quinn (1991) contend that trust in public health
authorities must be rebuilt through an open, scientifically sound, culturally sensitive discussion
of genocide and the Tuskegee study. Mays and Cochran (1988) caution that white change agents
tend to misinterpret resistance to AIDS prevention efforts among African Americans when
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cultural differences influence the way targeted individuals articulate why those efforts are
inappropriate.
Denial
Individuals tend to engage in denial or dismiss information when they are
exposed to high fear appeals (Mays & Cochran, 1988). McGhee (1992) notes that black
churches throughout the U.S. have mirrored the denial mentality among much of the
collective black community by not dealing directly with the AIDS issue. Participants in
church services and activities often see HIV as less significant, or as a less easily
acknowledged problem, than unemployment, crime, drugs, homelessness, poor health
care, and other urgent issues affecting community survival (Goldman, 1990). The lack of
acknowledgment that many adolescents are sexually active is a primary social barrier to
developing explicit, aggressive, and innovative AIDS prevention programs targeting
youth (DiClemente, 1993).
Fatalism
A major barrier to perceived susceptibility is fatalism, the belief that people get AIDS
only if they are predestined to contract the disease, and vice versa. Sources of fatalism
include cultural myths, misinformation, apathy, depression, and emotional distress. When
prevention information is presented in an overly fear-arousing manner, it increases the
likelihood that individuals will adopt a fatalistic attitude (Mays & Cochran, 1988).
African Americans tend to become fatalistic when they depend solely on their black
peer group for individual definition and fail to develop a separate self-image. This is because
they tend to perceive their fate as inextricably linked to that of the group and internalize all
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images, characteristics, and treatments of the group as statements about their individual
nature (Jackson, McCullough & Gurin, 1992).
In her study of cancer information, Freimuth (1990) found fatalism to be a major
health-related cultural belief among African Americans. To counteract fatalism, an AIDS
prevention message must emphasize that people from all walks of life are vulnerable to
AIDS and offer concrete steps that individuals can take on their own behalf, embedded in the
self-efficacy message that they have the power to take personal control in preventing
transmission of the disease.
Lack of Cultural Relevance
Much AIDS prevention advice given to African Americans through government-
sponsored, culture-free PSAs and brochures is not presented in culturally relevant language and
does not account for the everyday situations they routinely encounter.
For example, they are asked to “negotiate” safer sex contracts in relationship situations
by “talking with their prospective partners.” This language makes advice sound complicated,
and the wording itself may be difficult to comprehend for lower literacy audience members. In
addition, the advice does not account for the fact that many African Americans may not bother to
ask about previous sexual or drug use behaviors because they know their partners will lie or
discount the risk. African American women are advised to have one lifelong sexual partner,
even if they live in a community where men are scarce, relationship instability is the norm, and
65 percent of black women older than age 15 are not currently married (Mays & Cochran, 1988).
The advice of many mass audience public service announcements is based on the
assumption that relationships are based on power equality and honesty. However, Mays and
Cochran (1988) note that in many relationships each person is expected to keep past sexual
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behaviors a secret until the relationship has been well established. Further, disclosure may be an
unaffordable luxury for those who do not have the money or other resources to guide their
choices.
For African Americans, individualistic action appeals may not be as effective in
motivating behavior change as messages built on a model of social responsibility that emphasize
ethnically based values of unity, cooperation, and faith in a vision (Mays & Cochran, 1988).
These values are emphasized through the African American holiday traditions of Kwanzaa.
Specifically, the holiday celebrates core values of unity, collective work and responsibility,
ethnic self-determination, cooperative economics, purpose, creativity, and faith.
Myths and Misinformation
Cultural barriers between African Americans and AIDS educators can reduce the
exchange of information and the educators’ ability to communicate the importance of
preventive measures and the availability of services (Florida Health Net, 1997).
Ignorance of AIDS, a major barrier to self-efficacy among African Americans (Leigh,
1995), includes myths and misperceptions regarding the transmission and origin of the
disease (Stevenson & White, 1994).
A challenge in confronting the AIDS problem in the black church is the
underlying public association of homosexuality with the disease, which Grossman (1991)
calls a “double stigma.” Mills (1992) notes that the predominant meaning assigned to
AIDS is a profound fear and dread of homosexuality. Gleaton and Johnson (1995)
comment that some black ministers urge gays to marry and have children as a way to “get
over” their homosexual feelings.
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DiClemente, Boyer, and Morales (1988) reported that African Americans and
Latinos were more likely than whites to report that "All gay men have AIDS." Some
black men believe they are not at risk for getting HIV as long as they do not engage in
sex with a white gay male (Peterson & Marin, 1988). Schiller, Crystal, and Lewellen
(1994) note that people with AIDS generally are portrayed in the media as either white
gay men or street people abandoned by family and friends. This construction of HIV has
led to distancing and denial of personal risk by people who don’t relate to these “social
deviants.”
Taboos
A primary challenge in developing an AIDS prevention strategy is attempting to
frame taboo topics such as illness, death, sexuality, and homosexuality. Sex in nearly all
human societies is surrounded by taboos. Few people can discuss such a sensitive issue
without making or implying moral judgments or feeling that others are making moral
judgments about them. Further, when people from one ethnic group discuss AIDS and
sexual behaviors within another ethnic group, it often arouses suspicions of racial
prejudice (Gleaton & Johnson, 1995).
AIDS represents a dilemma for black churches that take a conservative view of
moral issues such as homosexuality, promiscuity and drug use. Dalton (1989) argues that
the African-American church, being fundamentalist and conservative, has stood in the
way of ADDS education. African American fundamentalist religiosity often promotes
attitudes of sexism, homophobia, proselytism, and intolerance for or erasure of individual
difference (Perkins, 1995).
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General AIDS prevention messages in black churches are often phrased in moralistic
terms, condemning homosexual behavior, sex outside marriage, and drug use. Such messages
sometimes conflict with existing, well-established behaviors. Moreover, because the majority of
churchgoers are women, men often are isolated from these types of prevention messages
(Goldman, 1990).
Rubin (1994) found that black churches are not adequately addressing many
prominent issues facing African American adolescents. The needs and perspectives of
youth and other at-risk individuals often go unheard within the African American
religious community because of the stigma surrounding their behaviors. The culture in
which risky behaviors are normalized must be changed before behavior change can occur
(CAPS, 1993). Because sex outside of marriage, including homosexuality, fornication,
adultery, and prostitution, is considered a sin, individuals who engage in these behaviors
cannot be normalized until churches can accept, protect and incorporate them and create
safe places where they can come for help.
Johnson (1987) found that factors leading to an attitude of intolerance of AIDS
victims included: lower levels of education, low self-esteem, political conservatism,
religious fundamentalism, and the belief that America has not appreciated the
contributions of Christian fundamentalists. Ambrosio and Sheehan (1991) found that
intolerance of people living with AIDS is linked to a “just world belief’ in which people
are blamed for their own misfortune.
St. Lawrence (1990) found that many college students hold highly stigmatizing,
prejudiced attitudes towards AIDS patients, particularly when a patient is perceived as
homosexual. Similarly, Pryor (1989) found that a symbolic connection between
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homosexuality and a disease victim may result in rejection of the victim. Although
beliefs about contagion are unrelated to a desire to avoid an AIDS-infected person,
attitudes toward homosexuality are significantly related to this avoidance behavior.
Bishop (1991) argues that individuals who have a disease associated with homosexuals
are perceived as being more responsible for their illness.
Outcomes
The Outcomes domain of the theoretical framework includes the various
individual consequences of exposure to a behavior change message. “Outcomes” have
different labels within different existing theories. Many refer to outcomes as “behavior”
(Social Cognitive Theory, Theory of Reasoned Action, and Theory of Planned Behavior),
while others refer to outcomes as “enactment” (i.e., AIDS Risk Reduction Model) or
compliance (Health Belief Model). Gerbner’s (1956) General Model of Communication
highlights outcomes in the statement: “Someone - reacts - conveying content - of some
consequence.” Similarly, Diffusion of Innovation theory (Rogers, 1995) identifies
decision, adoption, rejection, implementation, and confirmation as possible outcomes.
The Stages of Change model (Prochasta & DiClemente, 1984) identifies four
types of outcomes expectations: physical risk behaviors, alternative behaviors (physical,
social, or self-evaluative), social reinforcement of a new behavior, and self-evaluative
reinforcement of the new behavior. According to the Input/Output Matrix (McGuire,
1989), the response steps that mediate persuasion include behaving in accord with a
decision, post-behavioral consolidating, and yielding (attitude change).
The Transformation Model of Communication (Kreps, 1994) lists three types of
outcomes: cognitive, behavioral, and physiological. Cognitive outcomes include
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understanding/knowledge, commitment to health, adjustment of health beliefs,
confidence, satisfaction, trust, diagnostic information, self-efficacy, managed
expectations, and fears/anxieties. Behavioral outcomes can include compliance with the
recommendation, adoption of preventive/health promoting behavior, assertiveness,
communication competence, motivation, and relational quality between source and
receiver. Physiological outcomes can include disease prevention, long-term survival,
quality of life, and maintenance of desired health.
The cognitive structure change process described by the Elaboration Likelihood
Model of Persuasion (Petty & Cacioppo, 1981) posits that when cognitions are adopted,
stored in memory, and made salient, they either lead to enduring positive attitude change
(persuasion) or to enduring negative attitude change (boomerang effect). Similarly, the
Extended Parallel Process Model (Witte, 1996) identifies adaptive vs. maladaptive
changes.
The model shown below, Figure 13, highlights key components of the
“outcomes” domain of the conceptual framework. The following section discusses the
types of attitudinal and behavioral outcomes that can result from an individual’s response
to an AIDS prevention message.
Predictors of Behavioral Outcomes
Unlike product marketing campaigns, health campaigns aim to change
fundamental behaviors rather than mobilize an existing predisposition (i.e., switching
brands). While product advertisers are typically satisfied with small shifts in market
share, health campaigns aim to change a large proportion of the population and do so by
targeting specific, well-defined sub-groups (Flay & Burton, 1990).
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INDIVIDUAL PROCESSES
CULTURAL CONTEXT
FIGURE 13: Responses to AIDS Prevention Advice
A major role of behavioral theory is the prediction of outcomes. Predictive theories
generally state that “if * occurs, theny is more or less likely to occur” (Maibach & Parrott,
1995, p. 1). A person’s intention to perform a given behavior is the best single predictor of
whether or not the person will perform the behavior (Fishbein, 1980). However, predictions
of behavior often can be improved by measuring intentions with respect to all of a person’s
alternative courses of action, particularly when attempting to predict habitual behaviors such
as sexual activity, drug use, or drinking (Petty & Cacioppo, 1981).
Bandura (1986) posits that outcome expectations can take the form of physical
effects (outcomes that could increase or decrease health or the pleasures of living), social
effects (incurring approval or disapproval of others), or self-evaluative effects (incurring
approval or disapproval of self). People develop their outcome expectations “through
some combination of direct experience, observational learning, and persuasive
communication” (Maibach & Cotton, 1995, p. 50). Jemmott and Jones (1993) identified
four types of outcome expectancies that are of particular interest to those designing AIDS
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prevention campaigns targeting African American youth: altered risk of harm, hedonistic
costs or benefits (effects on sexual pleasure and/or fun), social sanction, and social
approbation.
In predicting college students’ intentions to engage in premarital sex, Fishbein
(1966) found that for females, the attitude component (their own view of the
consequences) was more important in determining intentions than the subjective norm
(others’ views), but for males, the subjective norm component was more important than
attitude.
The stronger a person’s judgments of self-efficacy and response efficacy for a
particular behavior, the more likely he or she is to have positive outcome expectations.
Even if individuals believe a behavior will lead to desirable outcomes, they are not likely
to be motivated to attempt it if they have no confidence that they can perform the
required behavior (Bandura, 1986).
Personal goals are major sources of motivation because they “provide both a
direction and reference point against which people can compare their progress” (Maibach
& Cotton, 1995, p. 50). When a behavior is enacted or maintained at a level that meets
the goal, a person tends to be satisfied and have positive self-appraisals; conversely,
when a person fails to progress towards a goal, he or she will tend to be dissatisfied and
have negative self-appraisals. When goals are attained, people often adjust their goals
upward and increase their level of effort; when they fail to progress, they usually will
renew their effort toward attaining the original goal (Maibach & Cotton, 1995).
Subjective expected utility models predict that outcomes are a function of several
variables. For example, Rogers’ (1975) protection motivation theory posits that
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persuasive outcomes are a multiplicative function of the perceived vulnerability,
perceived severity, and response efficacy. If any of the three variables took on a zero
value, the fear appeal would not be persuasive.
In addition to their complexity, attitudes, values and behavioral tendencies are
acquired gradually. Zimbardo, Ebbesen and Maslach (1977) argue that individuals grow
rather than change:
We are not succumbing and being persuaded, coerced, or induced to be other than
we are. Rather, we perceive that we have chosen freely to become our own
person. It is the recognition of a change that seems more sudden, abrupt, and
discontinuous than normal that raises the possibility of external, special forces at
work. An action that violates what seems appropriate, or that does not fit our
expectations, is more likely to be thought of as “coercion” (p. 1-2).
Desirable Outcomes
Outcome or effectiveness evaluation focuses on determining whether health
campaigns or messages successfully achieve the desired outcomes. From the perspective
of a campaign planner, each possible behavioral outcome will be either desirable or
undesirable.
The long-term maintenance of individual change usually requires behavior
changes by the bulk of the targeted population, not just the 5 to 10 percent that are most
easily influenced by mass media campaigns. Thus, government and community
involvement are essential to help promote the long-term practice of recommended
behaviors (Flay & Burton, 1990).
Although behavior change and long-term maintenance are the ultimate desired
outcomes of a behavior change campaign, various interventions within a campaign may
strive to achieve outcomes that are lower on the hierarchy of possible positive effects.
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Cartwright (1949) identified three psychological processes in behavior change in
campaigns: cognitive structures (knowledge), affective structures (motivation), and
action structures (behavior). Media campaign messages supported by face-to-face
communication are more likely to lead to recommended behavior changes because the
combination of these channels is more likely to activate all three types of psychological
structures (Flora, Maccoby, & Farquhar, 1989)
According to McGuire’s (1989) Input/Output Matrix, positive outcomes can
include yielding (attitude change), decision on basis of information retrieval, behavior in
accordance with a personal decision, reinforcement of desired acts, and post-behavioral
consolidating. The behavioral objectives of the Stanford Community Studies included
helping individuals “become aware, increase knowledge, increase motivation, learn and
practice skills, take action, assess outcomes, maintain action, practice self-management
skills, and influence social network members” (Flora, Maccoby, & Farquhar, 1989, p.
235).
Other campaign effects can include awareness of the consequences of
noncompliance, self-efficacy, cognitive management of fears and expectations,
assertiveness or communication competence, changes in perceived susceptibility or
perceived threat, changes in social norms that affect behavior, and verbal commitment to
behavior change.
The desirable outcomes of a fotonovela intervention might include:
• Verbal expressions of interest in AIDS issues
• Awareness or knowledge of AIDS-related behavioral risks
• Changes in social norms within church networks (overcoming denial)
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• More open discussion about preventive behaviors between adults and teens
• Behavior change: Sexual abstinence or the postponement of sexual
involvement.
Undesirable Outcomes
Undesirable outcomes, inevitable in any behavior change campaign, vary depending
on the type of recommended behavior. In a fotonovela campaign in which teens are urged to
postpone or otherwise abstain from sexual involvement in order to avoid disease, the
undesirable outcomes might include.
• Sexual involvement: initiation, continuing, or relapse.
• Withdrawal from social support networks.
• Reduced interest in AIDS issues.
• Confusion about AIDS transmission.
• Denial of personal risk.
• Self-devaluative behaviors.
Bandura (1994) posits that self-reactive control prompts people to refrain from
transgressing because the conduct would lead to self-reproach. For people whose
behavior is regulated by social sanctions, they refrain from self-serving or reprehensible
conduct for fear of being ostracized.
When people are socially pressured to engage in behavior that violates their moral
standards, social influences will have little sway as long as the perceived self-devaluative
consequences outweigh the benefits for choosing socially accommodating behavior.
When faced with an ethical dilemma, however, people often modify their personal
framework of moral standards to regulate their conduct, and the remaining self-sanctions
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can be nullified if certain internal controls are disengaged. In the present study, a self-
devaluative behavior might be the decision to have sexual intercourse despite
internalized religious beliefs that label such behavior as sinful.
Bandura contends that most people avoid conduct that produces self-devaluative
consequences such as guilt. People usually do not engage in deplorable conduct until they
have justified to themselves the morality of their actions. When people rationalize their
own self-deplored conduct, it leads to cognitive restructuring, which may include:
• Euphemistic labeling, or justification by a "high" moral principle.
• Minimizing, ignoring, or misconstruing the consequences.
• Dehumanizing or blaming victims.
• Reducing or displacing personal responsibility for the act.
• Making palliative comparisons, which contrast a self-deplored act with other
more deplorable acts committed by others.
Summary of Literature Review
The purpose of the preceding literature review, as presented within the eight domains
of an organizing theoretical framework, was to describe the conceptual dimensions of
processes and factors that could influence an individual to comply with AIDS prevention
advice. The present study explored the barriers and inroads to dialogue about this prevention
advice in various religious contexts among African American youth and women.
While the organization of concepts was a broad synthesis of the structural
components of existing health behavior change models and other related theories, the
empirical evidence presented within this framework focused on the AIDS-related behaviors
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and attitudes of African Americans, particularly among adolescents. In addition, the general
model that emerged from the synthesis of existing literature later was used as an organizing
framework for data analysis.
The following chapter will describe the methodology of the present study,
including site selection justifications, research questions, study objectives, and
procedures used in the collection of data through participant observation, long
interviews, and focus groups. The chapter also will explain how research participants
developed a fotonovela, as well as how the investigator conducted readability analysis,
provided informed consent, evaluated validity threats, and transcribed, analyzed, and
interpreted the data-texts.
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CHAPTER 3
METHODOLOGY
The primary goal of this study was to explore the inroads and barriers to AIDS
prevention dialogue within various religious contexts in the African American
community, in order to develop strategies for educating youth about their behavioral risks
of contracting the disease. On an individual level, the various predisposing factors,
enabling factors, cognitive processes, and outcomes of exposure to an AIDS prevention
message were explored, as well as the culture-level environmental, message design, and
normative processes that can influence individual choices. A three-tiered approach was
used to examine these health behavior domains:
(1) Participant observations of church meetings, HIV prevention activities, and other
public events in the African American community.
(2) In-depth interviews with clergy, AIDS organization leaders, and church members.
(3) An iterative focus group design that encouraged youth and women to express their
ideas and views about AIDS-related issues throughout the process of creating,
evaluating, and disseminating an AIDS prevention fotonovela, a photo-illustrated
story booklet, to youth within their social networks.
The flowchart on the following page, Figure 14, presents the basic strategy and
sequence of data collection procedures used in this study:
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FIGURE 14: Strategies and Procedures of Data Collection
Selection of Method
Qualitative research methods were selected for the present study because the
disproportionate level of HIV infection among African Americans, coupled with the lack
of effective AIDS prevention interventions targeting this population, call for more
exploratory research about the cultural norms that can influence behavior change efforts.
Compared with quantitative methods, qualitative research can provide deeper
understanding of the context and language of behavior in a community, and it is better
suited to illuminate motivations, enable discovery, interpretation, and exploration, and
provide holistic insight and more fruitful explanations of trends (Smith & Debus, 1992).
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Qualitative research has been useful for understanding social conditions
associated with the spread of HIV as well as for developing culturally and socially
targeted means to reduce infection (Bletzer, 1993; Bolton & Singer, 1992; Cruise &
Dunn, 1994; Weeks, 1993). Smith and Debus (1992) advocated the use of qualitative
methods to blaze new trails in prevention research.
The AIDS epidemic dramatizes what we do not yet know about human sexuality,
exposing the limitations of our behavioral research technology and challenging us
to develop new ways to learn about some of humanity’s most private and taboo
behaviors. To help people protect themselves from HIV infection we must offer
alternative practices which are acceptable to those at risk. We must present
information in ways which not only inform but persuade. We must find the
means to overcome fear, prejudice and denial among groups of people who feel
victimized and ostracized by society as a whole. This task requires not only good
epidemiology and excellent survey research; it demands that we find new ways to
collect data and understand the relationship of knowledge and attitudes to the
behaviors which place people at risk of HIV infection, (p. 57)
Atkin and Freimuth (1989) assert that formative evaluation researchers should
“attempt to learn as much as possible about the intended audience before specifying
goals and devising strategies” (p. 134). Planners of community-based health campaigns
have increasingly emphasized research using qualitative methodologies to enhance the
potential for achieving social and behavioral change (Palmer, 1981; Windsor, 1984).
Based on a model of action anthropology (Gearing, 1960), this study attempted to assess
a norm of community self-determination by involving African Americans in the design
and implementation of an intervention and by encouraging dialogue that can facilitate
greater awareness, mutual concern, and behavior change.
In an effort to understand the lives of individuals from each person’s perspective,
McCracken’s (1988) “lived text” approach to interviewing was used. Fisher (1984)
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theorizes that people are inherently storytelling animals, and telling narratives about the
significance of events in their lives enables them to create meaning from chaotic events.
An understanding of how African Americans talk and think about AIDS in their
community is negotiated between each individual and the researcher. This ethnographic
approach seeks to validate the subjects’ cultural context and requires the explicit
acknowledgment of the interaction between the researcher’s own cultural template and
the “culture” being studied.
The planners of the Blacks Educating Blacks About Sexual Health Issues program in
Philadelphia included the development of prototype educational materials for review by
focus group participants (USCM, 1990). This study was based on the BEBASHI model, in
that three layers of focus group feedback as well as long interviews and participant
observation are used to develop and refine a fotonovela for use as an HTV education tool.
Data collection methods for the current study include participant observation, as well
as in-depth, ethnographic interviews with both individuals and focus groups.
Site Selection
Gainesville, Florida, was selected as the site for this case study. Gainesville has a
population of 89,500 and 33,700 households (SRDS, 1997), and it is located in Alachua
County, a rural, agricultural county in north central Florida with a population of 196,106.
About 57 percent of the Gainesville population and 26 percent of Alachua County’s
population are students, faculty, and staff of the University of Florida, and an additional
16 percent of Gainesville’s population is comprised of students, faculty, and staff of
Santa Fe Community College (Alligator, 1997).
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Gainesville was chosen as the site for this research for nine primary reasons.
Additional background information and other supporting details are provided in the
discussion below the list. Many of the rationale statements for these nine items relied on
county or state statistics when city data was not available.
1. African American population: Nearly 1 in 5 residents of Alachua County are
African American, and a fourth of the African American population are teens that
may be at risk of HIV infection.
2. AIDS rates: Florida is annually ranked third in the nation in number of AIDS
cases. In Alachua County, an AIDS rate of 246 per 100,000 ranks 19th - within
the top third of 67 counties. This means that 246 individuals per 100,000 have
been diagnosed with AIDS, which is 13 percent higher than the national rate. For
the 25-34 age group, more years were lost due to AIDS in 1996 than deaths from
all forms of cancer, cardiovascular disease, accidents, homicides, suicides, and all
other causes.
3. Disproportionate AIDS incidence among African Americans: Statewide, 43
percent of AIDS cases are among African Americans, compared with 35 percent
nationally. The rate for blacks is almost three times greater than the rate for
Hispanics. African Americans represent the highest number of diagnosed cases
of AIDS for female teens, and the second highest for male teens. More than seven
times as many black children as white children have AIDS, and 81 percent of all
pediatric AIDS cases are black. Four times as many black women as white
women have been diagnosed.
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4. Behavioral risks: Local and state statistics about unwed pregnancy rates, drug
use, and intention to commit suicide indicate the extent that individuals may
engage in HIV-related risky behaviors.
5. Lack of eligible African American males could be a potential risk factor in
Alachua County, particularly among women, because the ratio of African
American females to males increases dramatically as they get older.
6. Truancy: Twice as many African American youths than white youths in Alachua
County drop out of school before the 9th grade. The county’s dropout rate is
nearly 80 percent higher than the average dropout rate in Florida. One in five
African American adults in Alachua County never finish high school.
7. Economic disadvantage: Among African Americans 16 and older in Alachua
County, nearly a third are unemployed or otherwise do not work. About 38
percent of all African Americans in the county live below the poverty level.
8. African American AIDS Task Force: The development of this study was guided
by the advice and observation of the African American AIDS Task Force, a
Gainesville volunteer group that designs and implements AIDS prevention and
education initiatives within the black community. This study was intended to
help AAATF meet several of the goals established during the group’s first,
organizational meeting:
• To involve African American youth as peer educators and in brainstorming
and developing AIDS education materials.
• To create a quality, culturally sensitive brochure.
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• To help reduce the stigmatization of HIV/AIDS in the African American
community.
• To help mobilize the churches, starting with the most progressive ministers.
9. Local mass media: The niche for a fotonovela intervention was highlighted by an
examination of Gainesville’s mass media organizations. This information was
included because prior literature has shown that AIDS knowledge and beliefs are
associated with media access and use.
African American Population
About 19 percent or 34,539 Alachua County residents are African American (U.S.
Bureau of the Census, 1996). Minority youths under 18 years of age comprise a third of
the population, and a fourth of the African American population in the county are teens
who may be at risk of HIV infection. About 12 percent of the 34,539 African Americans
in the county are ages 12 to 17, and 13 percent are ages 18 to 24. A quarter is aged 25 to
44, the age group reporting the highest number of AIDS cases (U.S. Bureau of the
Census, 1997). In the 12 to 24 age group, the target of the fotonovela intervention in this
study, 4,596 of Alachua County African Americans are females (13 percent) and 3,943 are
males (11 percent), for a total of 8,539 potential target audience members (U.S. Bureau of
the Census, 1990).
AIDS Rates
Florida ranks third, behind New York and California, in the number of
cumulative AIDS cases, and ranks second in the number of pediatric AIDS cases. In
December 1997, the state reported 58,911 AIDS cases since 1981, a rate of 606 per
100,000 population. Miami ranks fourth in the top 10 list of metropolitan area infection
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rates, and the city accounts for 30 percent of cases in the state, which means one in 40
adults there may be infected (CDC, 1996). Although state law prohibits Florida public
health officials from reporting HIV incidence to the public, they estimate that 137,500
residents probably are infected (Florida Health Net, 1997).
In 1996, a 25 percent drop in AIDS-related deaths, across all ethnic groups, was
attributed to the increased use of anti-retroviral drugs and other preventive therapies.
This decline, the first since the epidemic began in 1980, is expected to continue given the
use of protease inhibitors, a particularly effective class of new anti-HIV drugs that were
not widely available until the middle of 1996 (Kertesz, 1997). The 25 percent drop in
Florida is more than double the decline in AIDS deaths reported nationwide, and more
than three times the drop in the South (Facts on File, 1997).
From 1981 through 1996, Florida has reported 60,710 AIDS cases, 58 percent of
whom have died. Of these cases, 44 percent were infected through male to male sexual
contact (compared with 50 percent nationally); 18 percent through injection drug use (26
percent nationally), 15 percent through heterosexual contact (9 percent nationally); 5
percent through male to male contact involving injecting drug use; 2 percent of the cases
were transfusion related; and less than 1 percent were hemophiliacs. Eighty percent of
adult AIDS cases are among men.
These state figures do not account for the people who have tested positive for
HIV infection, but only for those diagnosed with full-blown AIDS. Public health
officials speculate that for every case of AIDS reported, three other Floridians are
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infected with HIV. In Alachua County, this would mean that 1 in 130 people were
infected with the virus by 1997 (Florida Department of Health, 1997).
Among male AIDS cases, 24 percent of African Americans reported they were
infected through male-to-male sexual contact, compared with 76 percent of white cases.
One-fourth of blacks were infected through injecting drug use, compared with 8 percent
of whites, and 6 percent of blacks contracted AIDS through male-to-male contact and
injecting drug use, compared with 7 percent of whites. About 7 percent of blacks
contracted AIDS through heterosexual contact, compared with 1 percent of whites. The
exposure factor was undetermined for 26 percent of blacks, compared with 5 percent of
whites.
Among women, 29 percent of blacks reported that they had contracted AIDS
through injecting drug use, compared with 38 percent of whites; 16 percent of black
women were infected through heterosexual contact with an injecting drug user, compared
with 18 percent of whites; 26 percent of black women contracted the virus through other
heterosexual contact, compared with 25 percent of white women. The remaining 29
percent of black women either did not report a risk factor or had more than one risk
factor. Among mothers giving birth, the HIV seropositivity rate is 470 per 100,000
(Florida Department of Health, 1997).
The AIDS rate in Alachua County is 246 per 100,000 population, which is 13
percent higher than the national rate. As of October 1997, Alachua County reported 405
cumulative AIDS cases, which means that 1 in 390 residents were diagnosed with AIDS
by that date. Although Alachua County ranks 20th in population among Florida counties,
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its current AIDS rate of 246 per 100,000 ranks 19th - within the top third of 67 counties.
This rate is 57 percent higher than it was in 1992. The first AIDS case was reported in
Alachua County in 1983, and county health officials have seen an exponential growth in
the number of cases each year since then. The number of cases doubled between 1987
and 1988 and tripled between 1992 and 1993.
In examining the impact of premature and preventable mortality in Alachua
County, the Florida Health Department (1997) found that 743 years of potential life have
been lost before age 65 due to AIDS deaths, which accounts for 9 percent of years lost
due to all causes of death. The AIDS deaths in the 25 to 34 age group account for more
than 5 percent of all years lost, and 61 percent of years lost due to AIDS. For this age
group, more years were lost due to AIDS than deaths from all forms of cancer,
cardiovascular disease, accidents, homicides, suicides, and all other causes.
Disproportionate Incidence among African Americans
The disproportionate incidence of HIV and other STDs in Alachua County
indicates that AIDS could reach epidemic proportions in Gainesville. In 1996, the
county’s cases of gonorrhea, chlamydia, infectious syphilis, and tuberculosis exceeded
the average per-county cases (Florida Department of Health, 1997).
Melanie Gasper, former executive director of the North Central Florida AIDS
Network, listed the primary HIV risk factors for African Americans in Alachua County as
substance abuse, heterosexual infection, homosexual infection, and multiple risk factors
related to prostitution. The North Central Florida Health Planning Council further
identified three groups in this region that should be targeted with AIDS prevention
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efforts: minority populations, especially African Americans, women of childbearing age,
and at-risk youth (Gromley, 1996). These trends were shown by reports from AIDS case
workers.
The number of cumulative AIDS cases among African American women between
ages 15 and 44 in North Central Florida was three times greater in 1995 than in 1990. As
of June 1996, 60 percent of the women of childbearing age in this region who have been
diagnosed with AIDS are African American (HRS, 1996). In Alachua County,
childbearing women test positive for HIV antibodies at a rate of 270 in 100,000 (Florida
Health Net, 1997). Florida public health officials estimate that African Americans will
account for more than half the state’s cases by the year 2000 (Bergstrom, 1997).
Behavioral Risks
The rate of unwed pregnancy can indicate the extent of risky sexual behaviors
among youths. About 75 percent of teenage mothers in Florida in 1992 were not married
at the time of the birth. Among sexually active Florida adolescents, 67 percent reported
using no contraceptive, reported using the withdrawal method, or did not know if any
contraception was used during sex. In Alachua County, 3 percent of females under 18
gave birth in 1994, which is the same as the statewide average. In Florida, 18 percent of
the girls who gave birth before age 18 had a repeat birth in 1994 (Florida Health Net,
1997).
Suicidal behavior, evidence of severe depression, has been shown to be a predictor of
risky HIV-related behavior among youths. Among Florida teens in all racial categories, 24
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percent said they had considered suicide seriously in the past 12 months (Florida Health Net,
1997).
Drug use is another major risk factor, particularly among teens. In Florida, 35
percent of male teens and 26 percent of female teens reported having had five or more
drinks in a row within the previous 30 days, while 17 percent of teens reported using
marijuana within the previous 30 days (Florida Health Net, 1997). Among blacks
diagnosed with AIDS in Florida through 1996, 25 percent were infected through injecting
drug use, compared with 8 percent of whites. Among African American women, 29
percent reported that they had contracted AIDS through injecting drug use, and 16
percent were infected through heterosexual contact with an injecting drug user (Florida
Department of Health, 1997).
Lack of Eligible African American Males
In Alachua County, African American females account for 54 percent of the black
community, while males account for 46 percent. The ratio of African American females to
males increases as they get older: for those 12 to 17 years of age, the ratio is even, 1.0; for those
18 to 24, 1.3; for the 25 to 44 age group, 1.2; for those 45 to 64,1.4; and for those 65 and older,
1.6 (U.S. Bureau of the Census, 1990). While the female-to-male ratio is even among
adolescents under 18, young women between ages 18 and 24 are most affected by a sex-ratio
imbalance. Given that this problem is widely recognized and lamented among African American
women of child-bearing age, adolescent girls may feel pressured to “get a man at any cost” while
they still have the chance. Knowing that fewer eligible men will be available in the near future,
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they may give in to unsafe sex to initiate and maintain a relationship or to gain the prestige of
being “kept” (Mays & Cochran, 1988).
Truancy
Truancy is another serious problem among youths in Alachua County. About 8
percent of African Americans in Alachua County drop out of school before the 9th grade,
compared with 4 percent of whites (U.S. Bureau of the Census, 1997). African American
children constitute about 35 percent of enrollment in the Alachua County school system,
which serves about 24,000 students in 21 elementary schools, six middle schools, and six
high schools (Resnick, 1992). The dropout rate for the 1995-’96 school year in Alachua
County was 6.4 percent, which reflects a 73 percent increase since the 1991-’92 school year
and is nearly 80 percent higher than the average dropout rate for the state (Florida
Department of Education, 1997).
In Alachua County, 83 percent of all residents over 25 in 1996 had a high school
diploma, and 35 percent were college graduates. Among African Americans over 25
years of age, 20 percent did not complete high school (compared with 14 percent of
whites); 32 percent had a high school diploma but no college education (compared with
86 percent of whites); and 19 percent were college graduates, compared with 48 percent
of whites (U.S. Bureau of the Census, 1997).
Economic Disadvantage
Alachua County has a large economically disadvantaged population. The
unemployment rate overall averaged 3.7 percent in 1996 (U.S. Bureau of the Census,
1997). However, among African Americans 16 and older, nearly a third are unemployed
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or otherwise do not work. About 24 percent of all residents and 38 percent of all African
Americans live below the poverty level. More than 17 percent of African Americans
earned less than $15,000 in 1989, and their average per capita income that year was
$6,448. Similar to national statistics, 73 percent of all black families living below the
poverty level in Alachua County are headed by a female with no husband present, while
married-couple families account for 11 percent (U.S. Census, 1990).
In Alachua County, 87 percent of all residents living below the poverty level do not have
access to dental care, compared with 76 percent statewide (HRS, 1994). Access to dental care is
important in AIDS prevention and treatment because thrush and other oral manifestations of AIDS
are often the earliest indications of HTV infection.
In Florida, 46,000 individuals are believed to be homeless, which is 1 in 354
residents (Florida Health Net, 1997). If the state homelessness rate were applied to
Alachua County, an estimated 554 would be homeless today, and the national rate
implies that nearly 5,900 county residents would have been homeless at some point in
their lives - 1 in 392 residents.
African American AIDS Task Force
This study was intended to dovetail with the mission and long-range goals of the
newly formed African American AIDS Task Force, an organization in Gainesville,
Florida, which designs and implements AIDS prevention and education initiatives within
the black community. The principal investigator gained entry into the African American
AIDS Task Force through information-gathering conversations with several key
informants. In a conversation that occurred several weeks before the task force was
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launched, the executive director of the North Central Florida AIDS Network described
her agency’s strategy in recruiting prominent leaders from the African American
community and invited the investigator to participate. The investigator chose an overt
research role in the group and presented a brief overview of her dissertation agenda
during the third meeting of the task force.
As a grassroots effort, HIV prevention in the U.S. consists of local organizations
developed to respond to many aspects of the epidemic, including prevention, care,
support, and advocacy. The activity of these organizations has yielded volunteer
commitment and an intimate knowledge of at-risk communities (Stryker, 1995).
The African American AIDS Task Force in Gainesville, Florida, is a grassroots
network committed to the empowerment of the African American community in
controlling the spread of AIDS and reducing the stigma of the disease. According to the
organization’s mission statement, AAATF is
Seeking inroads to serve the church community through culturally sensitive AIDS
programs and seminars, tailored to address moral and religious standards, which
foster care, compassion, education, HIV prevention, training, information, and
referrals.
Launched in November 1994 by the North Central Florida AIDS Network
(NCFAN), the task force meets one night a month to develop objectives and implement
plans for community AIDS prevention and outreach activities. Melanie Gasper,
executive director of NCFAN, commented that her organization “understands that
involving influential members of the African American community ensures that
culturally sensitive decisions will be made in all phases of planning and implementation,
and that in all efforts, chances for success will be improved.”
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The task force includes health care professionals, ministers, social workers,
attorneys, law enforcement officers, educators, community leaders, and other citizens.
Gwen Love, one of 12 African Americans who helped launch the task force, remarked
during the group’s first meeting that many African Americans:
Feel like they’ve been left out of the system. They need to know and feel the
support of family and community. They need the basic tools to survive, but often
they’re too proud to ask.
During the first meeting, AAATF members brainstormed goals for educating local
minority youth about AIDS. The following nine goals were scribbled on a flipchart by
volunteer leaders of the organization:
1. Involve African American youth:
• As peer educators
• In brainstorming and developing AIDS education materials.
2. Provide AIDS education materials and curricula for Headstart and K-12 schools.
3. Create a quality, culturally sensitive brochure.
4. Mobilize the churches, starting with the most progressive ministers.
5. Help reduce the stigmatization of HIV/AIDS in the African American community.
6. Select African American role models that can be trained as AIDS educators.
7. Request mission offerings at local churches.
8. Develop television and radio PSAs promoting AIDS information and services.
9. Develop a video with rap music to appeal to teens.
Mass Media
Campaign planners should consider the social environment and lack of media
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access among low-income African American adolescents when selecting channels and
designing messages targeting these individuals.
In general, adolescents do not read newspapers, and public service
announcements on radio, television, and posters often are too short to provide enough
informative details to audience members. Many PSAs also fail to reach individuals
because they are aired too infrequently, outside prime time, or on noncommercial
stations, or because they often must be directed at a broad audience.
By contrast, the fotonovela format has numerous advantages over traditional mass
media channels: it is much less expensive to develop, test, and produce than a radio,
television, or film production, it does not require the use of electronic equipment, it has
the potential for more lasting impact because it is more likely to remain in the readers’
possession and less likely to be discarded, it is more effectively disseminated to a target
audience than traditional print materials because of its greater potential to informally
circulate within existing community networks, it is more likely to be in demand among
those who read similar materials for entertainment, and it can be read at an individual’s
convenience.
The fotonovela also has the capacity to be “translated” into mass media formats
and thus can be integrated into multi-media ADDS prevention campaigns. For example, a
fotonovela script can be adapted for use as a radio spot (radionovela), video script
{telenovela), or its script and accompanying photographs can be published as a poster, or
in a magazine, newspaper, web site, or other print format. In addition, fotonovelas can
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be distributed through the same channels as traditional pamphlets, such as tabling events
(i.e., festivals and health fairs), school curricula, direct mail, and health care offices.
The potential niche for a fotonovela as an AIDS prevention information channel
as part of a multi-media campaign in Gainesville, Florida, is highlighted by facts about
the city’s mass media organizations, as well as previous research about the use of these
types of media channels among African Americans.
In a Midwestern university town similar in size to Gainesville, a recent media use
survey showed that 30 percent of African Americans over age 18 used newspapers more
than any other media. Although 70 percent used television more than newspapers or
radio for news and information, they used newspapers more than television to get local
news. Most African Americans in this town used television for entertainment and radio
for music, and 70 percent said they used newspapers more for advertisements about food
and clothing than for news (Perry, 1996). The results of this study imply that telenovelas
might be most effective in reaching African Americans who watch television for
entertainment, particularly if the spots were aired during the entertainment programs with
the highest number of adolescent African American viewers. In addition, a fotonovela
published in local newspapers might reach the greatest number of people if it were
printed or inserted on the day of the week that the papers have grocery coupons.
The Gainesville community is served by numerous media organizations that could
support a multi-media, novela AIDS prevention campaign targeting African American
teens: two daily newspapers, a bimonthly African American newspaper, two network
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television stations, a public broadcasting television station, an African American radio
station, two Christian radio stations, and 15 other radio stations.
The daily newspapers are the Gainesville Sun, a New York Times Regional
Group morning-delivery newspaper with a circulation of 51,378 (SRDS, 1997), and the
Independent Florida Alligator, a student-run, free, weekday newspaper with a self-
reported circulation of 32,000 (Alligator, 1997). Mass media channels that target African
American audiences include the Mahogany Revue, a bi-monthly newspaper, and Magic
101.3, a soul-format radio station. The station manager, an active leader of the African
American AIDS Task Force, frequently has donated free air time for AIDS PSAs.
Research Questions
Given the exploratory nature of the qualitative methodologies in the present study, it
was difficult to predict all relevant research topics or settings that could arise during data
collection. However, the development of data collection instruments and selection of
methods were guided by four key research questions:
1. What are some specific inroads and barriers to AIDS dialogue within the
African American church?
2. What are differences and similarities between the processes by which women
and youth engage others in interactions about AIDS, and in what settings does
this kind of dialogue occur?
3. Among youth, what factors serve as barriers to their postponement of sexual
involvement or abstinence?
4. What enabling factors could empower youth to practice abstinence-based
AIDS preventive behavior?
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These four questions were explored using a triangulation of participant
observations of religious and AIDS prevention activities, in-depth interviews with clergy,
church members, and AIDS organization leaders, and focus group interviews with low-
income youth and women. The following discussion provides a rationale, philosophy,
and logistical details for each of the methods used in this study.
Participant Observation
Participant observation is a fundamental technique in ethnographic research that
is concerned with the observation of naturally occurring behavior in natural contexts
rather than in scientifically manipulated contexts.
In the present study, the investigator was an active participant observer, in the
sense that she became involved in a key group rather than trying to operate anonymously.
The researcher served as a volunteer consultant in coordinating community AIDS
education projects for the task force. In addition, she entered the field setting with an
openly acknowledged investigative purpose, but conducted the study from the
vantagepoint of an official position within the membership.
Participant observation was conducted in order to inform strategies for the
fotonovela intervention, whereas the in-depth interview and focus group methodologies
described below were conducted in order to help inform theory modification and
development.
Participant observations were recorded for about 20 monthly meetings of the
African American AIDS Task Force (AAATF), five Sunday worship services, two
AAATF tabling events during ethnic festivals, three church youth group meetings, a
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multicultural Bible study in a predominantly white church, a faith community breakfast
sponsored by the AAATF to raise awareness of AIDS issues among religious leaders, as
well as five planning meetings for that event, a 30-minute AIDS workshop for Baptist
deaconesses, and a health fair in inner city Washington, DC, sponsored by several
metropolitan African American churches.
When possible, observations were recorded in brief field notes at the site and in
expanded field notes on the same day that the observation took place. The method
allowed the researcher to focus attention on particular scenarios while recording and
participating in those scenarios. For example, the researcher helped a subcommittee of
the African American AIDS Task Force in planning an AIDS awareness breakfast for
leaders of the faith community, rather than merely watching others work and asking
questions about the work.
In-depth Interviews
McCracken (1989) states that the long interview is “one of the most powerful
methods in the qualitative armory” because it can “take us into the mental world of the
individual, to glimpse the categories and logic by which he or she sees the world. It can
also take us into the life-world of the individual, to see the content and pattern of daily
experience.” Morley (1988) notes that the long interview method provides access to the
linguistic terms and categories or the logical scaffolding through which respondents
construct their worlds and their own understanding of their activities. McCracken notes
that the long interview allows the researcher to “accomplish certain ethnographic
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objectives without committing the investigator to intimate, repeated, and prolonged
involvement in the life and community of the respondent.”
Semi-structured, ethnographic interviews were conducted with 12 key informants
from two African American churches and two AIDS organizations. The questions were
developed to encourage clergy and informants from churches and AIDS organizations to
provide detailed explanations illuminating their activities, opinions, knowledge,
language, and logic (Appendices A-l & A-2). While the list was flexible enough to allow
respondents to freely and openly present their views, their responses were useful in
constructing the context in which the individuals thought and talked about AIDS.
These interviews were administered individually and followed a standardized
format in terms of the goals of the interview, the general questions utilized, and informed
consent procedures. However, the questions were phrased in a general and non-directive
manner and often were based on topics grounded in participant observation. In addition,
the questions were supplemented by floating prompts, including the investigator’s
repetition of a key term from the informant’s response or her asking, “What do you mean
by... ?” Planned prompts asked informants to contrast, categorize, or recall examples of
topics or incidences. The sequence in which the questions are asked is determined by the
informant’s responses (McCracken, 1988, pp. 34-37).
The in-depth interview protocols contained both grand tour and logistical
questions, was open-ended and improvisational in tone, and was developed with the
intent of sustaining the flow of conversation and following the nuances of the moment.
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Prompts were sometimes used, within the context of the dialogue, to gather additional
information or opinions about particular topics.
The AIDS-related questions were designed to uncover what AIDS means to the
individual, the individual’s experience with or knowledge of AIDS and people living
with AIDS, sources of AIDS information, and existing knowledge and beliefs about
AIDS. The respondents also were asked to talk about and evaluate any previous
conversations they have had about AIDS. Several questions asked participants to define
and explain personal limits regarding the kinds of AIDS education efforts they might
consider acceptable within their churches, and the specific contexts in which AIDS
dialogue would be permissible.
The interviews were tape recorded, and when possible, recorded in hand-written
field notes during the conversations. The respondents determined the location and
scheduling of the interviews. When possible, interviews were conducted in non-
academic settings. Interview locations included business and church offices, restaurants,
an outdoor church fair, and homes. Interview length depended on the informant’s
interest, communication style, and competing time commitments, with the shortest
interview taking 30 minutes, and the longest interviews taking more than two hours.
Most interviews lasted about one and one-half hours.
The long interview was more appropriate for this study than participant
observation alone because far more field time would have been required to observe any
AIDS-related discussions that might arise within the African American churches, given
that none of the churches were significantly involved in these discussions at the
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beginning of the study. In keeping with ethnographic methodology, the
operationalization of the key concept, HIV dialogue within African American churches,
and the categories of analysis were allowed to arise from the data collected. The broad,
logistical purposes of the long interviews, based on aims suggested by Lazarsfeld (1944),
included the following:
• To clarify the meanings of common opinions about the potential roles of the
black church in AIDS prevention and to identify the factors that influence an
individual to form these opinions.
• To classify complex attitude patterns and to distinguish among the decisive
elements of expressed opinions, particularly as they relate to religiosity.
• To identify personal motivations behind the behaviors that comply or fail to
comply with various AIDS prevention recommendations.
Recruitment of Key Informants
In developing community-based campaigns, qualitative methods are essential for
uncovering both the roles of community activists as well as the roles of legitimizers and
others who may be less directly involved in the more public aspects of dialogue (Nix,
1977). In this study, the in-depth interviews solicited views of community leaders such
as ministers and AIDS organization members, while the focus groups and follow-up
individual interviews solicited the views of adolescents and women from lower-income
neighborhoods.
Portnoy, Anderson, and Eriksen (1989) argue that communication research too
often focuses on the individual as the unit of analysis, while largely ignoring the
importance of network relationships within the larger organization or social system. This
218

is often because the investigator assumes that because the individual is the unit of
response, then the individual must also be the unit of analysis.
Given that descriptive ethnographic information does not represent a population
in the quantitative sense, random sampling was not utilized. The goal of the
ethnographic sampling was to establish the range of variation rather than the proportion
of “typical” traits in a population. The work began with key informants, who are
considered “experts” on the topic of interest. Subsequently, a network of participants
was developed.
A combination of judgment and snowball sampling techniques were used, and
both are non-random sampling techniques. The snowball sampling technique
conceptualized by sociologists Palmore (1967) and Laumann (1973) was used to identify
key informants in this study. This multistage approach asks the first round of informants
to identify other informants, who then become respondents in the next phase of data
collection. In using judgment sampling, participants were selected on the basis of
characteristics considered relevant to the research questions, including ethnicity and
organizational affiliation. As more information was gathered about the African
American community, additional in-depth interviews and participant observations were
conducted in order to maximize divergence of perspective and experience relevant to the
research.
The interviews were designed to reveal the nature of social networks, as well as
the concerns and inhibitions of community residents and their potential openness or
219

hostility to AIDS-related discussions. Informants were chosen for reasons outlined by
Lindlof (1995):
• They commanded respect from their peers.
• They could articulate their goals and opinions, as well as opinions of their
peers.
• They expressed willingness to assist with the goals of this research proposal.
Nix and Seerley (1971) recommend at least 15 interviews be conducted, as a rule
of thumb, in cities of 10,000 to 100,000 population when using the community
reconnaissance method. McCracken (1989) argues that eight long interviews should be
sufficient for thorough representation of any given population, but emphasizes that
additional interviews should be conducted until the researcher is confident that the point
of information redundancy has been reached.
For the present study, 12 respondents were selected for long interviews. The chart
on the next page summarizes the key characteristics of these interviews. The sample was
comprised of the following clergy, AIDS organization members, and church members:
• Ministers from early-adopter churches in Gainesville:
1. A female pastor from a large Pentecostal church.
2. A male pastor from a small, conservative, nondenominational church.
• Leaders from the African American AIDS Task Force in Gainesville:
3. The chairwoman of the organization.
4. The co-chair of the organization.
5. The head of the organization’s faith community committee.
• Four church members:
6. A female youth leader from a low-income neighborhood.
7. A mother secretly living with AIDS.
220

8. A teenage girl who serves as a youth leader.
9. A teenage girl who attends church regularly.
• Three leaders who helped launch HIV prevention programs in inner city African
American churches in Washington, D.C.:
10. The director of an AIDS ministry in a large Methodist church.
11. The interim director of the U.S. Agency for HIV/AIDS and consultant for the
National Minority AIDS Council.
12. The official from the Agency for HIV/AIDS who serves as a liaison to the
religious community.
Table 1 on the following page provides further details of the subjects of the in-
depth interviews, including interview location, length, number of 1.5-spaced transcript
pages generated, main topics of the interview, and a link to the appendix containing the
protocol used for the interview.
The interview participant who did not exclusively fit into one of the key
informant categories was a 37-year-old mother who had never publicly disclosed her HIV
status (Appendix A-4). Her interview was included in the study because her testimony
revealed direct and rare insights about stigma and coping with the disease in secrecy. In
most research contexts, the only people known to be living with AIDS are those who
have “gone public” and typically tell their personal testimonies to many large groups of
people.
Because of the lack of isolation, speechmaking routines, and social support
characteristic of their everyday lives, these individuals may not experience the same level
of stigma, secrecy, and hopelessness as those who have not gone public.
221

Type
Affiliation or
Identification
Sex
Location
Length,
Date
# Pages of
Transcripts
Main Topics
Protocol
(Appendix)
AIDS
org
AAATF chair
F
Her office
1.0 hrs,
4-12-95
4
Local HIV risks
and prevention
strategies
A-l
AIDS
org
AAATF faith
community
committee chair
F
Restaurant
1.0 hrs,
4-12-95
6
Local churches’
response to
AIDS epidemic
A-l
AIDS
org
AAATF co-chair
F
Restaurant
2.0 hrs,
6-12-97
12
Inroads for
church AIDS
prevention
A-l
AIDS
org
U.S. Agency for
HIV/AIDS
(director)
F
Her office
in DC
30 min,
8-10-95
2
Strategies/ideas
for church
AIDS-related
events
A-l
AIDS
org
U.S. Agency for
HIV/AIDS
(religious
community liaison)
F
Her office
in DC
30 min,
8-10-95
2
Barriers to
AIDS dialogue
in black
churches
A-l
AIDS
org
Mt. Calvary AIDS
Ministry (director)
M
Church
AIDS fair
in DC
20 min,
8-12-95
2
History, goals,
and challenges
of his AIDS
ministry
(none)
Church
member
Mother living with
AIDS
F
Church
office
1.0 hr,
8-3-97
7
AIDS stigma,
challenges, hope
A-4
Church
member
Church youth
leader & focus gr.
member
F
Church
office
30 min,
8-3-97
2
Fotonovela
experiences
A-l
Clergy
Pastor (small, non-
denom. church)
M
His office
1.5 hr,
9-26-96
9
Youth ministry,
gay issues
A-2
Clergy
Pastor (large
Pentecostal church)
F
Her office
2.0 hrs,
6-4-97
10
Inroads for
church AIDS
prevention
A-2
Church
member
Teen & youth
leader in small
church
F
Her home
45 min,
7-4-97
5
Fotonovela
evaluation
A-3
Church
member
Teen who attended
small church
F
Friend’s
house
45 min,
7-4-97
5
Fotonovela
evaluation
A-3
Church
member
Bible study leader
F
Her home
30 min,
1-13-98
3
Member check:
follow-up
interview
(none)
TOTAL
13 individuals
11F,
2M
Eight
different
locations
12,3
hours
69 pages
(8 tapes)
18 major
topics
Four
protocols
TABLE 1: In-depth Interviews with African American Key Informants
222

The woman in the present study participated in one of the focus groups, without
the other group members knowing that she had AIDS. She agreed to do an in-depth
interview only after participating in the group session and negotiated the time and terms
of the interview through her pastor, the only local person other than health care workers
who knew that the woman had AIDS. She said she wanted to do a private interview
because she could relate to stories shared by women who had a loved one die of AIDS
and because “the Lord had everybody placed there for a purpose.”
However, she said she was afraid to reveal her HIV status to the other women in
the focus group:
The one lady who was talking about her brother, I could relate to that. I could sit
down and talk to her all day, ‘cause she and I are on the same level. The lady that
talked about the dying child, and the other lady in the comer who talked about her
daughter, I could relate to that. I was sitting there relating to all those stories, but
I couldn’t talk like I wanted to.
The rationale for selecting African American ministers and community leaders
for interviews was based on the positional-panel method of community reconnaissance
(Nix, 1977), in which leader-respondents are selected on the basis of their formal
authority in critical community sectors. This method was used by the Minnesota Heart
Health Program (Bracht, 1988) not only to identify influentials but also to involve them
directly in campaign planning to promote the eventual community ownership of the
campaign.
The names and addresses of African American clergy from 53 churches in
Gainesville and outlying areas within Alachua County were compiled from lists provided
by the North Central Florida AIDS Network, the Gainesville Black-on-Black Crime Task
Force, and by Florida Representative Cynthia Chestnut. These lists were used to assess
223

the denominational diversity of the religious community and to develop key informant
contacts, including ministers and female lay leaders, within several key churches. In
evaluating the denominational diversity in Alachua County, about 40 percent are
Missionary Baptist and other Baptist churches, 30 percent are Pentecostal, 7 percent are
United Methodist, and 4 percent are American Methodist Episcopal (AME) churches.
Focus Groups
Focus group interviews have been used in health communication research to
assess beliefs and attitudes, design materials and programs, and evaluate programs
(Heimann-Ratain, 1985; Shepherd & Achterberg, 1992). The methodology also has been
commonly used by advertising agencies and other marketing organizations to explore
consumer attitudes about advertising and new product development. In social marketing,
the technique typically involves one to two-hour, semi-structured interviews with small
groups. The exchange of ideas and opinions in the focus groups can prove more valuable
than opinions emerging through one-on-one interviews.
Focus groups provide a way of investigating issues by allowing participants to
critique, comment, explain, and share their experiences, opinions, and attitudes.
Interaction among participants generates discussions that provide a deeper understanding
of issues (Krueger, 1994).
Focus groups alone cannot provide an adequate basis for assessing a population’s
educational needs and the best strategy toward reaching them with HIV prevention
information. Rather, focus groups should be triangulated with other methods of inquiry
such as long interviews, participant observation, surveys, experiments, or analysis of
224

population data. In addition, the most critical component of program development is an
organization’s ongoing experience in working with a target population (USCM, 1990).
Blacks Educating Blacks About Sexual Health Issues (BEBASH1) of
Philadelphia, a community-based AIDS education organization, conducted teen focus
groups to define commonly held beliefs about sexuality, AIDS, and relationship issues,
then used this information to design pamphlets targeting black teens (Sanders, Egbuonu,
& Hassan, 1988). The BEBASHI empowerment-based strategy was used as a model for
focus group data collection in the present study.
The primary objectives for the focus groups conducted in this study were to use
an AIDS prevention fotonovela as a springboard for discussions about actual and
perceived barriers and inroads to HIV prevention within the church, to demonstrate how
this tool can be used in discussing AIDS issues with youth, and to get feedback about
how it might be improved for use as a full-scale intervention in the future. Specifically,
the research domains for the focus groups included
• AIDS knowledge: transmission, black genocide theory, and sources of
information about AIDS.
• AIDS attitudes: emotional responses, views of Magic Johnson, reactions to
people living with AIDS, such as stigma and fear.
• Perceived susceptibility to AIDS: meta-perceptions about other black teens
and whether they see the issue as “close to home.”
225

• Trust and source credibility issues: Whom they talk to about sex or AIDS.
• Drug and alcohol use as AIDS risk factors and the extent that these behaviors
are perceived as common among peers.
• Premarital sex and abstinence: views about what is real and what is realistic.
• Sexual scripting and social influence in hypothetical sexual situations.
• Religious dialogue about AIDS and sex, including views about AIDS talk in
this context and the role of religion in their lives.
• Barriers and inroads to AIDS education efforts in the church.
• Knowledge and attitudes about AIDS and risk behaviors.
• Connections between religiosity and AIDS-related attitudes.
• Social contexts and settings relevant to the promotion of sexual abstinence.
• Personal relationships with youth and efforts to provide guidance.
• The role of church and church leaders in educating youth about AIDS.
• Perceptions of AIDS-related susceptibility, seriousness, and threat in the
community.
• Effectiveness of using a fotonovela as an AIDS prevention tool targeting
African-American youth.
The two churches that facilitated the focus group sessions had been identified as
early adopters of AIDS dialogue in Gainesville’s African American community.
Ministers from these churches had attended at least one of the two annual Faith
Community AIDS Awareness Forums sponsored by the African American AIDS Task
226

Force. The ministers’ attendance at these events was considered evidence of their
awareness, interest, and willingness to be publicly associated with potentially
stigmatizing AIDS issues.
The focus groups were conducted in a church, a community center, and in a low-
income housing project facility with African American youth in vacation Bible school
and a summer community youth program, as well as African American women who were
members of new Bible study group at a subsidized housing facility. Rather than use a
single list of questions for multiple focus groups, the investigator developed five different
protocols based on intervention-based goals for each of 10 focus groups in the study:
• Girls and boys pilot groups, in which participants discussed their AIDS
knowledge, attitudes, and beliefs (Appendices B-7).
• First-round girls and boys groups. Topic: AIDS knowledge, attitudes, and beliefs
(Appendices B-l and B-2).
• Second-round girls and boys groups. Topic: fotonovela evaluation and strategies
for disseminating the booklet among peers (Appendix B-3).
• Third-round girls and boys groups. Topic: The fotonovela-bascd conversations
they had with friends and family members (Appendix B-4).
• First-round women’s group. Topic: AIDS knowledge and beliefs, strategies for
sharing the fotonovela with youth (Appendix B-5).
• Second-round women’s group. Topic: fotonovela evaluation and the
conversations they had with youth about this booklet (Appendix B-6).
227

The chart on the following page, Table 2, displays the composition, goals, and
context of each focus group, and the subsequent discussion provides further
methodological details about these groups.
In light of the totals reported at the bottom of the chart (Table 2), it is important
to note that several teens and women participated in more than one focus group. A total
of 14 women participated in a focus group, while a total of 20 youth participated in the
two pilot study focus groups. It is not possible to determine the number of adolescents
who participated in the other six focus groups because each child was required to bring a
signed parental consent form only prior to the first time that he or she participated.
Thus, most youths participated in three groups but were not identified by name after the
first day because of a confidentiality agreement.
Pilot Study
The pilot study was conducted as part of a Vacation Bible School program in an African
American, non-denominational church (Appendix B-7). Separate focus groups of 10
girls and 10 boys were interviewed about AIDS knowledge, attitudes, and beliefs by
the investigator and a white male graduate student. In describing the nature of the church
that served as the pilot study site, its pastor remarked:
There are no rules about wearing hats or certain kinds of clothing. There’s
nothing that identifies us as different.
After the pilot focus group sessions, the youths participated in a pizza party and a two-
hour, skit-writing workshop. During this workshop, the investigator asked the youths to
volunteer ideas for various plots, scenarios, and AIDS prevention messages for original
skits in an informal, classroom-style environment. The investigator listed these
228

Time¬
line
Group
Type
Sex
Age
Group
Size
Length,
Date
No.
pages
Setting & Church
Linkage
Session
Objectives
Pro¬
tocol
Week
Pilot
F
10-
10
1.0 hr,
8
Vacation Bible
HIV knowledge
B-7
1
youth
17
6-17-97
School (church)
& attitudes +
skit writing
Week
Pilot
M
10-
10
1.0 hr,
8
Vacation Bible
HIV knowledge
B-7
1
youth
16
6-17-97
School (church)
& attitudes +
skit writing
Week
1st
F
10-
11
1.0 hr,
13
After-school
HIV knowledge
B-2
3
youth
16
6-30-97
enrichment
& attitudes +
program at church
skit writing
Week
1st
M
10-
9
2.0 hrs
9
After-school
HIV knowledge
B-l
3
youth
16
6-30-97
enrichment
& attitudes +
program at church
skit writing
Week
2nd
F
10-
9
45 min,
12
After-school
Fotonovela
B-3
4
youth
16
7-7-97
enrichment
evaluations &
program at church
IP strategies
Week
2nd
M
10-
3
45 min,
8
After-school
Fotonovela
B-3
4
youth
16
7-7-97
enrichment
evaluations &
program at church
IP strategies
Week
1st
F
25-
6
30 min,
5
Bible study in
HIV knowledge
B-5
4
women
65
7-10-97
low-income
& attitudes,
apartments
fotonovela
strategies
Week
3rd
F
10-
9
30 min,
37
After-school
Fotonovela
B-4
5
youth
16
7-10-97
enrichment
program at church
experiences,
peer evaluations
Week
3rd
M
10-
6
45 min,
5
After-school
Fotonovela
B-4
5
youth
16
7-10-97
enrichment
program at church
experiences,
peer evaluations
Week
2nd
F
25-
12
1.5 hrs,
33
Bible study in
Fotonovela
B-6
7
women
55
7-24-97
low-income
evaluations &
apartments
experiences
TOT
10
4M
85 =
11.3
138
3 different
8 session
9
groups
6F
57F +
28M
hours
pp.
locations
objectives
TABLE 2: Focus Groups of African American Adolescents and Women
ideas on a large paper pad and gave the youths a skit-writing handout (Appendix C-l)
designed to help them develop characters, setting, scenario, conversation, and important
factual information to include in their scripts.
229

After the group discussion, pairs and small groups of youths collaboratively
brainstormed and jotted down their scripts using neon-colored pens and pastel-colored
legal pads. The youth were permitted to write and discuss anything they wished.
Although several adults supervised the workshop, the youths were not told to use any
particular formula or theme.
After 45 minutes of collaborative writing, the youths were given the chance to
perform their skits and raps for the entire group. An “AIDS Peer Education Award”
certificate was presented to every skit workshop participant during a worship service the
following Sunday. In addition, yogurt shop gift certificates were awarded to authors of
the first-place skit.
An analysis of transcripts from the pilot focus groups and field notes from the skit
workshop helped refine the protocols, moderator training guidelines, and skit workshop
procedures for the/oto«ove/a-intervention youth focus group sessions.
Youth Focus Groups
The focus groups for youth and women served a dual purpose in this study: (1) to
enable participants to develop, distribute, and evaluate a fotonovela targeting youth with
AIDS prevention advice, and (2) to explore attitudes, beliefs, and perceptions of others’
behaviors through semi-structured interview protocols and through discussion of the
fotonovela at every stage of its development and testing. Figure 16 is a comparison chart
of all focus groups.
Within the setting of an after-school summer enrichment program sponsored by
another Pentecostal African American church, three rounds of focus groups were
230

conducted with boys and girls during a three-week period. The participants were
separated into girls and boys focus groups. The average age of the adolescents was 13,
while their ages ranged from 10 to 16. A 16-year-old African American girl was trained
to moderate the three girls’ groups, while a 20-year-old African American man was
trained to moderate the boys’ groups.
The first round of focus groups, with 9 boys and 11 girls in the summer
enrichment program, required VA hours. The protocols for these groups (Appendices B-l
and B-2) were designed to obtain a baseline assessment of knowledge, attitudes, and
beliefs about AIDS and sexuality, as well as views of AIDS-related dialogue in various
contexts.
The session began with the showing of “On the Pillow,” a dramatic video about
an African American teenage boy who becomes HIV infected and seeks comfort from his
minister (Appendix C-6). The 9-minute video was produced, written, directed, and
photographed by Parrish Smith, a former graduate student at Howard University Divinity
School (Smith, 1995). The 1995 film tells the story of Terrence, who becomes drunk
with his friends, goes home with a beautiful stranger named Crystal, and discovers a note
from her the next morning welcoming him to the world of AIDS. After testing positive
for HIV, Terrence confides in his minister, the Rev. Barnes, that he has probably infected
his pregnant fiancée, Alicia.
The focus group moderators encouraged participants to comment on issues
presented in the video, including issues of AIDS awareness, abstinence, risky behaviors,
and communication with adults about dating relationships.
231

After the first-round focus group sessions ended, all youths participated in a pizza
party and a two-hour workshop in which they wrote and performed skits and raps about
AIDS. At the end of the summer, an “AIDS Peer Education Award” certificate
(Appendix C-5) was presented to every focus group participant during an awards
ceremony.
The second round of focus groups, in which 3 boys and 9 girls participated, was
conducted one week after the first round. The second round protocol (Appendix B-3)
was designed to solicit feedback about the fotonovela and to elicit strategies for using the
booklets as a peer education tool.
The third round of focus groups, in which 6 boys and 9 girls participated, was
conducted a week after the second. This final group protocol (Appendix B-4) asked
youth to talk about their experiences in sharing the booklet, as well as their peers’
evaluations and reactions. In addition to asking participants to assess the nature and tone
of these real-life conversations, they were asked to discuss strategies and preferred
settings for future conversations. If any individual participated in the third session but
not the second, he or she was asked to provide an evaluation of the fotonovela itself
rather than personal experiences in using it.
Women’s Focus Groups
Given that ties between women constitute the core of the social network within
the African American community (Stack, 1974), women were recruited to serve as
opinion leaders for disseminating an AIDS prevention fotonovela to youth.
232

The moderators for the women’s groups were two African American women: a
church leader interested in AIDS ministry, and an African American AIDS Task Force
member who also was a registered nurse and trained AIDS educator.
Two women’s focus group sessions were conducted during a two-week period
that was concurrent with the youth focus group schedule. The women in both focus
groups met at a subsidized apartment complex, in a small brick clubhouse furnished with
folding metal chairs and tables, a television, and kitchenette.
A female pastor recruited participants for both women’s focus groups by asking
church members to recruit friends to attend a “special AIDS program” that would launch
a new weekly Bible study group in the apartment complex. The ages of the women
recruited for the focus groups ranged from early 20s to late 60s, while most were in their
early to mid-30s.
During the first women’s group (Appendix B-5), the six participants watched the
“On the Pillow” video, received copies of the fotonovela (Appendix D), and discussed
strategies for sharing the booklets with youth. Three informative handouts were provided
to stimulate this discussion: “Tips for Using the Story Booklet,” (Appendix C-2), “How
to Break the Ice” (Appendix C-3), and “How to Talk to Kids about Sex” (Appendix C-4).
Overall, each woman was encouraged to endorse the positive value and benefits of sexual
abstinence, to avoid a “preachy” tone (i.e., “You should not... ”), to use herself as an
example in conversations whenever possible (i.e., “I had a similar experience when I was
your age...”), and to explain why she is sharing the fotonovela.
233

During the second women’s group (Appendix B-6), the 12 participants were asked
to evaluate the fotonovela and discuss their experiences in sharing the booklets with
youth.
Moderator Training and Protocol Development
Each of the six focus group protocols (Appendices B-l through B-6) was a
comprehensive list of questions designed to address certain topics and meet specific
objectives. The protocols included a moderator’s guide to help ensure compliance with
research procedures and to serve as an aid in conducting the focus groups.
Four focus group moderators were trained to explain objectives and ground rules
for their sessions. In an effort to promote an open and non-threatening atmosphere and to
help participants better articulate their feelings, the investigator trained moderators to use
transitions and prompts, to mirror participants’ comments, and to provide summaries of
topical discussions.
The moderators also were instructed to refrain from personally responding to the
questions or from making other comments not included in the protocol, except to re¬
phrase a question or to recap a discussion. Although some participants displayed
disruptive behavior or talked at length about topics unrelated to study goals, neither the
investigator nor the moderators displayed disapproval during data collection. In addition,
the tasks of discipline and controlling the discussion were left to the moderators.
Moderators were encouraged to help respondents feel relaxed, to manage group
dynamics in such a way that the greatest number of people could participate, and to ask
questions in a tone that does not bias the answers.
234

For each focus group session, the questions were listed by topic within a detailed
protocol that included introductory statements, open-ended questions written in a non¬
threatening tone and first-person voice, transitional statements, and a checklist of topics
at the end. Some questions asked participants to think about hypothetical situations,
while others were designed to elicit meta-perceptions. In general, the questions that
asked participants to voice potentially embarrassing personal views were listed after the
questions that asked them to speculate about the views of their peers.
The focus group questions were based on the research objectives, concepts from
the theoretical framework, and issues discussed in previous in-depth interviews and
during the pilot focus group study. Questions were designed to allow the respondents to
follow their own thought processes. Some questions were rephrased or otherwise
clarified after moderators offered suggestions during training about items that they found
to be confusing.
Fotonovela Development
Adolescents aged 10 to 16 were the target of the fotonovela demonstration.
Youth in this age group, as well as women aged 18 and older, were the key opinion
leaders selected for dissemination of the fotonovela to targeted youth. About 20 youth
participating in the summer program, as well as 6-8 youth involved in the pilot group,
contributed skit scripts that were synthesized into a single fotonovela script. The youths
wrote these scripts as part of an AIDS skit workshop, described earlier in this chapter.
Excerpts from the youth-written skits, as well as ideas obtained through one-on-
one conversations and observed behaviors, were combined to produce a story line and
235

script. This narrative was intended to portray everyday situations experienced by African
American teens in this age group, using slang and other colloquialisms popular among
the youth. The names of characters were borrowed from various youth-written skits.
The fotonovela narrative depicted African American youth discussing HIV-related issues
in an abstinence-based context.
The fotonovela was pretested before it was published for distribution to focus
group participants. Pretesting AIDS prevention materials is “a systematic process of
testing target audience reactions to specific messages, vocabulary, visuals, sequences,
and materials before they are produced in final form,” and it “allows programmers to
determine if materials are clear, persuasive, attractive, and seen as relevant among a
particular audience” (Smith & Debus, 1992, p. 68).
A draft of the fotonovela script, including the story, raps, and AIDS facts, was
reviewed and critiqued by two 16-year-old girls who were not focus group participants.
The girls both attended a small, conservative church other than the one sponsoring the
summer youth program, and one girl was a church youth leader. The pretest was
conducted prior to the photo sessions because the evaluators’ recommended changes in
the script required a revision of the planned storyboard as well. The girls’ opinions were
solicited during a one-hour, taped discussion session at the home of one of the evaluators
(Appendix A-3).
As suggested by Krueger (1994) and Meade & Smith (1991), the girls evaluated
the script on such criteria as leamability, reading ease, organization of information,
legibility, motivation or interest in the material, cultural appropriateness, the amount of
236

time required to read the material, and possible effects of a reader’s experiential history
and prior knowledge. This feedback was used to edit and refine the fotonovela, such that
it could be written at a 6th grade reading level.
After the final revision of the fotonovela script was finished, 15 members of the
summer youth program were photographed for the illustrations needed to coordinate with
the script and raps. Using a 35-mm zoom-lens camera, the investigator took posed
photographs of youth acting out each scene of the skit. In addition, candid photos were
taken of various everyday, non-staged youth activities such as boys playing basketball in
the parking lot and girls practicing their step show on the sidewalk.
Out of 85 color photos taken, 20 were selected for use in the fotonovela. These
photos were scanned in grayscale and paired with the script, using Microsoft Word
software, in order to assemble the final booklet. More than 300 copies of the fotonovela
were individually printed in black-and-white on an inkjet printer, and each booklet was
hand-folded. The fotonovela could not be effectively photocopied because the gray tones
were eliminated, regardless of the photocopier quality or settings. (For future fotonovela
interventions, it is recommended that the booklets be printed in bulk using an offset
printing process to minimize the time and expense of hand-printing and folding.)
A fotonovela “kit” for focus group participants consisted of a business-sized
envelope containing 5 to 10 booklets and a small log sheet where the focus group
participant could record the names of those with whom they shared the booklets.
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The moderators distributed the kits to the focus groups, after asking each
participant to think of four individuals with whom he or she intended to share the
fotonovela before the follow-up focus group session.
Fotonovela Content
The fotonovela used in this study was a short, illustrated drama presented in a tri¬
fold, legal-size brochure format (Appendix D). Although the traditional fotonovela
format used in Hispanic communities is typically much longer, at least 10 pages in
length, prior research shows that a shorter format may be more culturally appropriate for
African-American audiences (Gromley, 1996). In a study of HIV sexual risk reduction
interventions for African American women, DiClemente and Wingood (1995) found that
a brief, social skills-based and contextually relevant educational intervention can have
more value than a longer but less-tailored HtV education intervention. Similarly, the
BEBASHI program described earlier in this chapter encouraged African American teens
to contemplate the challenge of standing up against peer pressure in their community
(Sanders, 1988).
The primary objectives of the fotonovela in the present study were
• To educate African American women and youth, including low-literacy
individuals, about abstinence-based AIDS prevention.
• To encourage them to ask more questions and seek more information.
• To encourage them to initiate dialogue and offer social support in discussing
AIDS-related issues.
• To take preventive measures to slow the spread of AIDS
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In developing an AIDS prevention video message, Maibach (1989) found that
those who model the behaviors should be similar to the audience in gender, age, race, and
attitudes, and behavior strategies should be demonstrated in settings similar to those that
the audience will encounter.
The fotonovela script attempted to incorporate elements of humor, drama, and
romance, as well as the consequences of AIDS. The skit highlighted who is vulnerable
and why, promoted personal control in AIDS prevention, provided information about
HIV transmission, showed that the AIDS threat is local and close, and demonstrated
strategies for interpersonal communication about AIDS.
Intended Outcomes
This study explored how various predisposing and environmental factors
informed the design and delivery of a fotonovela targeting African American youth, how
cognitive and normative processes affected their involvement in the intervention, and
how culturally specific barriers and enabling factors mediated their attitudinal and
behavioral responses to the fotonovela. The intended outcomes of the fotonovela
intervention included:
• Open dialogue about AIDS prevention, between and among adolescents and
adults.
• Verbal expressions of interest in AIDS issues.
• Greater individual awareness and knowledge about AIDS-related behavioral risks.
• Changes in social norms within church-based networks, including the initiation of
AIDS prevention dialogue by opinion leaders.
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• Sexual abstinence or the postponement of further sexual involvement.
• Open but sensitive dialogue about condoms, in a manner and context that is
acceptable among religious individuals.
Consistent with the goals of communication network research, as described by
Rogers and Kincaid (1980), the present study attempted to identify communication roles
as well as connectedness between individuals and within personal networks. These roles
were assessed by examining the number of youth who received fotonovelas from focus
group participants, the criteria that participants used to select these young people, the
nature of social relationships between the participants and the youth they targeted, and
the settings where the youth were contacted.
Readability Analysis
Readability is commonly defined as “interesting to read” or “capable of being
read easily.” A readability formula is a mathematical equation that estimates the number
of years of education needed to easily understand a selection of text (Hitchner, 1991).
Most HIV educational materials developed for use by injecting drug users is
written at a reading level several grades above that of the target audience (Johnson,
Mailloux, & Fisher, 1996). Readability formulas are a desirable tool for evaluating AIDS
prevention materials because of their long-standing use in school settings, their half-
century reputation for methodological accuracy for categorizing reading materials by
grade level, and reported internal consistency within and between various formulas when
determining reading levels (Meade & Smith, 1991).
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Readability formulas are intended to be used as an evaluation tool for revision of
a completed text, not as a tool for writing a text (McClure, 1987). Given that the targeted
readers of the fotonovela were in middle school (6th and 7th grades), a desirable
readability score for this study would be 6th grade or lower. Similarly, Davis (1989) used
language appropriate for readers at the 5th grade reading level, corresponding to the
average Gunning Fog Index score of articles in popular magazines, in designing an
instructional pamphlet for condom displays in pharmacies. To ensure that the fotonovela
scripts could be comprehended by the average African American reader aged 12 or older,
readability scores were computed for each revision of the fotonovela until a score was
achieved that corresponded to a 6th grade reading level.
The Gunning Fog Index, the most widely used and documented readability
formula (Wells & Spinks, 1991), was used to compute these scores. This formula, unlike
others, is designed to measure levels of comprehension rather than levels of speaking
(Gross & Sadowski, 1985). Davis (1994) argues that the Fog Index is more stringent, and
thus tends to compute higher-grade levels for texts than other readability formulas.
Robert Gunning (1968) used the word “fog” because he felt that most writings
were clouded and muddled - only after the “fog” settled could the true meaning of a
writing be revealed and understood (Spinks & Wells, 1993). The Fog Index reading
grade level is computed by multiplying 0.4 by the sum of the average number of words
per sentence and the percentage of words containing three or more syllables. Word length
is associated with precise vocabulary, which means a reader must exert extra effort to
identify the meaning of words containing more than one syllable. Long sentences
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typically have complex grammatical structure and thus require readers to remember
several parts of the sentence before they can combine the parts into a meaningful whole
(McLaughlin, 1969).
The SMOG Grading formula developed by Fry (1968) is considered to be more
valid than other readability formulas, including the Flesch Reading Ease, Dale-Chall,
Spache, and Wheeler & Smith formulas, as well as the Cloze procedure and the McCall-
Crabbs Test Lessons in Reading (Meade & Smith, 1991; McLaughlin, 1969). However,
the SMOG formula does not compute a readability score below sixth grade and thus is
not usable in this study. Olson (1986) reported a correlation coefficient of R=.67
between the SMOG formula and Fog Index, the highest correlation of any pair of six
different readability formulas.
Thus, for reasons of optimal validity and logistics, the Fog Index was considered
the most appropriate formula for evaluation of the fotonovela’s readability. Beyond
assessment of semantic and syntactic complexity using Fog Index score calculations, the
overall readability of the fotonovela was evaluated using feedback from youth
informants.
The Fog Index also was used to assess the readability of the informed consent and
youth assent forms. These calculations showed that the women’s focus group form was
written at a 10th grade level, while the parental consent form was written at a 13th grade
level (high school graduate) and the youth assent form was written at a 6th grade level.
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This procedure was considered essential in light of Priestly et al’s (1992) study
which showed that 96 percent of consent forms for research on adults were more difficult
to read than an average newspaper article, which is typically written at a 13th grade level.
Similarly, Goldstein (1996) found that the average reading level of university-sponsored
consent forms was 12th grade, and less than 10 percent of the forms were written at a 10th
grade level or below.
Informed Consent
Participants were required to express a willingness to articulate their opinions and
to assist with the goals of this study and were given the opportunity to opt out of the
discussion.
All participants in the in-depth interviews were asked to sign a consent form
(Appendix F-l). A standard form also was used for participants in the adult women’s
focus groups (Appendix F-2). A youth assent form (Appendix F-4) was read to youth
focus group participants at the beginning of each session. Each child was required to
bring a signed parental consent form (Appendix F-3), and children who did not present
this form were not interviewed or photographed.
Transcripts from the in-depth interviews and focus groups were not shown to
others, in compliance with confidentiality restrictions of the informed consent agreement.
The interviews did not pose physical, economic, nor psychological harm to any
participant, although participants may have benefited by gaining new understanding
about AIDS risks and about what they could do personally to help slow the spread of the
disease in their community. Although a few participants may have considered certain
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topics to be controversial, no question probed into personal sexual behaviors or other
issues that might be considered personally embarrassing. Preliminary conversations with
African American leaders suggested that controversial themes might include condom use,
drug abuse, homosexuality, promiscuity, stigmatization of people with AIDS, and
genocide beliefs.
Focus group moderators were paid $10 an hour for their assistance, while focus
group and in-depth interview participants were not compensated. Funding for the
moderator stipends was provided by a Graduate Student Research Award grant from the
University of Florida College of Journalism & Communications.
Data Analysis Procedures
Focus group interview data was compared with individual interview data to show
patterns in the influence of peer norms on individual attitudes, values, and beliefs about
AIDS prevention. Direct quotes from participants were included to provide a feel for the
narratives, and paraphrases also were used to help contextualize many remarks.
The data analysis generally was driven by the research question, “What are the
inroads and barriers to AIDS dialogue within social networks among African
Americans?” Given that the themes were organized using a theoretical framework, the
contexts of participant comments and observations were identified using only simple
labels that identified the gender (male or female), age (youth or adult), and type of
interview (focus group or long interview). This data analysis strategy permitted
conceptual, rather than contextual, comparisons and interpretations of various narratives.
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In analyzing the transcripts and field notes from participant observations, long
interviews, and focus groups, the investigator subdivided these data-texts into small
“chunks” (each comprised of a word, phrase, sentence, or paragraph) and then assigned a
descriptive, interpretive, or pattern-oriented label to each chunk. From an initial list of
246 labels (Appendix E), a coding scheme was developed that synthesized conceptual
tags ranging from micro to macro levels. In general, the resulting themes accounted for
settings/contexts, definitions of situations and topics, perspectives, ways of thinking
about people and things, processes, activities, events, strategies, relationships, and social
structures.
The exploratory research design elicited data from a wide variety of settings and
sources, using a sequential and iterative methodology. This approach created a data set
comprised of far more topics and perspectives than likely would have been accumulated
through the traditional method of using one protocol for all individuals or groups. Thus,
a major challenge in analyzing this data was to find a way to effectively organize the vast
array of concepts while logically and systematically modifying the existing theories that
predict the prevention of AIDS risk behaviors. This was accomplished by
contextualizing the emerging themes and interpretations within the conceptual
framework and by using verbatim excerpts from the transcripts to illustrate these themes.
Theme analysis was conducted through scanning all data-texts for commonalties
and differences, comparing incidents applicable to emerging categories, and integrating
categories and their properties. The categories and terminology were eventually
delimited to achieve parsimony and scope, at the point where the category set became
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theoretically saturated and new incidents added little, if any, new value to its conceptual
content.
The theoretical model described in Chapter 2 was used as an organizing
framework for various sections of theme analyses of the data-texts. Both the framework
and theme analysis of various texts included and interpreted data-texts from focus
groups, interviews, and participant observation.
This approach has been advocated by Miles and Huberman (1994), who note that
an increasing number of qualitative researchers are using pre-designed conceptual
frameworks and pre-structured instrumentation (p. 20). The use of theoretical
frameworks are particularly useful for data analysis in large-scale qualitative studies,
given that “text is an unwieldy display device and that therefore better displays are a
major vehicle for valid and reliable research” (Henwood & Pidgeon, 1994, p. 230).
While the use of general, over-arching themes is an effective strategy for
qualitative data analysis in certain situations, the use of a theoretical framework as a data
analysis tool was a more appropriate approach in this study. The model was
conceptualized using existing theory and evidence, and subsequently it was re-evaluated
in light of new data.
The theoretical framework based on existing literature, presented in Chapter 2,
subsequently was modified in Chapters 4 and 5 through the examination of data-texts in
light of various constructs. Thus, the theoretical model was used to illuminate
comparative observations and other facets of the data. This approach is justified by the
assumption that useful, existing theory
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Illuminates what you are seeing in your research. It draws your attention to
particular events or phenomena and sheds light on relationships that might
otherwise go unnoticed or be misunderstood. (Maxwell, 1996, p. 33)
Maxwell (1996) asserts that some categories may be drawn from existing theory,
while other categories may be developed inductively by the researcher during analysis or
taken from the conceptual structure of the people studied. This dual strategy was used in
developing the categorization scheme. Miles and Huberman (1994) explain:
Categories such as ‘social climate,’ ‘cultural scene,’ and ‘role conflict’ are the
labels we put on intellectual ‘bins’ containing many discrete events and
behaviors. No researcher, no matter how inductive in approach, knows which
bins are likely to be in play in the study and what is likely to be in them. Bins
come from theory and experience and (often) from the general objectives of the
study envisioned. Setting out bins, naming them, and getting clearer about their
interrelationships lead you to a conceptual framework.... Having to get the
entire framework on a single page obliges you to specify the bins that hold the
discrete phenomena, to map likely relationships, to divide variables that are
conceptually or functionally distinct, and to work with all of the information at
once. (p. 18,22)
Similarly, Maxwell proposes a “theory as coat closet” metaphor to illustrate how
a framework that synthesizes existing theory can be used for qualitative data analysis:
A useful, high-level theory gives you a framework for making sense of what you
see, particular pieces of data that otherwise might seem unconnected or irrelevant
to one another or to your research questions can be related by fitting them into the
theory. The concepts of the existing theory are the ‘coat hooks’ in the closet; they
provide places to ‘hang’ data, showing their relationship to one another, (p. 33)
The use of existing theoretical concepts as coding categories also is an accepted
practice in qualitative research. For example, Gilgun (1994) argued that “previous
research and theoiy also provide concepts and hypotheses that can be used to organize
data” (p. 119). In the present study, the theoretical framework was the conceptual basis
247

for the analysis, but the findings were inductively derived and intended to reflect the
perspective of the informants.
Maxwell (1996) argues that qualitative researchers fail to make good use of
theory when they fail to “explicitly apply or develop any analytic abstractions or
theoretical framework for the study, thus missing the insights that only theory can
provide” (p. 36). Using concepts from prior theory is as valid as concocting interpretive
categories from the data, because as Henwood and Pidgeon (1994) argue,
“Philosophically speaking, theory cannot simply emerge from data. Observation is
always set within pre-existing concepts, and this raises the question of what grounds
grounded theory?” (p. 232). Miles and Huberman (1994) point out that a conceptual
framework serves to specify “who and what will and will not be studied” and it
illuminates some relationships among concepts.
Throughout Chapter 4, the theoretical model was used as an organizing
framework, not as a theory in itself to be “proven.” The study was constructed and
conceptualized such that the model was used as an organizing and framing device for the
data. Themes were developed within the various categories, using the topics and
language of the research participants. For example, six themes illuminated dimensions of
individual religiosity (i.e., “Reading the Word,” “The ‘Inner Spirit,’” The Life ‘Out
There,’” “The ‘Slip Up’”), and examples and discussion of each of these particular
themes were presented within the Predisposing Factors domain because those themes
and corresponding examples logically could be discussed under the broad concept of
religiosity as a psychographic variable in this particular context of the analysis. Other
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facets of religiosity were discussed elsewhere in the chapter, such as “pastoral norms”
and “church influence” within the Normative Processes domain; “compassion” and
“reinforcement of religious values” within the Enabling Factors domain; and the “just
world belief,” “church as protection,” “church politics,” “religious taboos,” “expectation
for divine healing,” and “church stigma” themes within the Barriers domain.
The eight theoretical domains used to organize themes were used as “intellectual
bins,” without which the investigator likely would have overlooked many important
distinctions and subtle dimensions of the various factors that influence AIDS preventive
behaviors among African Americans. Without such an organizing framework, the data
analysis would have been oversimplified, and a web of important theoretical distinctions
would have been lost that eventually facilitated the modification of existing theory. Most
themes and sub-categories that emerged from the data, described within each of the eight
domains, were different from the sub-categories that emerged from the existing literature.
Some properties within the domains are variables or other sub-categories of major
theories, while others are broad individual factors, such as religiosity, that are used as
headings to logically group together related themes that emerged from the data. Strauss
and Corbin (1990) recommended that categories be dimensionalized by separating out
their different properties. Similarly, Maxwell (1996) advised that
An initial framework often works best with large categories that hold a lot of
things you haven’t yet sorted out. However, you should try to differentiate these
categories, making explicit your ideas about the relationships among the things in
them. One way to start this is by analyzing each one into subcategories and
identifying the different kinds of things that go into each. (p. 32).
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While the intent of the study was not to “prove” the validity of the theoretical
framework, a key purpose of this study was to critically examine the constructs of
existing health communication theory through the cultural lens of the African American
community. This analysis was conducted in order to discover how various theoretical
concepts ought to be modified in order to develop a more culturally appropriate AIDS
prevention model.
The use of the theoretical framework facilitated the addition of new dimensions
to existing theoretical models such as the Health Belief Model and Theory of Reasoned
Action, and in turn, these cultural insights helped explain health behavior patterns among
African Americans. Villarruel and Denyes (1997) argue that in studying diverse ethnic
populations, “conducting theory-testing research is necessary to establish, verify, or
refute the link between theoretical concepts and unique realities” (p. 283). Maxwell
(1996) also supported this approach:
A review of relevant prior research can be a source of data that can be used to test
or modify your theories. You can see if existing theory is supported or challenged
by previous studies. Finally, you can use prior research to help you generate
theory (p. 43).
Similarly, Silva and Sorrel (1992) indicate that by using inductive theory testing
strategies, generalities that constitute the substance of theory can be identified. Mays and
Pope (1995) argue that if the findings “diverge from those predicted by a previously
stated theory, they can be useful in revising the existing theory in order to increase its
reliability and validity” (p. 111). Panitz (1997) argues that it is not sufficient for changes
to existing theory to be only “purely conceptual, suggesting further research” (p. 170).
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Given that the theoretical model was used as an organizing framework for data
analysis, the presentation of findings in Chapter 4 included discussion of theoretical
linkages. In their critique of the standards of rigor in qualitative research, Mays and Pope
(1995) support this approach:
It is not normally appropriate to write up qualitative research in the conventional
format of the scientific paper, with a rigid distinction between the results and
discussion sections of the account. It is important that the presentation of the
research allows the reader as far as possible to distinguish the data, the analytic
framework used, and the interpretation (p. 114).
Gilgun (1994) notes that many qualitative researchers “seek to link findings to
previous research and theory” (p. 117), and Howe and Eisenhart (1990) assert that
qualitative researchers must provide a “useful balancing of present research with broader
bases from other bodies of knowledge” (p. 2). Further, Silva and Sorrel (1992) state that
a major criterion of qualitative theory testing is that “findings are discussed in terms of
how they relate to existing theory” (p. 12).
The theoretical framing of data in Chapter 4 also is defensible by methodological
standards of qualitative research. In dealing with the “sheer volume of data customarily
available,” Mays and Pope (1995) argue, a researcher should “present extensive
sequences from the original data, followed by a detailed commentary.” They further
argue that a standard of rigor in qualitative research is that the researcher must “make
explicit in the account the theoretical framework at every stage of the research” (p. 114).
In addition, Gilgun (1994) asserts that framing findings with previous research, theory,
and “practice wisdom” can enhance practitioner utilization of the research findings (p.
123).
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Maxwell (1996) further recommends that the conceptual framework serve to
present the data analysis “in a form that allows it to be grasped as a whole” (p. 80).
Similarly, Miles and Huberman (1994) argue that flowcharts or figures representing
causal networks are particularly useful for “analysis of a wide range of problems and
settings” (p. 11).
Many previous qualitative studies (i.e., Hirschman & Thompson, 1997;
Contractor & Eherlich, 1993; Villarruel & Denyes, 1997) have used a framework of
existing theory as a data analysis tool. In their study of consumers’ relationships with
advertising and mass media, Hirshman and Thompson (1997) drew upon theories from
several different disciplines to develop an analytical framework that included concepts of
ideological structures, cultural frames, active readership, production of meaning, and
consumer socialization. These constructs were used to frame research questions and to
identify interpretive strategies that consumers use to form relationships with the mass
media. The authors explained that “concepts and findings from relevant prior research
are used to provide context for our discussion and a theoretical web for the results” (p.
47).
Threats to Validity
Qualitative research has its own set of standards of quality and rigor. In
describing the potential roles of qualitative research in AIDS prevention, Smith and
Debus (1992) assert that
Not every casual conversation is an ‘in-depth interview,’ not every group meeting
is a ‘focus group,’ and not every neighborhood visit is an ‘ethnographic study.’ (p.
70)
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While a number of quality checks can help ensure that qualitative research is
carried out rigorously, it is important to evaluate and weigh each recommendation in
light of the particular objectives of a study rather than to indiscriminately apply some
textbook “recipe.” Maxwell (1996) warns that
Ultimately the identification of plausible validity threats requires a creative and
open-minded approach, rather than simply going through a pre-established
checklist such as that given by Campbell and Stanley (1963). (p. 93)
The following list offers remedies to common threats to validity in qualitative
research, and each recommendation is discussed in light of the research design of the
present study.
1. Use verbatim transcripts of audio/video recordings of interviews. Smith and
Debus (1992) recommend that a data analysis description include quotes from
participants as well as paraphrased remarks because this data “permits the planner
to get a direct feel for the data” (p. 70).
A related threat to valid description is the inaccuracy or incompleteness of
the data. In the present study, tape-recorded discussion during all in-depth and
focus group interviews was transcribed verbatim, including the participants’ use
of slang, improper grammar, rambling, and colloquialisms. Each transcription
was verified against the tapes. In addition, the investigator did not rely on
memory, impressions, or hand-written notes except in conducting participant
observation.
2. Use member checks. According to Guba and Lincoln (1989), obtaining member
checks involves systematically soliciting feedback about one’s data and
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conclusions from the people being studied. While the participants’
pronouncements are not necessarily valid, their responses are taken simply as
evidence that the researcher’s account is valid (Hammersley & Atkinson, 1983).
In the present study, numerous informal member checks, including a more
structured member review of findings, were conducted throughout the data
collection and analysis phases of the research.
3. Use open-ended questions. Asking leading, closed, or short-answer questions
does not give participants the opportunity to reveal their own perspective. Most
questions in the in-depth and focus group protocols were open questions, and
group moderators were trained to use question prompts to further encourage
participants to elaborate. Stewart (1990) explained that closed questions elicit
brief answers like yes or no or maybe, whereas open questions “invite long,
unrushed, rambling answers.” He also noted:
Leisurely open questions get to the heart of things faster than those fast-
paced, closed inquiries. Using open and closed questions with some
awareness is basic to effective information gathering.... Learning and
using (these talk tools) as adults won’t guarantee results, but getting
accustomed to using the right tool can make stunning improvements in
effective information gathering, (p. 72)
4. Triangulation. Patton (1989) argues that triangulation of data sources, theories,
investigators, and/or data collection methods can help remedy threats to validity
caused by the subjectivity of interpretation. In this study, all four of these types of
triangulation were used to improve the validity of the research results.
Patton (1989) states that investigator triangulation is “the use of one or
more researchers or evaluators.” Further, investigator triangulation is not limited
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to the use of multiple coders. Flynn et al (1991) argue that investigator
triangulation can take the form of multiple observers who participate in data
collection. In the present study, four focus group moderators not only assisted in
data collection but also offered their own insights about their observations.
Given the type of data analysis needed to expand and modify existing
theory, the author of this study was the sole coder of the data-texts. The use of
only one coder is acceptable practice in qualitative research. In describing basic
steps of qualitative data analysis, Kvale (1996) notes that “the transcribed
interview is interpreted by the interviewer, either alone or with other researchers”
(p. 189) and “the analysis of interviews is often undertaken by the researcher
alone” (p. 208).
Maxwell (1996) argues that qualitative research “is not primarily
concerned with eliminating variance between researchers in the values and
expectations they bring to the study, but with understanding how a particular
researcher’s values influence the conduct and conclusions of the study” (p. 91).
Kvale (1996) suggests the use of multiple interpreters as one way of controlling
analysis, but in the same discussion, she states:
An alternative to a multiple interpreter control of analysis is that the
researcher present examples of the material used for the interpretations
and explicitly outline the different steps of the analysis process, (p. 209)
5. Use rich data. “Rich” means that data is “detailed and complete enough that they
provide a full and revealing picture of what is going on.... The key function of rich
data is to provide a test of one’s developing theories, rather than simply a source of
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supporting instances” (Maxwell, 1996, p. 95). Becker (1970) argues that the use of
rich data “makes it difficult for the observer to restrict his observations so that he sees
only what supports his prejudices and expectations” (p. 53). In the present study,
theme analysis of all data was performed before examples were contextualized for
the purpose of theory generation and modification. Extensive excerpts were used
throughout the analysis to show the views of the participants.
6. Use comparisons of data. Miles and Huberman (1984) argue that qualitative studies
that evaluate individuals at more than one site should use comparisons in the data
analysis because the discussion of different settings can contribute to the
interpretability of cases and help the researcher ascertain the importance or impact of
various settings. In the present study, data comparisons were warranted because
participants were interviewed in a variety of settings, and several participated in in-
depth or focus group interviews at more than one site.
7. Integrate research participants ’ views into the interpretive framework A threat to
valid interpretation is imposing one’s own framework or meaning, rather than
understanding the perspectives of the people studied and the meanings they attach to
their words and actions (Maxwell, 1996). Maxwell further asserts that
The most important check on such validity threats is to seriously and
systematically attempt to learn how the participants in your study make sense of
what’s going on, rather than pigeonholing their words and actions in your
framework. ... However, it is clearly impossible to deal with these problems by
eliminating the researcher’s theories, preconceptions, or values (p. 91).
Maxwell warns that whenever a qualitative researcher imposes theory on a
study, it can lead to some degree of
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Shoehoming questions, methods, and data into preconceived categories and
preventing the researcher from seeing events and relationships that don’t fit the
theory.... To be genuinely qualitative research, a study must take account of the
theories and perspectives of those studied, rather than relying entirely on
established views or the researcher’s own perspective (p. 36).
Using Maxwell’s recommendation, the present study addressed this threat to
validity by developing theories and continually testing them and by looking for
discrepant data and alternative ways, including the research participants’ ways, of
making sense of the data. Examples of discrepant or exceptional data, particularly
cases that did not appear to fit the general patterns, are provided in Chapter 5. In
addition, the investigator considered rival hypotheses and alternative explanations for
many of the theoretical conclusions.
8. Link empirical findings to the conceptual material of the existing literature. Gilgun
argues that the use of concepts from existing theory to frame new qualitative data is a
form of cross-validation:
Linking empirical findings to the literature also raises the level of abstraction of
findings. The products of this research are conceptualizations based solidly on
empirical data.... The openness of induction is often combined with the more
deductive processes of hypothesis testing and cross-validation of empirical
findings with existing literature (p. 117).
The following chapter will present a synthesis of findings from focus groups,
interviews, and participant observations in light of the various domains of the theoretical
framework, as well as conceptual interpretations of these findings and excerpts of data-
texts that illuminate the emerging themes.
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CHAPTER 4
RESULTS
This chapter offers an organized synthesis of research findings, with emerging
themes and categories presented and interpreted within the eight major domains of the
theoretical framework described in Chapter 2.
The following section highlights the investigator’s observations during the
data collection process. The subsequent discussions integrate data excerpts,
interpretations, and observations of participants and their narratives in relation to
factors that facilitate or inhibit AIDS dialogue and AIDS preventive behaviors.
In each section, findings will be presented using the eight theoretical domains
as an organizing framework, as well as the emergent theory within each domain. A
model based on themes that emerged from the data is summarized for convenience in
Figure 15 on the following page. Exceptions to this framework will be described in
detail later in this chapter.
Each section of the chapter will begin with the organizing model, representing
the overarching framework of the study, with the appropriate domain highlighted.
Subsequent sections of the analysis will follow systematically through the entire
framework.
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259
INDIVIDUAL PROCESSES
Predisposing Factors
Personality
Demographics: Age,
Gender, Education, SES,
Religiosity
AIDS risk factors
Teen sex, pregnancy
Alcohol and drug use
Truancy
Sexual abuse
Sex-ratio imbalance
Motherhood norm
AIDS knowledge
Condom use
Environmental Factors
Family Norms
Local AIDS Situation
Community AIDS
Prevention Resources
CULTURAL CONTEXT
MESSAGE
DESIGN &
DELIVERY
Source credibility
Cultural sensitivity
Preferred channels
Message content:
Abstinence
Condom advice
New ideas
Folonovela eval:
Comprehension
Messages, info
Visual appeal
Age level
Realism
Raps, steppin’
Fear appeals
Humor
Dialogue barriers
Dissemination
Innovativeness
Innovation
DIFFUSION OF INNOVATIONS PROCESS
Knowledge
Awareness
Persuasion
Convergence
Opinion leadership
Enabling Factors
Self-Efficacy
Modeling
Heritage reminding
Achievement orientation
“Making it real”
Dialogue (AIDS, sex)
Telling “our stories”
Comm, skills, tools
Empowerment of teens
& women
Female opinion leadership
Religious values reinf.
Forging Inroads
Compassion
Social support for PWLAs
5
Potential Barriers
Lack of Efficacy
Familiarity
Fatalism
Lack of parent-child comm.
Denial
Secrecy
Desensitization by drama
Lack of AIDS knowledge
Homophobia
Religious taboos
Church politics
Church as false protection
Expectation for divine healing
Black genocide theory
Stigma
Euphemism, labeling
OUTCOMES
Involvement
Identification
Modeling
Persuasion
Willingness to talk
Dialogue initiation
Behavioral intentions
Decision
Adoption
Implementation
Confirmation
Consequences
FIGURE 15: Revised Conceptual Framework Based on Data Analysis

Predisposing Factors
Figure 16 below depicts the overarching framework for this study, highlighting
the predisposing factors, as identified by research participants, that could predict whether
individuals will engage in AIDS dialogue or comply with AIDS prevention advice.
INDIVIDUAL PROCESSES
FIGURE 16: Predisposing Factors, Identified by Research Participants,
That Influence AIDS Preventive Outcomes
Personality
Sensation seeking, a personality characteristic, may be a key motive for sexual
involvement among some African American teens. A boy in the first focus group session
remarked, “I’m gonna tell you - why they have sex is because they want to experience
something that they never had.”
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Depressive tendencies also may lead some teens into drug use or sexual
involvement. One girl suggested that teens use illegal drugs “maybe because they’re
depressed or stressed or something.” But another girl disagreed with her, arguing that
“very few teens are doing it because of depression.”
Age
Older age may be a predictor of perceived self-efficacy among African American
females. In comparing adults with teens, one woman commented that “we believe we
have control over what we’re doing, but they’re just getting started out there.” Higher
age also could be a predictor of perceived susceptibility to AIDS. One woman believed
she was not susceptible because of her age, remarking that “with me, I think it would be
different because I’m older, and I’m more mature, now that I don’t just jump for
anything.” However, another woman encouraged the first woman to place herself in a
young person’s shoes: “But, when you put yourself back a few years, you were at this
point.”
Even if the most religious African Americans in Gainesville are middle aged and
older, the primary target of church-based AIDS education efforts should be adolescents,
one male minister argued.
Among young children, it is unclear whether sexual activity is an expression of
curiosity or the initiation of sexual involvement. According to several focus group
participants, many African American children begin having sex outside their homes, even
without access to secluded places. For example, one boy in the pilot group said he
witnessed youth younger than 12 having sex in the school bathroom.
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Sexual experimentation among young children often may be seen as evidence of
molestation at home. As a kindergarten teacher, one woman once witnessed an incident
in which a boy on the playground leaned up against a pole while a little girl lifted herself
up, wrapped her legs around his, and mounted him. After the teacher separated and
questioned the children, the girl remarked, “I just had the urge to do it.” The teacher
commented that “to me, that’s a sign of somebody fondling her at home.” A similar
incident happened in a kindergarten ladies’ room:
I walked up on kids in the bathroom doin’ the nasty - touching each other,
fingering each other. And they say, ‘My momma say I could have a boyfriend.’
‘Do you know what a boyfriend mean?’ That’s the first question that come out of
my mouth.
Given that the booklet was designed for middle-school aged teens, one woman
argued that this target was appropriate for the fotonovela because many in this age group
are “out there having babies early.” She added:
Those are the main ones that will probably get it and don’t even know they got it
until it’s probably too late. They think they’re older before their time, and this is
what happens. We’re mainly focusing on the young ones to get their brains right
so that they won’t have to suffer through this. At least they can be more
conscious about what’s out there in the world, and yes, you can get it if you don’t
do right.
Even though a few women thought the tone of the fotonovela was “mild,” one girl
argued that the booklet should contain a warning for parents: “I think if they have like
young children, they should probably put like a little parent advisement thing on it.”
Another remarked that “it shouldn’t get any worse than this for kids.”
An evaluator argued that the fotonovela would not be harmful for children who
are not knowledgeable about sexuality or AIDS issues. She commented, “I’m sure the
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younger kids would have an idea of what it is, but it wouldn’t hurt them to get a little
more information about sex.”
One woman recommended a separate fotonovela targeting African American
children under 12. She said many young children
Can tell you something that turn your head around 20 times. We’re always
talking about teenagers, but we got to get to this bottom section to get their minds
focused on what’s really happening in this world, because they’re starting at a
young age.
Despite developmental differences between boys and girls and between older and
younger teens, the fotonovela has a common appeal among many African American
youths, one woman argued. She commented that the booklet “is very good for a lot of
young people in different situations that they can relate to.”
In discussing the selection of facts for use in the fotonovela, several women
debated the level of intensity that is appropriate for young teens. One woman argued that
to “show the effects of AIDS diseases and processes ... may be a little bit too strong” for
young teens. Other women disagreed:
Woman 1: When you’re talking about things like that with elementary kids, how
intense should you get with this information when you go past this
age?
Woman 2: Very intense. Let me tell you something. Most high school kids can
teach an AIDS 104 class.
Woman 3: Most kids have experienced something already.
Gender
Teen girls may have a greater concern about the consequences of sex and AIDS
than boys do at that age, possibly because they may take the issue more seriously. When
asked to guess about how the boys reacted to the “On the Pillow” video, most girls said
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the boys usually act immature, disruptive, or indifferent. One girl, however, still believed
the boys were listening to the advice in the video:
I think the boys are acting very immature, but then on the other hand, I think that
the guys are listening. They might act immature, but they’re gonna listen and
they’re gonna at least come around when they are mature.
Another girl commented that “some boys don’t really care about their life. Some
boys be like all acting crazy.” Then a girl added: “They’re probably sort of acting like,
you know, stuff like, ‘That’s cool’ and junk, but they’re just hanging around and they not
going to do like you want them to.” One girl believed that the boys liked the video
because they already engage in risky sexual behavior and do not feel vulnerable to the
possible consequences: “I think that them boys thinking ‘all right’ ‘cause they like do that
kind of stuff like that. It’s kind of like retarded, but they shouldn’t do that.”
Socio-economic status
Socio-economic status among African American teens may be linked to their
selection of AIDS information channels. Most boys in the pilot group came from a
higher socio-economic background than did the boys in the summer youth program
group. Many parents of pilot study participants were highly educated professionals such
as doctors, nurses, and lawyers. Most boys in the pilot group cited media as their primary
source of AIDS information, particularly television, radio, movies, and albums.
All the boys in the summer youth program group lived in subsidized housing.
Most said they received most AIDS information from a sex education class at school or
from their parents, but not from the media. They may have relied on these interpersonal
channels more heavily than mass media channels because of insufficient access to media
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or because they live in a sub-culture within subsidized housing areas that strongly
reinforces word-of-mouth communication.
Similarly, all the girls in the summer youth program group said they received the
most information about AIDS from school. Various girls said they remembered seeing a
video and hearing a man with AIDS speak to seventh grade classes. One girl said she has
never seen a television public service announcement about AIDS.
One woman who lived in a subsidized housing area said she got much of her
AIDS information through interactions with public health outreach workers, even when
she had a streetwise lifestyle:
When I was out in the streets, partying and everything, I was getting my
information through the health department workers, you know.
Religiosity
Several girls recommended that African American teens go to church activities at
least once a week. The recommended frequency of attendance ranged from “every time
they wake up” to “every Sunday” to “every time they have a chance.” One girl
disagreed, arguing that teens are not as religious as adults:
If you saved, then you should go every Sunday. But I’m saying like teenagers,
they should go like two times out of one month.
More than just a place for common worship and religious expression, the church
also is seen as a kind of extended family. One woman remarked that “your church is
supposed to be your home, your family.”
Several girls commented that church is a “good” and “marvelous” “place to feel
good about yourself.” However, a couple of girls pointed out that some attend church to
be entertained. One observed that “a lot of people just go to church and laugh at them
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people shouting.” Many youths may be afraid to express their religiosity in church unless
they are emotionally moved by a worship experience. One woman said she secretly
watched her 21-year-old son as he sat in church on Sunday to see how he was responding
to the service. She observed that
If you watch a face in the church, you can tell if they in the mood for the church,
or are they curious what’s going on. I kept focusing on his face to see what he
was feeling. I could see he enjoyed it. He was sitting there, kind of controlling
himself, ‘cause you know how men when they get that age, they macho. After a
while, the Holy Ghost kept flowing in the church, he jumped and whooped with
the pastor.
Several girls indicated that African American teens are more religious than white
teens, for various reasons. When one girl speculated that “black teens have more
problems than white teens,” another said this could be the case because “their problems
are probably more serious.” One girl argued that African American teens are more
religious because “that’s how they were brought up.” Another agreed, adding that “white
teens aren’t brought up as serious Christians as most black teens are.”
The style of worship may be quite different in black churches, compared with
white churches. One key informant from the Task Force remarked that her son asked a
white man at First Assembly of God “if they believed in shouting, and he said, ‘Yeah, we
get real loud.’ That’s where I’d say there’s a cultural difference.”
She also commented that many African Americans do not attend church because
the churches aren’t trying to communicate with the public about any issues, religious or
otherwise. She remarked:
A lot of churches aren’t talking about the gospel or about AIDS. A lot of people
are growing up not knowing anything. One lady said she thought Jesus was a
type of car, because all she’d ever seen was “Jesus” on people’s bumper stickers
and license plates.
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Because of rising apostasy among many blacks, many only attend church on
Easter, Christmas, or Mother’s Day, the key informant argued. A related trend among
many African Americans, particularly among youth, has been total apathy towards
church or religion. The woman observed that
You have a community that used to be very churchgoing and now there’s a lot of
apostasy. Nobody’s making their kids go to church. Some of them say they
stopped going to church when Grandmama stopped making them come.
Reading the Word
Reading the Bible daily generally was considered to be essential part of being a
true Christian and considered a guide to appropriate and healthy behavior. One woman
commented:
Being a Christian, you’re reading the word of God. He’s telling you all these
things that He would not stand for. If you want to live and be like Him, you have
to follow His rules, His commandments. There’s no substitutes about that. If you
want to be like Him, you go up there where He’s at, you gonna have to do what
He say. You cannot go like, ‘Well, I’m gonna do this anyway. That won’t
matter. I’ll repent later.’ That’s too late. You can’t do it both ways.
Another woman commented that reading the Bible helps Christians identify their
own and others’ sins and put these “mistakes” into perspective:
A lot of things we see going on in life actually has not surprised us because it’s in
the Word. And I think that helps a lot of times. I see several people still make a
lot of mistakes, even though they know they’ve been taught. Their parents have
done everything they’re supposed to do sometimes. They still make those
mistakes, or they still fall into it because they thought it was that one right person.
The more being able to read the Word or hear the Word, it helps you to actually
identify yourself within it.
The “inner spirit”
A tenet of African American religiosity appears to be the belief that when a
Christian pursues a daily walk with God, the Holy Spirit “speaks” and guides the
person’s behavior from one moment to the next. It is unclear whether a Christian’s
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reliance on this divine inner spirit could be a barrier to the prevention of risky behaviors,
as it could lend a false or irrational sense of protection, or that it could actually enable a
person to effectively banish such behavior from his or her life. One woman described
this inner spiritual voice this way:
Being a Christian, when you getting ready to do something, your inner spirit will
let you know. You will get that feeling or you will hear something in your head,
saying, ‘No, don’t you do that. It’s not the way to do that. Don’t go that way.
Don’t do that.’ You will get that inner spirit, that word spoken to you, but it’s up
to you to heed what it’s saying to you. ‘Cause if you like, ‘Oh, naw. I’m gonna
ahead on and do it anyway,’ then when you go and do it then, ‘Uh-oh. I should
have listened, ‘cause something told me.’ Your inner spirit told you not to do
that.
While an irrational decision is driven by emotions or physical desires, and a
rational decision involves the weighing of costs and benefits, a spiritual decision appears
to be based upon guidance from God’s voice, Bible interpretation, and other Christians.
One woman explained that living as a mature Christian involves surrendering control of
oneself to God, while recognizing the consequences of disobedience to His will:
Being a Christian, you get a lot more help because God makes it available for
you. There are things that you would have allowed yourself to do before you
became a Christian. You will not allow yourself, because now, you’re not a babe.
Sometimes a babe can make a real good decision, but if you’ve been in the Word
and you really, really want to live for Christ, you gonna know the do’s and the
don’ts. If you keep doing these things over and over, and He says, ‘Don’t do it,’
there’s a price you have to pay.
This woman not only feared God, she also feared that her sin might hurt Jesus and
herself:
If you fear God, you will not do a lot of things. You know that when you do
something like this, you gonna be hurting Jesus. I mean, it’s there in the Word.
You’re gonna be hurting not only Him, but you’re gonna be hurting yourself.
In addition to seeking God’s voice through prayer, she also seeks accountability
for her actions from other Christians:
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If you are a Christian, you’re constantly there because the pastor, different ones
around you, ‘You shouldn’t do this.’ It’s not just the Holy Spirit always saying
these things.
Before she became a Christian, one woman said she did engage in risky sexual
behavior, but she would not do these things now because her inner spirit protects her
when she is confronted with temptation:
I wouldn’t say that it would have been different when you were in the world, but
now, first of all, you’ve got more in you because you’ve got the Holy Spirit on the
inside now. And He leads and guides you, and He will say no, say no.
Another woman attributed her growing interest in AIDS issues to God’s voice,
manifested through her daily prayer life:
I myself didn’t know a lot about AIDS for a long time. But as I prayed, God told
me I was going to be greatly involved with AIDS. And at that point, I didn’t
know hardly anything about it. As I become more aware of it, the more I want to
be involved with this to try to help.
However, not everyone agrees about how this inner advisor should be consulted.
For example, when one woman claimed her inner spirit could tell her if her husband is
cheating, another woman scoffed at the statement:
Woman 1: “Her inner spirit should give her some kind of uneasiness.”
Woman 2: “Please!”
One woman challenged the efficacy of salvation and spirituality in preventing
“slip ups” when she brought up a recent news story about a prominent minister, the head
of the national Baptist association, who had been exposed in an adultery scandal. Her
question about this incident sparked dialogue about sexual mistakes among Christian
leaders:
Woman 1: Tell me what happened here. They found out that he has a woman on
the side. That’s what I’m sayin’ ‘bout how you never know.
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He done forgot about God, about the Holy Spirit.
A lot of people say, ‘I’m saved, and I won’t make that mistake. I’ll be
this way.’ But I think people are falling every day for the same
reason. It doesn’t mean they’re bad people. They make mistakes.
All of us can make mistakes. It doesn’t matter how close we are to
God. Even though some of them seem to be small mistakes, still yet
even like that preacher -
What about his conscience?
He had probably been doing this for awhile. If this is true, he could
have been doing it for years, and getting away with it. He may have
had this problem. Do you know how many people that have problems
and they hide it for years? And then when they put them on the TV,
they want to say, ‘Well, this is a preacher. How did this happen?’
This is happening every day.
Amen.
It makes you wonder if he really knows God. ‘Cause he’s a preacher.
That’s it. That’s what he’s committed to.
He’s just a man, but he’s in authority and that’s why it’s pointed out.
Because if it was me, any of us in here, nobody probably would even
care. It wouldn’t make the headlines. But yet we’re doing the same
thing. And not to say that he probably don’t have the Holy Spirit. It’s
just that he’s weak in that area. Maybe he has not been praying and
confessing like he should, or maybe he’s having home problems.”
The last woman appeared to believe that the fallen minister was saved and “had
the Holy Spirit,” the two prerequisites of spirituality that many women believed to be
protective factors. However, she argued that he was just weak and was not routinely
engaging in religious practices - prayer and confession - that should promote a level of
spirituality sufficient to protect him.
The life “out there”
Identifying oneself as a Christian sometimes promotes the sense that Christians
live within a protected subculture that transcends the sinful world “out there.” Several
Woman 2:
Woman 3:
Woman 4:
Woman 1:
Woman 4:
Woman 2:
Woman 3:
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women in the focus groups also referred to their pre-Christian lives as “out there,” the
time prior to a particular moment when they experienced a spiritual conversion.
One woman reflected on her past life in the world “out there,” and concluded that
she had engaged in risky behavior during a partying phase of her life, but later decided to
devote her life to Christ and become sexually abstinent. She began to share these feelings
after another woman asked her about past “mistakes”:
Woman 1: OK, in one night, you mean to tell me that this man come up to you,
and when you was out there in the world, you would have just went
and slept with him right then?
Woman 2: Yeah. Because the thing is when you’re out there, you’re not thinking
about AIDS. You’re not even thinking it’s gonna happen to you.
That happens to other people. That happens to the people down the
road, not you.
Although one woman argued that being a Christian often “makes you think” about
your own thoughts and actions more introspectively, there may be no significant
difference in the decision-making processes of a Christian compared with a non-
Christian:
I say there’s no big difference whether you’re a Christian or not. Sometimes
somebody who’s not a Christian can make a very wise decision. The person
that’s a Christian can do something that’s not as wise.
Another woman argued that merely having a moral or rational conscience is not
sufficient to prevent a person from engaging in risky sexual behavior. After people
experience a spiritual conversion, they are no longer “out there,” and they begin to care
more about others as well:
See, when you’re in the world, you don’t have that conscience. It’s surprising,
but it doesn’t like let you know that you shouldn’t do this. If you’re really out
there, you’re out there. You don’t really care who it hurts. So when you come
into church - no, not into church but when God comes into you - then you start
caring about other people. I think it’s different for me ‘cause I know when I was
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out there, I didn’t care. If I liked him, I just liked him. I didn’t know what the
different situations would be. I didn’t want to get into all of that. But now, if that
would happen to me, first of all, I’d be hurting somebody. Somebody else is
going to get hurt in that situation.
The difficulties that people have “out there” sometimes can draw them into the
church in the first place. As one woman involved in community outreach remarked:
I see a lot of times people come into the church because of things that have
happened to them out there. I don’t think you just walk in and say, I think I’ll just
go to church faithfully every Sunday. Something has happened to have driven
you there.
However, given that Christians are supposed to serve as models of morality to
others, many Christians may assume that their own failures will discourage the people
who are living “out there in the world” from seeking salvation. One woman observed:
Sometimes church women and church men should be an example to people in the
world. We’re doing things that are not right, so therefore in the world they see us
out there, and they do the same thing. In our church, we’ve got men and women
that are having sex before they’re married, having kids while they’re there and not
married, and doing all these things. So, why wouldn’t the world come in and say,
‘Well, they’re no different from us.’
Evangelism
Even when a women’s focus group moderator asked numerous questions about
the fotonovela and general AIDS communication strategies, many women responded
instead by discussing evangelism strategies. It appeared that the women were framing
the concept of AIDS-related dialogue using their own experiences of community
evangelism and were viewing AIDS dialogue and evangelism as similar tasks in terms of
importance, seriousness, urgency, and strategies.
The concept of “planting the seed” is a central tenet of Christian evangelism.
Reflecting on her own evangelism experiences, one woman remarked:
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When you’re trying to talk to them, a lot of times they may not come right then.
But you plant the seed, and you teach them what you can teach them. And it
comes a time when they will take it in.
Given the urgency of preventing a spiritual downfall, one woman argued that the
conversation must occur “hopefully before it’s too late.” Another woman believes this
prevention is entirely up to God. She explained:
You plant the seed, and let God do the watering. You got to realize they got to
want that first, a new change or whatever they want. They’ve got to accept Christ
on they own. You can’t go out and browbeat them. God don’t want it that way.
A potential barrier to sharing a salvation message with non-Christians is their
skepticism about praying to an invisible supreme being. One woman recalled a typical
remark she hears whenever she tries to persuade others to receive salvation:
‘Hey, that’s somebody they praising, and that man ain’t real. I don’t see him.’ If
they don’t see a person, they ain’t gonna believe in that person. Some people just
like that.
Given that HIV is an invisible virus, usually transmitted without notice and
infecting a person for many years without symptoms, perhaps a lack of “faith in the
invisible” could be framed as a barrier to perceived susceptibility to AIDS as well as a
barrier to religious salvation among African Americans.
Apparently, conversations about AIDS and sexuality can be contexualized within
evangelistic outreach. In sharing the fotonovela with teens in her neighborhood, one
woman talked about AIDS issues in light of her own religious faith. She said the teens
responded positively to this approach. Reacting to this story, another woman
commented:
I like to hear that they were very receptive to Jesus first, ‘cause a lot of kids are
still out there on their own and do not want to hear the word of God.
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One woman compared sharing the fotonovela with handing out religious tracts to
youth on the streets. She related:
Me and my cousin saw two little couples standing on the sidewalk. And I called
out to them, ‘Do you know Jesus loves y’all? I just want you to read this.’ They
say, ‘Yes, ma’am.’
Evangelism also may be a tool for helping non-Christians change their unhealthy
behaviors. One woman who is involved in evangelism said that being a Christian helps
her assist people who are living in sin:
I think being a Christian definitely helps you deal with things that are not in the
church, that y’all never deal with. They’re dealing with sin and what the effects
of it is, the different things that can actually happen from it.
Another woman agreed with this approach to AIDS education, remarking that “we
most certainly want to witness first to their hearts and souls. There are those we meet on
a daily basis or those you interact with on the street. They aren’t ready to receive
salvation.”
While many youths may not be persuaded easily to accept spiritual salvation,
several women argued, the church can offer them a place to experience the love and
acceptance they may not receive at home or from their friends. One woman suggested
that the love offered by the church can motivate youth to maintain a moral and healthy
lifestyle:
The love the church has, it makes a difference. A lot of young people, they really
want to know that somebody loves them. ‘Cause they want to know, T can go
back to this church where I know these people really love me.’ If they say to do
things, then they’ll just say it. But if that person be in a church, you will always
keep it. You get a young person into that church, and someone comes up and
says, T love you,’ and you keep that love going, that’s what a lot of young people
want. They don’t have it at home, and they need it. They’re looking for it.
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Conversely, many youths have sex because they are searching for love, one
woman speculated. Thus, a key to preventing AIDS among teens may be to ask them
questions about their spiritual needs and then to help fulfill their need for love through
involvement in a church community. The woman remarked:
Some kids are really reaching. That’s why I be talking to different people, trying
to find out, ‘What you searching for? Are you in love with Jesus? Come on with
me to church. I’ll arrange a ride for us.’ Once they come and see how the people
in the environment is, and how the spirit of love flowing through them, they can’t
help but come back. A lot of them get saved at that moment.
Bringing teens to church potentially can lead to problems, however. One woman
argued that the church is not actually providing what youth want and need. She remarked
that “most teenagers are looking for love and comfort, and the church is not giving that
love and compassion.” Furthermore, if youths feel they are expected to participate in
church activities or to present themselves as “saved” Christians, this pressure may
motivate them to rebel. One woman lamented that her own children may have turned
away from God, and she fears that her attempts to involve them in church may have led
to this apostasy:
I found you can be so deeply saved and a Christian, and you want to put that on
your kids. And all it does a lot of times is run them away. Once we get to be
parents, and we get to be in the church, we feel like all of a sudden we get these
sanctified kids. My son, I heard him talking with one of his friends, ‘My momma
thinks because she’s saved, I’m supposed to be saved.’ Because I would not let
him go to something he wanted to go to. I had to stop right then, and go right in
there and start talking to him, ‘You know, I’m not saying that you’re saved, but
it’s my job to teach you what’s right, what you should and should not do.’
The “slip up”
Both women and teens in the focus groups talked about the likelihood that most
people will “slip up” at some point and engage in risky sexual behavior even if they know
better. They talk about a “slip up” as if it is inevitable and unavoidable, an action beyond
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rational control. As one woman commented, “Sometimes, adultery just slips up or
fornication slips up, and it happens.”
Traditional wisdom may say that learning from one’s mistakes is the most
effective kind of learning. However, several women pointed out that it takes only one
“slip up” to contract AIDS. One woman commented:
A lot of times people don’t learn until after they make the mistake. And then
they’re in it. So then, they find out, ‘OK. I really messed up.’ And that’s really a
fatal way to try it.
Usually the “slip-ups” were discussed in the context of infidelity in marriage.
One woman recounted a true story to illustrate her point that “slip-ups” are very common:
You remember one of the doctors that came and talked to the kids at church one
time? He told the story about the man and woman who had the baby, and the
baby was tested for AIDS afterwards. They were already married, and they were
saying that, ‘It wasn’t me. It wasn’t me.’ And come to find out, one did slip. I
mean, it’s every day.
The marriage contract may promote blind trust among many African American
women. One woman noted that most married couples do not use condoms “because they
don’t feel like they need to use them.” In addition to recommending condom use within
marriage, another woman argued that wives should educate their husbands about the
dangers of extramarital sex, even if it is a difficult topic to discuss:
I feel like as women, even though our husbands are not here tonight, it can help us
even talk to them, to let them know how much if they make that one mistake, it
can not only hurt them it can hurt you. Adultery and all is not just a sin, but it’s
something that can cost you your life.
Teen sex and unwanted pregnancy
A female pastor estimated that 90 percent of African American teens already are
having sex, but that many are probably using condoms: “You may find out of 50, maybe
five that’s not. A lot of them are more aware about condoms, so they are being safer.”
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When asked what kids really think about having sex, one girl commented that
“they think it’s cool and fun.” However, another cautioned that “in a moment’s time it
goes away.” Then another added that kids do it “to get close and stuff.” The reasons that
kids have sex, according to several girls, included irrational impulse, desire for love,
revenge against a parent, and desire to please an attractive boy:
Girl 1: Some of the reasons, I feel, are made irresponsibly, and some of the
decisions are not made in the right mind.
Girl 2: They do it to get love, ‘cause some people - they have a TV show on last
night - they said they need to have sex ‘cause they momma don’t have
love in they home.
Girl 3: It’s just to get back at your momma and stuff.
Girl 1: ‘Cause they have this boy, he’s fine.
Alcohol use
Several focus group questions for youth addressed alcohol and drug use because
these behaviors are linked to risky sexual behavior. In addition, substance use was a
relevant and popular topic among many focus group participants. This may have been
partly because the “On the Pillow” video they watched portrayed the main character,
Terrence, engaging in unprotected sex after becoming intoxicated from drinking beer
with his friends at a bar.
All the boys perceived that drinking is common among their peers, either because
they themselves have done it, their friends talk about it, or they see physical evidence that
others are drinking. When asked how common drinking is among kids in school, one boy
admitted, “I know it is, ‘cause I used to drink at school, man.” Another commented that
“a lot of teenagers say they like drinking beer, like having fian.” One boy observed the
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litter on the school grounds: “Sometimes we walk, like, to school early in the morning. 1
see some beer bottles around here.”
A boy in the pilot group commented that some of his friends are allowed to drink
at home. Another remarked that “some of them drink booze.” Two boys in the pilot
group related a story about kids at church spiking some Kool-Aid with whiskey. One boy
said:
I know when the bishop was lecturing, they was getting into Jack Daniels, beer,
and all that. They put it into little orange cups, and they like, (slurp noise).
Then the other boy finished the tale:
Yeah, the teacher was like, you know, a cop will make you walk the line. And
she was like, come walk the line. And everybody was like, nah, make James and
Kevin walk the line. They acted like it was Kool-Aid. They had a bottle of Jack
Daniels. It gave them a headache. They was sick for the rest of it.
Although one girl contended that most teens her age smoke cigarettes far more
often than they drink, another added that drinking is still “very common” among kids in
her school and estimated that “one out of ten students is getting high, and five out of ten
are drinking.
One woman asserted that although drinking may reduce inhibitions, it does not
explain why many people engage in risky behaviors. She remarked that “some of them
do not have to drink anything -- kids as well as grownups even as well as women.”
Another woman admitted that her past life “out there” involved occasional one-
night stands, but she argued that she had made every effort to maintain rational control in
situations where drinking alcohol might lower her inhibitions:
I was out on my own when I was 15, out there in the world partying, drinking.
But when I drank, I would drink maybe one can, ‘cause I wanted to be focused. I
wanted to know exactly where I’m going, what I’m going to be doing, and
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everything. ‘Cause you wouldn’t take advantage of me. I had that much common
sense. I was partying, but I had sense enough to know when to stop.
Drug abuse
A female pastor said African Americans are more at risk of HIV infection because
“a lot of our people are more on drugs.” She said drug use and trading sex for drugs are
typical aspects of a streetwise lifestyle:
It’s like very easy for them to get involved with it when they are out there on the
street. Once they get out there on the street, they usually have to do a lot of
different things just to get their drugs. The ones that are on crack, a lot of them I
think have AIDS because they’re out there sleeping with anybody just to get some
drugs.
Reaching out to drug abusers in the community is a challenge for AIDS educators,
a key informant said.
You don’t want drug dealers to think you’re a non-paying customer. They’re
running a business here, and you’d be holding up their business (by giving them
AIDS literature).
One woman said she sees African American teens constantly hanging out in
groups within low-income housing neighborhoods, and often they use drugs in the
daytime in public view:
I see these kids every day drinking, smoking, doing drugs. And I say, what grade
you in? They say,‘the eighth.’ The older guys give it to them. And I say,‘Do
you know what you’re doin’ to yourself?’ And they’re like, ‘Yeah. I’m having a
good time.’ A lot of their parents are always in the house or they’re always gone
to work. All day long, I see the kids, but I don’t see parents.
One boy believed the existence of a drug education program at his school showed
that drug use is common among his peers. When asked, “How common is drug use in
your school?” he responded, “They talk about it in a program in our school, like they talk
about it all the time. They say stay away from drugs, stay out of trouble.”
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A girl said drug use is much more common in high school than in middle school.
A few girls indicated that some African American teens use crack and that many want
access to marijuana. One girl said no one she knows uses injecting drugs but “they crazy
if they do.” Another feared being implicated by discussing whether other teens in her
school use drugs: “I’ve heard about it, but it’s not like I know.” A couple of girls
observed that some drug-using teens lead a double life:
Girl 1: I know they do it, but they don’t brag about it.
Girl 2: They still have a good reputation with the teachers.
The social image of crack-using teens is not always glamorous among African
American boys. As one boy commented, “They gonna be a crack head.” Even if crack
use is common among African American adolescents, it may not be acceptable for them
to use it around adults. One boy observed that “they might don’t seem like they’re doing
it, but you know, they may hide it in their room.” Another boy said he’d tattle if he
caught a friend using crack: “If I see somebody doing it right now, I’d tell their parents or
their mom.”
Among boys in the pilot group, there were mixed opinions about whether many
African Americans in Gainesville use intravenous drugs. One boy in the pilot group said
he knew an African American teen who experiments with drugs. Two boys in the pilot
group commented that marijuana use is most common among white teens. When one
remarked, “I know a lot of white kids who smoke pot,” another boy added that “the
majority is white.”
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A female pastor who coordinates church outreach efforts within various housing
projects observed that many elementary and high school youths in low-income areas are
drug users:
The first thing they get into is drugs, especially crack. They’re more into
marijuana than any other drug because they start off there. So many of them are
selling drugs already. That’s why we see it to be so important to get out in those
neighborhoods to let them know they actually have a choice, but not beat them
down with religion.
One boy said people use illegal drugs because “it make them feel good.” The
easy accessibility of drugs may increase drug usage among many African American
teens. Two girls speculated that teens use drugs ‘“cause it’s easy for them to get to it,” or
because “they just want it, and it’s just there.”
Several boys in the focus group, as well as in the pilot group, openly described
various kinds of drug use practices and paraphernalia. Sawiness about these matters may
be a considered a mark of masculinity among pre-teen African American boys. For
example, when asked what most African American teens think about using crack cocaine,
one boy simply explained that “they put it in ice cubes. Then they cut them up.” Another
boy recalled seeing a hangout for intravenous drug users in another city:
I lived outside a city, near a harbor. There was a big warehouse. They go there,
and you know they gonna do injection, like crack.
Then it occurred to another participant that maybe this boy was really talking
about himself and asked, “You try cocaine, boy?” Another boy in the pilot group
recalled an intravenous drug user he once knew:
This one man, he used to live in this basement in New York. That man shot up so
much he was in no more pain. Every Friday night, he’d bring like five new
people down there and shoot up. You’d have to pay $20 to get in.
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Not all teens shunned the use of illegal drugs. For example, one girl argued that
illegal drugs should be legalized because “it’s not much of a hassle to have it. It should
be legal because people are making bad chemicals. It should be legal to make it safer.”
When asked, “Speaking for yourself, what difference does it really make whether kids
use drugs or not?” the same girl departed from the expected, socially desirable response
by defending a person’s right to use drugs in moderation:
It depends on what they’re using, and if they’re overusing it. I know that people I
know, they’re not overusing so their life is going all right. But if you overusing
and it’s causing a problem like with your family and stuff, I really don’t think you
should do it.
Although most teens may consider drug use to be taboo in many social contexts,
most boys considered the potential stigma or legal consequences to be more threatening
than any perceived health risks. As one boy commented, “If they mess around and go to
jail, they might not get out until, like a year.” Among the boys, the perceived health risks
from drug use are the risks of overdosing or being poisoned, not the risk of HIV infection
associated with impaired judgment. One boy wondered if smoking marijuana could be
just as dangerous as injecting heroin:
Most people say that marijuana is the most dangerous drug. But what about
heroin? Which drug is most dangerous? One day, you’re messing around, and
you die because you’re smoking or doin’ heroin. The carbon monoxide goes in
when you breathing.
These comments showed that many teens are curious and want more information
about substance use issues. For example, one girl remarked, “We need to know about it
before we face that problem.” A female pastor asserted that having a former drug addict
speak to youth about the consequences of drug use is far more effective than having a
parent or minister lecture them:
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A Christian or their parents may talk to them, and those may be the only adults
that try to tell them. They think, ‘These are just old fobies. They don’t know
what it is to have fun, so they’ll try to stop us.’ Unless they see some of the bad
things that happen from it from somebody who’s experienced it.
Despite a desire to learn more, most teens seemed to be indoctrinated with the
anti-drug messages that have been promoted in the mass media and in schools. For
example, at the end of each topic discussion when the female moderator asked the girls if
they wanted to add anything else, several girls usually volunteered their advice. Their
messages about drug use included: “Don’t overuse drugs,” “If you use them, be careful
what you do,” and “If you go crazy, you might walk over a bridge or something.”
A male minister commented that most African American churches in Gainesville
are able to freely discuss drug or alcohol abuse, but a few churches do not address these
issues. He commented that “talking about the use of illicit drugs used to be absent in
churches, but now the dangers are talked about.” A key informant observed that many
clergy preach an anti-drug abuse message, but they do not acknowledge the possibility of
drug use within their congregations.
When asked what they would do at a party where everyone is drinking or using
drugs, several boys said they would probably leave so they wouldn’t get into trouble.
However, the motives for leaving varied. For example, one boy said he would leave to
avoid being pressured into using drugs: “They’d try to make me try some of that dope. If
you stay like that, they’ll try to convince you.” Another boy feared that he would be
punished by his parents. His description of the consequences may have been too detailed
to be merely hypothetical:
I’d believe I’d go right back home. If they’re smoking marijuana, you come
home with your clothes smelling like that, and your mom or your parents would
say you’re lying.
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One boy said he would leave the party to avoid getting involved in a fight, and
recalled witnessing this situation firsthand: “They were using drugs outside my
apartment, and they started fighting on the ground.”
When asked the same hypothetical question, one girl admitted that she would
“probably drink a little bit if they were smoking hemp or marijuana and drinking.”
Another said she would just leave the party, but one girl said she would “just sit there”
and not drink. In order to fit in, one girl said she would “take a beer can and go back and
get some water.”
Truancy
A key informant said that many African American youths learn about AIDS on
the streets because they do not attend school frequently enough to learn it there:
They’re not learning about AIDS like they should, except if they learn about it in
school. But school attendance is poor. Most of them learn about it on the streets.
Probably a lot of incorrect information.
Another key informant observed that many African American youths who are at a
higher risk of HTV infection are high school dropouts who enroll in the Job Corps. Many
of these teens cannot complete traditional schooling, so Job Corps centers provide job
training and academic classes. While the youth are learning these new skills, they live in
a dormitory at the Job Corps site. The key informant commented that this dormitory
environment may create conditions for the rapid spread of HIV:
They’re all tested before they come here. But I’m as realistic as anybody. I know
that when you put these kids together in dorms and they’re all right there together
and their little gonads are screaming, and you know — that’s three weeks, so
someone who’s HIV positive can infect a whole lot of people, depending on how
they engage in sex.
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However, she said the classrooms at the centers could serve as an ideal
environment for AIDS education efforts:
With the youngsters in Job Corps and the juvenile detention center, you have a
captive audience and they have to listen to us.
Sexual abuse
Discussion in the second women’s focus group frequently turned to sexual abuse
issues, and it appeared that many women were personally concerned about it. Several
women in the focus groups contended that many African American teens are at risk of
HIV infection because they are sexually abused by relatives. The teens’ risk factors
include infection from the abuser, as well as their own risky behaviors rooted in the
emotional trauma resulting from the abuse.
One woman said she tried to help a young lady whose father molested her at
home. This girl “was very popular, and it made her from being smart to saying stuff that
was nasty, and she got in trouble. Somebody had to talk to her.” Another woman related
the story of a young girl she knows who suffered sexual and physical abuse from family
members for years:
When she was a little bitty girl, her momma’s brothers would come to her in the
night and mess with her. One day, she got tired of it, and she went to her mom
and she say, ‘Your brothers coming in making me have sex with them.’ She said
her mom beat her up and allowed them to do that, and she tell her, ‘You nothing
but a liar. My brothers would not do that, but you just making things up.’ She
was hurt, all the way deep. She came to me and was telling me about it.
Another woman related that incest occurred in her own home when she was
young, even though she came from a socially prominent family.
My grandparents were evangelists and had a high position in the church. During
that time she worked on the premises, so she allowed my mother to live with my
aunt, who had children. So everybody was family in the church. Children lived
with other children, cousins lived with cousins, and one cousin over here.
Sometimes these things happen, and incest does happen.
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Besides cases of incest, many African American girls are molested by their
mother’s boyfriends, according to several women. One woman explained that this often
happens because “women tend to be so in love with the man so much, they don’t listen at
the kids. They throw out signs.” Parents also neglect their own children in sexual abuse
cases when they do not know how to handle the situation. One woman observed:
The parents cover it up because they don’t know how to deal with it. I’ve noticed
when it comes to things that are bad, people hide it. They don’t say, ‘Look, I
made this mistake.’ Most people don’t know what to do with it. Get some help.
Another woman told a story about a young girl with AIDS, another sexual abuse
victim, who showed up at the woman’s door:
She really walked all night. She was so tired. I was talking to her, and she said
her mom put her out. She was so young, like 10 years old, started tricking with
men to support her momma’s habit. You can see that hurt go deep. She used to
come to me and say, ‘I’m so glad you’re home.’ And I said, ‘Come here, baby.
Let’s go take you a bath. Go change your clothes, and get in my bed and sleep.
Let me fix you something to eat.’ You see, I know for myself, I’d want more
people to treat my children the same. Any children. I don’t care whose children
they are.
One woman said that a member of her family was a gay man who died of AIDS.
Before he died, he told her that he became homosexual after his uncle molested him. She
commented:
You know, his uncle was a prominent person in the community, head of the
basketball team. He was asking me to keep it a secret, and I was like, T can’t
believe this.’ Then, when I told a couple of people, they were like, ‘Oh, my God.
You’re crazy!’ Everybody in the community knew he was with the boys, you
know, coaching basketball, and all the boys went to get on the team. You know,
he was molested by an uncle, and he got a homosexual bent. It’s a cover up.
Some child molesters hide within the church, another woman argued. She told a
story about a church deacon allegedly abused a teen-ager sexually, but opinion leaders in
the church “swept the accusations under the rug.” The woman commented:
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I’m not going to be so easily thinking, ‘Well, they’re Christians, and they won’t
do it.’ Because a lot of people hide in the church, and they do all these sneaky
things. I’ve seen a guy that molested children. And because he was a deacon,
everybody stands up to take their side, and nobody takes the victim’s side. When
the signs are there, when you go and find out things, don’t be so easy to excuse
the person and overlook them and pick them over your child or over a friend. If
you take out some time to listen and talk to that child, it will come forth. But the
reason why a lot of them don’t want to bring it forth is because they’re protecting
someone or they know as parents, ‘Don’t you tell anybody that.’
Scarcity of eligible men
One key informant encourages her friends to remain sexually pure, even when
there’s a lot of competition for men. “I tell them, you ain’t a Toyota - a man don’t need
to test drive you first,” she said.
The search for “a good man” also was an important issue among many women.
One woman remarked that AIDS education is important for African American women
because “it’s hard to get a real man, just looking at him. He looks good, but underneath
that -.” After watching the video “On the Pillow,” another woman commented, “If you
think about it, when you really look at men today, they are no different from him.”
Several women appeared to distrust men, in general:
Woman 1: You don’t know what he’s doin’ out there when he’s telling you he’s
goin’ out to get a gallon of milk or some gas or some money.
Woman 2: That husband’s going out to get a gallon of milk, and it’s taking him
four hours. I want him to take me where that cow was.
Woman 3: It don’t take no four hours going from home to get a gallon of milk.
He might want to stay out there a little longer, but it don’t take that
long to have no sex.
Woman 1: That’s what I know.
Woman 2: Five minutes at the most.
Woman 3: Wham, bam, thank you, ma’am.
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AIDS Knowledge
The level of knowledge among the teens was generally high, and it was higher
among teens than women. When asked how AIDS is transmitted, various boys in the
pilot group volunteered that HIV damages the immune system, that it is transmitted
through needle use, that the virus was sometimes detected in blood transfusions before
1985, and that many infected people do not show symptoms for 10 to 12 years.
The boys in the summer youth program knew that perinatal transmission of HIV
does not occur in every pregnancy. Although the boys agreed that having unprotected
sex can lead to HIV infection, several cited blood transmission such as a tainted blood
transfusion or contact with broken skin as a higher risk factor than sex. The concept that
HIV damages the immune system was also commonly understood among these boys. For
example, one commented:
Like if you got AIDS, and you tryin’ to do a lot of stuff you’re not supposed to,
you can die then. Like drinking alcohol.
Most women were knowledgeable about HIV transmission routes, including
needle sharing, sex, blood transfusion. One woman repeatedly brought up the particular
transmission scenario of a person becoming infected through contact with someone who
has cuts on his or her hand:
You don’t really know if they got it or not. You have to cover your hands if
you’ve got cuts anywhere on you. You have to prepare yourself for that. They
might think that you being funny, ‘Nah. I ain’t got nothin’.’ But they don’t know
that. Best to cover yourself than to be sorry in later years.”
Most women were aware that HTV is typically not transmitted through casual
contact or kissing, but a news story that ran the previous week raised some doubts
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because the CDC had announced that someone with poor oral hygiene became HIV
infected through deep kissing. For example:
Woman 1: They say you can get it through French kissing, but it’d have to be like
a quart of saliva.
Woman 2: That’s a lot of saliva.
Woman 3: They keep saying on the TV we don’t know exactly how, all the
things, you know - they did rule out some of the things, hugging and
kissing and toilet seats. They ruled that out.
Condom Use
Most boys made a strong connection between condoms and HIV prevention. One
boy warned that if you have sex without a condom, “you know what you’re gonna get.
You get HIV.” One pilot group participant said he remembered a third-grade teacher
talking about condoms. Other boys in that group mentioned that middle school teachers
sometimes discuss condoms along with other birth control methods, including abstinence.
A female minister commented that among African American teens, the older boys
often pass condoms down to the younger boys, along with the advice, “Man, if you gonna
do that, you better use this.”
After watching the “On the Pillow” video, one boy in the pilot group said he
definitely would insist on using a condom, even if the woman tried to prevent him from
putting it on:
If you have a condom, and the girl tell you no and slap it off, you put it on. If she
don’t want you to put it on, she must not want you to be on. That’s all I’m saying.
Another boy in the pilot group remarked, “If I told her I’m putting on that
condom, and she would have threw that condom, I would have rolled off” But even if a
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woman refused to let him use a condom, another boy said he would finish having sex
with her anyway:
I’d say, ‘I’m goin’, I’m gettin’ it up.’ If she don’t want to move, she gonna get
through. Finish off and all that. If she want to leave, bye.
One woman argued that abstinence advice should supplement safer sex advice
because condoms “are not 100 percent.” However, most women in the focus groups
approved of condom use to prevent disease transmission. An example of this
endorsement is a comment by one woman after she watched the video “On the Pillow”:
Now this guy in the movie, he should have been more responsible for using the
condom, if he was gonna do it. Put it on before you get there, whatever was
necessary. Be ready, ‘cause you don’t know what you might do.
Another woman speculated that couples often do not use condoms consistently
when one person is afraid of hurting or offending the other or when they become blinded
by the heat of passion:
Another thing I’ve seen, too, is most people would always say, ‘Well, like they
was already involved. She didn’t want to get hurt. She just wanted to get him.’
So the condom was just pushed aside.
A key informant from the Task Force said she believes condoms do not provide
total protection from HIV infection. She explained:
If you knew a person was positive, you wouldn’t want to use a condom with
them, or nothing. I understand condoms can make it safer, but I feel like it’s only
going to make it safer psychologically.
Environ men ta 1 Factors
Figure 17 on the following page depicts the overarching framework for this study,
highlighting the environmental factors, as identified by research participants, that could
influence whether individuals engage in AIDS dialogue or comply with AIDS prevention
advice.
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INDIVIDUAL PROCESSES
CULTURAL CONTEXT
FIGURE 17: Environmental Factors, Identified by Research Participants,
that Influence AIDS Preventive Outcomes
Family Norms
A key informant from the African American AIDS Task Force said the members
of her church serve as an extended family. When an unmarried teen in the church
became pregnant, many women rallied around the girl
All of us are God mothers, aunts. And that helps and will continue to help her
through her hard times, through the depressed times that she will go through.
If there is unconditional love and help, then we all can make it.
One woman pointed out that many African American youths who do not have a
mother or father in the home are part of extended families. Rather than looking to a
parent as a role model, they often choose a minister or older sibling. This situation can
lead to disappointment and loss of guidance for younger members of an extended family:
With extended families, there’s a lot of hurt. If that role model is not there, then
you are at a loss if you can’t see it and emulate it.
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Apparently, it is not unusual for an African American mother to use legal recourse
as a means of punishing or threatening a man who has sex with her daughter. One boy
apparently witnessed an incident in his neighborhood in which an older boy had been
charged with statutory rape. His remark at the end may indicate some personal
embarrassment about the event: “Her momma get mad, screamin’ all over the place, and
call the cops on you and arrest you. Next question, please.”
For boys in the pilot group, marriage means commitment, even if the union is a
common law marriage. One commented that “if you get married, you should stop just
like going out there and getting with everybody.” Then another added:
That’s commitment, because I figure even when they didn’t have licensed
preachers and everything, they still had marriages before God. As long as you’re
committed to this person before God, you don’t need a preacher.
Most married people apparently do not practice safe sex with their spouses, either
because they trust their spouses completely or because they accept the risks associated
with possible infidelity. One woman argued that taking marriage vows means assuming a
certain amount of risk, including the risk of HIV infection:
That’s the chance you take in life when you get married. Their life is in your
hands, and yours is in theirs.
Local AIDS Situation
The population most likely to be diagnosed with HIV in the Gainesville area are
African American women of child-bearing age, according to a Task Force leader. She
said many of these women are very ill, and grandparents often must care for the patients’
children.
A female pastor said she did not know how “wide range” the AIDS problem is in
Gainesville, because “if it is a lot, they’re just not really saying it.” She added that
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information about the local situation is not presented “in an open manner, where most
people know that it’s what we’re dealing with.” The only reason she personally believes
AIDS is a problem in Gainesville is that she knows several AIDS patients who “say they
have cancer or something else instead of AIDS.”
A participant in a women’s focus group commented that “right now, in our
community, the fastest people that are getting it are teenagers. They just keep spreading
it.” Another woman commented that the local AIDS problem is not just hitting “someone
who was a homosexual or whatever. It’s coming to a point where it’s hitting every
family.” Another woman commented that “the disease is so rampant that you can’t
ignore it. It absolutely will not go away.”
One woman was familiar with the soaring rates of HIV infection in the local area
because she had recently worked for a Centers for Disease Control office in a nearby city:
We started out with hepatitis and then tuberculosis. I had seen the rates go up
with AIDS, and I’m like, ‘Whoa.’ So I was working back there with them, and
then I see it now. They interviewed people and found out they didn’t know.
Apparently, Gainesville is not immune to many problems that plague urban
centers around the country, including prostitution, drug trafficking, and youth living on
the streets. Two key informants from the Task Force identified Porters Quarters, located
in downtown Gainesville near Tumblin Creek Park, as the primary prostitution and drug
trafficking area.
One key informant said she has spotted many prostitutes and drug dealers hanging
out on street comers at night:
It is in the middle of downtown, so everybody can have a piece of the action. I’ve
seen lots of women hanging out around there. You say, ‘What are you doing on
the comer?’They say,‘I’m waiting for a ride.’ It’s a very exciting place. My
church isn’t far from there, so it’s in a spiritually challenging neighborhood.
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When you get on the other side of Fourth Street, that’s where there’s lots of drugs.
On one side is where there’s poor whites -- that’s the prostitution side, and on the
other side is poor blacks — that’s the drug side.
A key informant also commented that many Gainesville prostitutes face a double
risk of becoming HIV infection because they sell their bodies for drugs:
You can see them walking down the street. You can see people leaning in cars,
and you know they’re not just giving directions. I mean, there are certain things
you look at and you say, ‘Hmmm . . . wonder what’s going on there.’ You can
see a string of police cars going up and down that street, and people scatter when
they see them coming. That’s a real good hint that something’s going on.
Another key informant said the Gainesville Police Department lacks the
manpower to control the prostitutes and drug dealers, particularly after dark:
Police don’t come through there nearly enough. They just let it go. They don’t
have enough cops, so they mainly patrol University Avenue. If you venture too
far off University Avenue, you’re on your own. Everything that goes on down
there, goes on pretty much uninterrupted except maybe in an election year to
make it look like they’re taking a bite out of crime.
In the middle of Gainesville’s red light district, one key informant said, is a blood
plasma collection center. Although the center tests plasma for H3V, she wonders if they
can catch all the infected samples:
People who are desperate for money are the ones who go there, and they’d go
every day if they could. They’ve got an assembly line of people going in and out
of there.
A male pastor commented that AIDS is a “big problem” in Gainesville because
the disease is “getting out of control, and the sad part about it is that the urgency to
respond to it is not where it should be. We’re not seeing that it’s on every billboard, but
we know that it’s a serious problem. There’s not enough information being generated,
and people are not receptive to seek out this type of information.” He observed that
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African American ministers in Gainesville do not place AIDS high on the pulpit agenda.
Beyond the church, AIDS “is not a number one issue” in Gainesville, either:
It may be the effects of what AIDS has done or can do has not actually hit. There
are some people who have had relatives with it, so they know it’s there. But it’s
not like if we were in a major city. Some metropolitan cities have big groups
devoted to this, and hundreds of people are involved. Gainesville is an educated
community, but it’s not there yet.
Community AIDS Prevention Resources
The African American AIDS Task Force (AAATF) of Gainesville is a grassroots
network committed to the empowerment of the African American community in
controlling the spread of AIDS and reducing the stigma of the disease.
Launched in November 1994 by the North Central Florida AIDS Network
(NCFAN), the Task Force has a two-fold mission: to educate the community about AIDS
and to assist those who are HIV positive with the resources they need. The volunteer
group meets one night a month to develop objectives and implement plans for community
AIDS prevention and outreach activities. Melanie Gasper, former NCFAN executive
director, stated in a memo that the AIDS network
Understands that involving influential members of the African American
community ensures that culturally sensitive decisions will be made in all phases
of planning and implementation, and that in all efforts, chances for success will be
improved.
The AAATF includes health care professionals, ministers, social workers,
attorneys, law enforcement officers, educators, community leaders, and other citizens.
Shortly after the group was launched, in-depth interviews with two key leaders reflected
the “ground floor” phase of the Task Force itself and the climate of anticipation,
evolution, expectation, and planning that surrounded the creative brainstorming of the
group. Several organizational themes emerged from the transcripts, including goals,
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momentum, evolution, inroads, outreach, community problems, and AIDS campaign
plans. The Task Force has planned various projects within Five sub-committees:
publicity, education, faith community, client services, and testing.
The other co-founder of the group, an African American man who died of AIDS
in June 1997, had developed an idea for the Task Force rooted in the belief that “African
Americans need to have someone of their own to be able to talk to and bring these issues
out in the open,” the female co-founder said.
In planning the first meeting, an African American college administrator, the
executive director of the regional AIDS network, and an African American nurse
involved in ADDS care collaboratively created a list of community leaders who might be
enlisted to found the new organization. In narrowing the list of names, the three women
selected representatives from the religious community, educational institutions, law
enforcement, the legal profession, and other areas of the community.
In a letter explaining the purpose and goals of the Task Force, the AIDS network
invited 25 people to the organizational meeting. Beyond this core group of leaders,
additional people from the community have participated in planning and decision
making.
The Task Force includes health care professionals, ministers, social workers,
attorneys, law enforcement officers, educators, and other community leaders. The
membership was never limited to African Americans. A key informant explained that
including people from other ethnic groups is helpful because “there are lots of people
from lots of different cultures who can help us in what we’re trying to accomplish.”
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A confidential support group for African Americans living with AIDS was
founded at the same time that the Task Force was launched. According to the woman
who co-founded both groups, the weekly support group only met for about a year, but in
the early months had 15 regular members — 10 living with AIDS, and five caretakers.
Occasionally, the patients’ children or spouses would attend also. She said the group
members often listened to guest speakers or discussed “the main issues of that week, so
we could meet the needs that were acute - if they weren’t able to take care of their
medications, if they were having problems getting their telephone deposit, housing.” She
said the group’s HIV-positive co-founder “was very instrumental in directing them to the
right persons who could help them without a whole lot of red tape or a whole lot of
delay.”
Given that many African Americans feel stigmatized if others know they are
going to the county health department to get an HIV test, the Task Force plans to promote
testing by mass producing a T-shirt that says “I was tested.” In addition, most Task Force
members tried to set an example by volunteering for testing. However, this modeling
effort apparently failed to influence African Americans outside the group. When the
Task Force set up an HIV testing site at an annual ethnic festival, the only person who
participated in the testing was one of the group’s leaders. Other AAATF members later
speculated that the testing effort failed because the group did not attempt to disseminate
testing information within the black community prior to the event.
One woman who was not a member of the Task Force speculated that the lack of
community support for the organization also could be attributed to widespread denial:
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The AIDS Task Force has been going on for a good while. So something is
wrong. Maybe there’s just not enough parents getting involved. Or maybe
everybody’s sitting back, still hoping it will go away.
To increase publicity for the group and its efforts, the AAATF has developed
several radio public service announcements and plans to create PSAs for television as
well. When the Task Force set out to develop a community awareness campaign, many
members spent hours making and distributing hundreds of buttons and T-shirts depicting
the group’s name and logo, rather than making items that promote an AIDS prevention
message. These buttons were distributed to group members and to community residents
during tabling events.
A key informant said the Task Force eventually plans to initiate education efforts
within the schools, but these efforts likely will be challenging because group leaders do
not have a sense of how youth may respond:
Trying to figure out how receptive the youth will be to our message will be a
challenge. How they respond is going to be the whole question.
During the first meeting, AAATF members brainstormed goals for educating
local minority youth about AIDS:
1. Involve African American youth as peer educators.
2. Involve youth in brainstorming and developing AIDS education materials.
3. Provide AIDS education materials and curricula for Headstart and K-12 schools,
4. Create a quality, culturally sensitive AIDS prevention brochure.
5. Mobilize the churches, starting with the most progressive ministers.
6. Help reduce the stigmatization of AIDS in the African American community.
7. Select African American role models who can be trained as AIDS educators.
8. Request mission offerings at local churches.
9. Develop television and radio PSAs promoting AIDS information and services.
10. Develop a video with rap music to appeal to teens.
Another key informant said she expected the group’s momentum to empower
many community leaders to achieve its goals:
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While we have this momentum, we want to keep it going. We also want to get us
out to the public, so the public will realize that we are functioning.
A male minister said he became involved with the group because “there’s a need,”
he likes volunteering, he has known people who have died of AIDS, and because he
believes AIDS could destroy the community.
The co-founder of the Task Force said she helped launch the group in 1994 after
having served as a nurse among AIDS patients for the state Department of Corrections.
She said this job raised her awareness and concern because many other nurses were afraid
to give medical treatment to AIDS patients, and families were not allowed to visit:
I had gotten kind of emotional about it because in DOC, families can’t come in to
be with their patient who’s dying. I thought, God, this is awful. If a person cannot
be physically with their family, with people that love them while they were dying,
we would have to find a way to show that compassion. You can’t sit there and
allow someone to just pass on like their life doesn’t count. No matter what.
The co-founder of the Task Force said she believes the AAATF has
“accomplished great things in the short time of our existence” because of “strong
educated role models who show compassion and concern for our people of color” and
because the group has been able to make itself visible through public relations activities.
She said the group needs to promote AIDS awareness in many more
neighborhoods, churches, and organizations in the African American community before it
will be truly effective in attaining its goals. Although the group has been effective in
promoting AIDS prevention, the group has largely failed to provide assistance for
African Americans living with AIDS, she said, and added:
We could go in and cook a meal. We could have youth groups that would clean
up their yard or take their pets for a walk on the weekend. We need to get that
kind of involved - personally involved. We are very knowledgeable in the area of
preventive education, and our persons are at many festivals and workshops. But
when someone sees that T could not have done this for myself today, and you
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touched me, that means so much to me and gives me hope to live tomorrow.’
That’s what we need to be about.
Although many Task Force members are highly educated, they may not be in
touch or concerned about the African American individuals who are most at risk or most
in need, a key informant said. She added that the situation “still saddens my heart.” To
illustrate this point, she told the story of a young HIV-positive, African American mother
from Miami, whose family did not want to care for her. The woman moved to
Gainesville with her 6-month-old infant, and she did not know the HIV status of her son.
She struggled financially and emotionally to take care of the baby, could not afford to pay
for a phone line, and often did not have enough food for her family. During her first year
in Gainesville, her preschool-aged son drowned in a sink hole. The Task Force co-
founder brought the woman’s tragic story to the Task Force in an attempt to initiate a
fund-raising effort to provide assistance. However, when the group did not respond to
the request, the other co-founder withdrew from the Task Force. Recalling the incident,
the female co-founder remarked:
You know that was such a devastating experience. We tried to bring this before
the Task Force, to say this is what we’re about. It didn’t get off the ground. I
have no idea what she received from the network, if it was anything. But it did
not touch the need, with the hurt that she carried. So it’s like we’re creating
missions as we are in places of authority, but what are we actually doing?
Message Design and Delivery
Figure 19 on the following page depicts the framework for this study, highlighting
message design and delivery factors, as identified by research participants, that could
encourage individuals to engage in AIDS dialogue or to comply with AIDS prevention
advice.
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INDIVIDUAL
FIGURE 19: Characteristics of AIDS Prevention Message Design and Delivery,
as Identified by Research Participants
Message Content
Fotonovela messages
The fotonovela's dual message of abstinence and safer sex was understood by the
girls. At the end of one focus group session, one girl summarized: “The message is if
you have sex, be careful.” Then another girl added, “Don’t have sex at all.” However,
when they tried to guess about what their friends might learn from the booklet, the key
messages were quite different. These messages included: “Watch who they hang out
with,” “Watch who they call fine,” and “Watch who you lay down with.”
A fotonovela evaluator said the idea she would be most likely to remember about
the story is that she could get AIDS. When asked to describe any new information they
learned from the booklet, girls mentioned:
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I didn’t know it happens every hour.
I didn’t know about the number of African American women in the Gainesville
area who have AIDS.
I ain’t know that a person can have HIV for 10 years or longer without knowing
it.
The HIV prevention advice in the story, according to several girls, included:
“Don’t have sex is your safest choice,” “Don’t have sex if you don’t have no condom,”
and “Don’t have sex till you’re in a committed marriage.”
The main thing her friends learned from the booklet, one girl said, was “don’t
have sex until you are in a committed marriage. And if you do, protect yourself.”
When asked to name the most important things they learned from the story, the
boys said the two lessons were “to use a condom” and “don’t do it.” One boy said the
new information his friends learned from the booklet was “to say no.”
Sometimes the “don’t do it” message was associated with protection rather than
with abstinence. One boy concluded that “if you ain’t got no protection, don’t do it.
Back off.” Another boy explained that “it’s like telling a person don’t jump in too fast.
If you gonna have sex, wait till you have a condom, then do it.” One boy explained that
the booklet is
Trying to tell you to protect yourself, ‘cause sometimes you don’t really think
about it. You just jump into it. Just jump into it. They trying to keep you from
dying, but some things try to keep you from living.
One evaluator said the booklet’s AIDS prevention message should be more overt.
She suggested that the message say, “Abstinence is the best policy, but if you’re going to
have sex, have a condom.”
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One boy said his friends would probably learn “a lot” from the story, and another
boy said the story would remind them to “watch out.” However, one boy disagreed,
arguing that his friends would not really learn anything because “they’re gonna go out
and do what they wanna do.”
Factual information in thefotonovela
The information on the back of the booklet included “some very pertinent facts,”
one woman commented. “It’s not overpowering them, but it’s giving them the exact
information that they need. Every hour, one African American child or teen dies of
AIDS. That’s a fact. And that’s something they can identify with, and they can recall.”
None of the boys wanted to change the story or its dialogue, but many wanted it
to be longer by adding more information to it. Suggestions for new information, made by
several boys, included an explanation of the origin of AIDS and more advice on AIDS
prevention. A number of girls and boys suggested that the booklet contain “how to”
instructions for condom use.
Another message that should be emphasized, one woman argued, is the fact that a
person can become infected by having sex only once.
Several women commented that the booklet did not address sexually transmitted
diseases other than AIDS or specific HIV infection risks such as blood contact from cuts.
A news story was released from CDC the week before the second women’s focus group,
which reported that a woman with poor oral hygiene became HIV infected through
kissing a man. A woman in the focus group keyed on this story and argued that a
warning about kissing should be included in the fotonovela. She commented that “if you
have very sensitive teeth and your gums bleed just from touching it, and you kiss
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somebody with HIV, you’ve got it through the mouth.” In light of these suggestions, one
woman remarked:
There’s only so much information you can get on the pamphlet. These could be
updated as new information is coming about. These sessions could continue so
we can create more in-depth booklets, and we’ll have more pertinent information.
One woman suggested that a contact person’s phone number should be printed on
the back of the booklet, and this person should be available to answer questions, address
concerns, and provide additional information when people call in.
Humor in the fotonovela
An evaluator said the tone of the fotonovela was “not too serious. It what goes
on. When you’re talking about sex and AIDS, you want it to be funny, but yet you want
to get your point across. I think it’s real -- it’s not too serious. It doesn’t have any funny
anecdotes or anything.”
Most girls believed that sharing the fotonovela was a serious task and that the
booklet itself was serious. One girl said she would tell her friends, “Don’t laugh, ‘cause
it ain’t no joke.” Another girl remarked:
If my friend want to joke about it, then I’d say, ‘If you get AIDS, that’s too bad. ’
I not gonna feel anything if she got AIDS, because she wanted to play games.
Many girls did not find the story booklet funny or otherwise humorous, but one
girl did laugh about the scene in which Kevin talked about the “Mo Booty” video.
Although the girls generally did not perceive the booklet as humorous, many of
their friends apparently did. One girl commented that “lots of people liked it when I
showed it to them, and they laughed at the jokes, like ‘that’s the bottom line.’ They liked
the jokes very much and the people in it.” In assessing their friends initial reactions to
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the booklet, one girl said one of her friends laughed, while another girl said “some
laughed, some smiled.”
The boys were more likely to find humor in the fotonovela. One boy said he
thought the raps were funny, while a couple of boys said the “Don’t let AIDS block your
shot at life” slogan was humorous.
Suggestions for fotonovela stories
Various fotonovela stories could portray the many different ways that African
Americans can become infected, one woman suggested. Both evaluators said a
fotonovela should do more to show the perspectives of an African American person
living with AIDS. She explained that a stoiy should portray a person living with AIDS
because “they may read statistics, blah, blah, blah, but if kids don’t know anybody that
close up, it won’t affect them.” The other girl also remarked:
If someone with AIDS came up and told them they have AIDS, I believe they’d
stop having sex, period. You don’t want to necessarily scare them, but you want
to prove to them that this stuff actually happens to kids. They want proof.
Several teens suggested that a tragic ending would make the prevention message
more effective. One evaluator suggested a scenario that would show the fatal
consequences of risky behavior:
You should have — when Tatiana is talking to Josh, and they go home and do
whatever, I think somebody should get in trouble. She could say, T’m not that
kind of person,’ you know what I’m saying? But they could decide to go do
something, and then after two weeks she’ll get tested. She could get AIDS or
pregnant.
Similarly, one boy said that he would “show them messing up. They’d probably
be scared and not want to do it.” But in response to this idea, another boy speculated that
those readers’ friends likely would “start saying they was chicken” and as a result,
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“they’d do it anyway.” An evaluator suggested a similar alternative ending that also
shows terrible consequences:
You could leave Josh and Tatiana the way they are, but include the message that
they do get married, but that it’s too late.
Suggested messages for AIDS campaigns
The advice offered by various participants in the women’s focus groups could be
viewed as potential material for the construction of future AIDS prevention messages
targeting African Americans. The following are a few examples of these “words of
wisdom”:
You never can learn too much.
Be careful of who you sleep with.
Make sure you are tested before you lay down.
It can happen to me, and I’ve got to cover every step.
All it takes is to trust the wrong person.
That one time that you take the chance could be the one that take you out.
Never take anything for granted.
That one you love so much could well be the person to take you out.
When asked to state the lesson of the “On the Pillow” video, one boy said,
“Always wear a condom.” Similarly, a boy in the pilot group summed up his advice with
this statement: “It’s good to wait, but if a situation happens to pop up be sure you’re
protected.” In summing up the moral of the video, several girls issued words of warning.
For example, one said, “You have to look after people and watch what you do, and be
careful and use protection.” Another commented, “I’d have second thoughts about doing
things with people I don’t know nothing about.” In arguing that the video character
Terrence was foolish to have cheated on his fiancee, one girl concluded, “Keep your
pants zipped.” Similarly, when asked what keeps kids safe from getting AIDS, one girl
said, “Girls keep their shirts down.”
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Abstinence advice
Apparently the public schools in Gainesville do promote postponement of sexual
involvement, prior to the 9th grade, as one AIDS prevention strategy. One girl recalled
specific bits of advice she has received from her school teachers:
They teach you about it, like once you get older and you want to get married, like
stuff about having kids and safe sex. Like, when a boyfriend gets AIDS, ‘cause
by chance they were with somebody that had it.
Another girl wanted to postpone sexual involvement so that she would not be
burdened with the responsibilities of early parenthood. She said she wants “to finish
having time to go to the mall, going out of town, and stuff.” Then one girl added:
You need to live your childhood. I feel that you have to make a wise decision. If
you did have a baby, you’d be able to support the baby. You would have a job,
you would have a good living.
When one girl reflected on her own sexual decision-making, she keyed on one
main issue: “I feel that if he can’t wait for you, I wouldn’t do it.” Other girls commented
that before a person begins having sexual intercourse, she should “wait till you’re real
ready” and be “committed to marriage.” However, neither readiness nor commitment
necessarily implies abstinence until marriage or monogamy.
The advice to postpone sexual involvement was not considered realistic for one
girl, and she further equated abstinence with joining a convent: “If you don’t wanna use
condoms, it be best if you become a nun.” The advice also may have a mixed meaning
for some youth. One boy in the pilot group argued that waiting to have sex does not
prevent HIV transmission. He remarked:
If you had sex when you was 10 years old, or if you wouldn’t have sex till you’re
like 40 — you could still get AIDS. That’s waiting till you’re older. It don’t
matter about your age.
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He later remarked that being abstinent will not protect people from HIV infection
if they “go shoot up some needles.” But another boy corrected him, saying that a person
must be “abstinent from that, too!” Most girls supported sexual abstinence as the most
effective way to avoid HIV infection, but several were quick to add that protection and
preparation are needed, too. For example, when one girl advised that “abstinence is the
best way to do it,” another added, “Always be sure you’re ready.”
In assessing the possibilities for developing an abstinence-based campaign
targeting African American teens, a key informant commented:
I think it’s a wonderful challenge, and I know it can be done. Our fight would not
be with students, it would be with bureaucracy, school boards. After you master
that, a lot of the students are not being taught AIDS education in the home, so the
parents are willing to relinquish that duty to the church.
An abstinence message could be more effective today than in the 1980s, a key
informant argued, because the decision to have sex is more knowledge-based:
They’re making choices, and the decision is that T choose to, or I choose not to.’
Before, it was a certain amount of immaturity about their actions: T just want to
be with him, and if he doesn’t want to, I won’t.’ The students today are so much
more intelligent. They have the knowledge given to them.
One mother said she often advises her daughters to maintain abstinence but gives
them an alternative as well:
I tell my girls, ‘In the case that you cannot be wise, do not allow yourself to be
placed in a position where the other person means so much more to you than your
health means to you. So you have to be very strong in your decisions about what
you’re going to do in your sexual life.’
Another woman said that taking a public stand for abstinence is a Christian
responsibility, and it can encourage youth to reach out for guidance:
If you make that statement to a young lady or man who might not openly say, T
want to be sexual,’ they will seek you out and ask you, ‘Can you help me?’ If you
do not open the arena further, then they’re going to ask somebody else - their
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friends or whatever. Then they’re going to get in trouble. But if you open the
arena, then later on they will call. That’s what your Christian duty is.
A female pastor said abstinence is the most appropriate AIDS prevention message
for youth, but “to them it’s unreasonable.” She added:
I deal a lot with the kids, and it’s been in one ear and out the other. I watch the
little girls. They’ll do anything for one of those little boys. And it don’t matter
how much we taught them, they’ll do it. I watch stuff like that and it lets me
know that there are more chances that they are going to do it than not.
The advice to wait until marriage for sexual involvement is not just reserved for
teens. One church-going woman warned the single women in the focus group:
Now, I’m sure that the ones that are single in here, that don’t have husbands, the
first thing you’re going to be doing is like, ‘Wait a minute. Before I have sex
with him, I’m going to marry him.’
Several women in the focus groups lamented that despite their best efforts to
discourage children from having sex, the youth still do it. One woman said:
They’ve been told about AIDS. They’ve been told about not to trust someone and
have sex - you may get pregnant. But still yet, they’re getting pregnant. And I
mean, more so than they’re not.
A female pastor said her teenage son recently announced that his girlfriend is
pregnant. She commented that her son
knows that sex was really made for marriage, not for couples outside of marriage
and all. And he knows it’s something I’ve talked to him since he has been big
enough to talk to him about. And he hears it because Daddy preaches it. The
young lady that he’s been dating - she’s been hearing it because my husband
preaches it. I often get them to themselves and tell them why they couldn’t tell
that no matter how clean a person is, but still yet, she got pregnant.
In another situation, a 16-year-old virgin had sex when she sneaked away from
home for the weekend. The female pastor said this “quiet young girl” pretended to be
spending the weekend with a friend to go to the prom:
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She and her mother are real close, and they were trying to trust her and let her go.
Turned out, they went back to pick her up and found out she hadn’t been there the
whole weekend. The mother is constantly saying T don’t want you to make the
mistakes I made.’ But even in the midst of educating her, her father is saying,
‘No birth control.’ And then here she is, out having sex.
One woman argued that the abstinence message is not being taught in school or at
home, and as a result, no one is taking the advice seriously. She remarked that “most of
them walk around with a condom, and that’s it - ‘cover myself so I won’t get it.’” An
important component of an abstinence message, she said, is the idea that it is OK to be a
virgin. She suggested this approach because many virgin teens feel out of place and
“don’t want anyone to know that they’re a virgin.”
A male minister said he is not afraid to preach about sex outside of marriage, even
though “lots of folk don’t.” In his talks with youth and Sunday morning sermons, he
teaches an abstinence message emphasizing that
if they play around, have casual sex, it can be traumatic in the long run, whether it
be AIDS or pregnancy or something else. The Bible lets us know that sex outside
of marriage is taboo, it’s wrong. You want to keep yourself for your husband-to-
be or your wife-to-be. It’s something special that you want to hold onto.
The main reason youth should postpone sexual involvement, this minister argued,
is that “it’s not the right timing.” He said youth are not mentally ready for sex, and he
often advises them that the consequences of sex
Could set you back 10 years. Put all your goals in front of you - you’ve got
college, you’ve got med school, you want to be a professional. You don’t have
time, if you go out and commit fornication, to get a baby early or pick up a
venereal disease. That can be traumatic and throw your whole life off.
Another reason, he tells them, is that sex can ruin the enjoyment of youth:
You’ve got to remember that you’re still trying to enjoy those young years, and
you don’t want all these other things pulling at you and adding to the frustrations
of your life. You have a few ups and downs, but life should be enjoyable.
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The minister said one of his sermons about abstinence focused on Proverbs 3:5-6,
which states: “Trust in the Lord with all your heart and lean not on your own
understanding. In all your ways acknowledge Him, and He will make your paths
straight.” The minister said this scripture provides a rationale for postponing sexual
involvement:
You believe God for everything, and you know that He has your best interests in
mind, and that everything’s under control. He’s going to supply all of your needs,
so there will be no need for you to actually go out and make things happen for
yourself. If I’m a person who figures ‘Well, God’s not moving fast enough for
me,’ or ‘Things are not happening, and I’m not finding the right person that I
really want to marry’ - if you don’t trust the Lord, you’ll put your trust or
confidence in someone else, and you’ll find yourself running behind something
that won’t ever be yours. Then you can find yourself in some predicaments where
you’re being used, taken advantage of, because you’re vulnerable.
Controversial condom advice
While the church is expected to uphold Biblical principles of sexual purity, it also
is supposed to extend compassion to sinners, according to their needs. The dilemma over
whether to recommend condoms as safer sex advice highlights this moral conflict
because failure to help individuals protect themselves could result in AIDS deaths. One
male pastor observed that most African American churches in Gainesville “won’t go
along with the condom issue, so they’ll stress abstinence or they’ll stress safe sex.” He
agreed with this approach, saying, “That’s just the way it would be, according to the
Bible.” He also said he will not promote condom use in his church because that advice
would condone premarital sex, which is a sin:
I probably would not tell anyone that ‘Well, if you’re going to have sex, use a
condom or birth control pills.’ I would have a problem telling them that. That’s
like saying, ‘Here, go ahead and do as much as you want.’ The message I really
want to get over to them is ‘Keep yourselves. Don’t destroy your young lives.
You can wait. I know there’s some pressures.’
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Several women disagreed with this stance, arguing that the church should not
condemn safer sex advice. Although promoting condom use may endorse sexual sin, one
woman confronted this dilemma by remarking that “we’re walking a fine Une, and the
fine line is we like compassion.” Another woman explained her position this way:
You’re not saying it’s OK. You’re just realizing that these kids are human just
like us. Some of them are going to try it. So the best thing to do is teach them
abstinence, but don’t be foolish enough not to teach them what to do after
abstinence. I know a whole lot of young ladies, and they’ll come and tell me,
‘Yes, I am already having sex. Yes, I am doing it every day with someone.’ So
what do you tell them after that? You have to tell them how to protect
themselves.
When the boys were asked what kind of advice they might give to a friend who
wants to become sexually active, one said he’d encourage the friend to have sex but warn
him to use protection: “Take it, buddy. Take it. You need to be protected.” Another
disagreed, saying that he would advise his friend to be more cautious: “I’d say don’t do it.
Man, I’d be like, ‘Watch your thing.’ I’d be like, ‘You should think about what you’re
gonna do before.’” One boy argued that giving abstinence advice might not persuade a
friend to postpone sexual involvement. He commented, “You can’t tell somebody not to
get it.”
The church has a utilitarian obligation to help its weaker members avoid trouble
by offering realistic alternatives to Biblical mandates. One woman argued that Christians
should “help the whole” by reaching out to those who cannot comply with abstinence
advice:
In helping the whole, there may be one who will not be able to maintain, and we
need to be a help to that person. We need to be there with loving arms and
unconditional love. If you cannot maintain, we need to talk to you about keeping
you healthy and safe. If you choose to indulge in sexual behavior, you need to
protect yourself. For those that will not be strong, we have a responsibility to
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make sure they know how to keep themselves safe and understand the
consequences of their actions.
When talking to her own children about sex, a female pastor said she gives them
conditional abstinence advice:
I tell them, ‘I’m not crazy. I’ve been there where you’re at. And even though I
want you to not have sex, and I want you to get married and do it the way you’re
supposed to do it, I am going to give you another option. If you happen to do this,
use a condom.’ And people are like, ‘You did that?’ ‘Yes.’ Because I feel like
anything else is stupid. I really do.
She argued that parents should provide condoms and safer sex advice when they
are suspicious about a teen’s behavior:
To me, it’s stupid if you know the child is showing you all the signs that they’re
going to do it and you’re gonna tell them they shouldn’t. I feel like because they
make a mistake it shouldn’t be something that’s gonna take their life.
The pastor also believes it is morally defensible to advise youth to use condoms, but she
does not talk about condom use in public settings because she must fulfill a pastor’s role
in a conservative church:
I mean, I wouldn’t get up in front of a church and just say that. But when I’m
doing individual counseling and stuff, I try to tell them that because, I mean,
there’s just so many situations that I get to see that a lot of Christians don’t get to
see. It’s not a compromise for you to tell them that they need to be aware that if
they have sex and they’re not protected, it’s not that you just get pregnant. You
get AIDS. I feel like that’s not against God’s rule, because He always teaches us
what to do. But then He also shows us that He has love and forgiveness. He
knew that there was gonna be that place where people were not going to be
absolutely true to what they are supposed to be.
The teen focus groups were conducted as part of a church-based summer youth
program. The director said she set up the program to be funded and operated as a
community services program so that youth leaders could have the freedom to discuss
sensitive issues such as condom use in ways that might not be acceptable in a more
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traditional church setting. She commented that in planning summer activities for the
youth:
Any program we do doesn’t have to be based on what our religious beliefs are.
We’re not going to do it in church, but we can do it through this program. We’re
dealing with church kids, so we need to say abstinence first because they need to
know, OK, this is the church’s background. But, you know, if for some reason
it’s more possible than the abstinence, we can do that.
Visual appeal of the fotonovela
Among both the girls and boys, the major criticism of the booklet’s appearance
was lack of color. One girl commented, “I’d like it better if it wasn’t all black and
white.” Another girl commented, “We need some color.”
The boys tended to be more candid in their evaluations of the fotonovela's
appearance. One remarked that “it’s ugly. You need to get a new color.” Another boy
agreed, commenting that “it’s black and white through the whole pictures, and they look
grayish.” One boy suggested that “green would be a good color.” Although most boys
thought the photos otherwise looked acceptable, one boy argued that the booklet would
fail to draw attention unless it contained color:
You’re telling kids how to protect themselves by showing them this book. Why
would kids want to read it if it don’t got no color to it?
One boy argued that even without color, the fotonovela was effective because “it
shows kids what’s going on.” However, another boy said the booklet should do more to
“show them how you catch AIDS.” One boy said he wanted “to see some action,” while
another boy wanted to “make it more exciting.”
None of the girls objected to the size of the booklet. Most boys, however, thought
the booklet was too short and small. Many repeated this criticism throughout the
evaluation group session. For example, one boy commented, “But see, they only got four
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strips in here. They need to have more than that.” A conversation among the boys
highlighted their thoughts about the booklet size:
Boy 1: You could add more pages. Like cut it bigger, so you can put more
information in it.
Boy 2: Yeah. I thought it was gonna be, like, big.
Boy 3: If you’re gonna have it front and back, you could at least have some pages
to it. And more information.
Boy 1: You need to have lots of information, and lots of color pictures and stuff,
so you will know what’s going on.
The girls were pleased with the type size and style of the booklet’s lettering. One
girl recalled that her friends “said it was neat looking.” Another girl commented that “it
looks neat and pretty.”
The boys were more critical of the lettering. One commented that “they look
straight,” while another suggested that “for the title, make it neater, make it stylin’.” One
boy did not like the way the photos and script was placed on the panels and suggested
that we “make the book neater.”
Fotonovela photography evaluation
Most girls said the photography was their favorite aspect of the booklet. The girls
said they liked the photos for a variety of reasons — because they were funny, realistic, or
simply “‘cause they go with the words.”
The favorite photo, among both the boys and girls, was the picture of two boys,
with one holding condoms and the other holding a video box for a pornography movie
titled “Mo Booty.” Referring to this photo, one boy remarked that “there was just one
picture where it shows you the true meaning of ADDS - what to do and what not to do.”
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Another boy explained that this photo was his favorite because it symbolically shows
boys how to protect themselves:
I really like that video and the condoms, showing them, because they’re what
you’ve got to use for protection. It’s not just showing you a woman, it’s showing
you condoms. Suppose a woman had AIDS, and you wanted to have sex with
her. They got condoms, so you have the protection you need.
One boy said all his friends liked the booklet, and the aspect they liked best “was
when they was playing basketball, and when they was holding up the video,” one boy
remarked.
When the photos were being taken for the “Mo Booty” scene, in which one boy
was showing condoms to his friend, four other boys were hanging out nearby and asked
to look at the condoms. The boy who was not holding the condoms in the photo became
upset because he wanted to be the one shown holding them. After the photos were taken,
the boys went inside except the boy who was shown holding the condoms. As soon as
the other boys were out of earshot, he asked if he could keep a couple of the condoms for
himself, then quickly tucked them into his pocket. Apparently, he did not take the
condoms to impress his friends, or possibly he feared getting into trouble with the adults
who ran the summer youth program given that it was church sponsored.
One girl said her friends were “more interested in the pictures” than the story or
AIDS facts. She added that “they were picking about their hair and stuff like that.”
Interest in the photos may have promoted discussion about the booklet and its
issues, however. Many of the girls’ friends were inquisitive because they recognized
some of the teens in the photos. One girl remarked that her friends “asked like, ‘Who are
the actors?’ They seen the pictures that were funny and they like ‘Who is this?’ Then
they asked me some questions after that.”
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A few girls who were self-conscious about having their photos shown in the
booklet still reacted positively to the booklet. They were most concerned about not
looking pretty or about being shown with boys. When asked what she thought was the
worst thing about the booklet, one girl simply said, “Me.” Then she went on to say:
I like the pictures. I just don’t like my picture. I don’t like the one with me on it
‘cause I look all swollen. If I looked pretty on it, I’d like it better.
Another girl pointed out, “Clarissa, there’s your belly.” Then another remarked,
“I look like I had some drugs.” When asked to tell what she thought was the most
important thing she learned from the story, one girl said, “Not to take a picture with no
boys.” One girl commented that when the boys see the booklet, they would probably “be
like, ‘Ooh, I don’t want to take no picture with that person.’”
When the teens were photographed for the fotonovela, one boy objected to sitting
next to the girl who played Tatiana’s part. Even after his friends insisted that he sit next
to her just for a quick photo, he refused to sit within three feet of the girl. After the
booklet was published, a girl in a focus group remarked to the girl who played Tatiana:
“It’s like you got AIDS. He don’t want to be beside you.”
Concerned about her mother being upset about sexual dialogue being linked to her
photo, one girl remarked that “It sounds stupid, ‘I’m gonna make you feel so good.’ I
ain’t talking about the pictures. I’m gonna get in trouble when my mom sees it.” At one
point during the focus group session, this girl interrupted the discussion and announced,
“All right, y’all. Don’t show anybody.” She said she feared her boyfriend or her mother
might see the photos of her sitting next to another boy and jump to the conclusion that the
situations described in the story had actually happened.
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Source credibility
The influence and credibility of the African American church is rooted in the oral
tradition within extended families, argued Jean Tapscott of the national Agency for
HIV/AIDS. As an African American who has served 11 years as an agency administrator,
she has observed that the church plays a major role in the black community because “the
older people are moral teachers who can pass on information in the home, to their kids
and grandkids, nieces, and nephews.”
Tapscott’s agency has developed AIDS intervention strategies for African
American churches that utilize this cultural norm. She explained that “we have a saying,
‘Each one, teach one.’ Using AIDS literature and workshops, we are teaching church
members to teach others. The church’s credibility is the entire issue.”
A male, African American minister in Gainesville acknowledged that his church
members look up to him for guidance. He remarked:
Ministers and those in authority are looked at in a certain light, and there are
things that people will respect when it’s coming from them, as being like gospel.
I think there’s a lot of credibility behind that role as a minister.
He further asserted that trust is a key component of credibility, especially parental
credibility:
If kids feel that they can’t come and talk to you about those real sensitive things
they’re going through, they won’t see you as a trusted person. One of the beauties
of having children is when you get to know them, they get to know you, and they
trust you and feel comfortable talking about the things that are happening in their
little lives.
In discussing how their parents talk about sex or AIDS, a conversation among
boys in the pilot group revealed that parents do not always have high credibility in
dealing with these issues:
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Boy 1: They need help.
Boy 2: They like, ‘You go around much with that girl, you’re gonna catch
something, messing around.’
Boy 3: And like, ‘If she ain’t very easy, you won’t catch no AIDS.’
Boy 2 : They like freak if they catch you doin’ it on the sly.
Many AIDS PSAs on television, one woman argued, use adults rather than teens
as spokespersons. She remarked that using teens as sources is “a big start, I would say.
Because when the kids do it they say, ‘Wait a minute. This is someone I know.’” One
woman said she first learned about AIDS from famous African American male
spokesmen on television. She remarked:
I think mine came through television, mostly with the tennis guy, Arthur Ashe.
He was one of the ones that I heard about that contracted it back in the 80’s, and
then Magic Johnson and Ezy-E and Rock Hudson and all these guys came along.
It became more popular. Then, you started seeing it in big, bold letters.
In response to this comment, one woman asked, “Were most of those gays?” and
another woman remárked that, “They were just messing around.” However, a woman in
another group viewed these men as heroes:
Like that Ezy-E, one of the kids’ favorite rap stars, Rock Hudson, different people
like that we watch on TV - we see those people, and those are our heroes.
The women also appeared to hold high respect for Magic Johnson as an AIDS
spokesman. One woman commented:
I think by him announcing that he had AIDS and getting off the team to protect
the guys on the team and the other players, he did something that most people
wouldn’t do. He started when American people started really focusing on AIDS,
and children when he went around to different schools and different things. I
think he made a step that opened up more information concerning AIDS.
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Another woman pointed out that “children are more apt to listen to him because
they like him, and he’s been a public figure for such a long time. He had a commitment
and made a mistake. And that mistake cost him his future, his career.”
When asked what she thought of Magic Johnson, one girl indicated that he was
highly credible in her eyes: “If I saw him on TV, I’d listen to him, and I’d probably think
about his experiences and perspectives.” Another added that she thinks Johnson is “still
all right, even though he have AIDS or HIV.”
One girl knew that Johnson contracted HIV when “he cheated on his wife” and
that his wife “ain’t got no AIDS.” A boy in the pilot group mentioned Magic Johnson as
an example of someone who was infected for many years before he discovered it. In
response, another boy remarked, “I would not play professional basketball with that
man.”
Given that the other boys focus group was conducted the day after the Tyson-
Holyfield boxing incident, many expressed concern that Holyfield’s ear injury may have
exposed him to HTV if Tyson were already infected with the virus. In light of the recency
and sensationalism of this event, the boys were far less interested in talking about Magic
Johnson than the boxing melee. However, one boy did say that Johnson no longer has
AIDS. His comment may be consistent with the view among many African Americans
that Johnson is able to pay for superior AIDS treatments that are financially out of reach
for most other HIV-positive individuals.
Similarly, Johnson was seen by several girls and women as a wealthy man who
can afford AIDS treatment that others cannot afford. One girl commented:
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There are medicines that really help, but the regular day person working at a
teacher’s salary couldn’t afford that. I know who could afford it is Magic
Johnson, and he gets his shots or whatever.
While boys may not be influenced by Magic Johnson, many may view other
basketball stars as their heroes. One woman said her 13-year-old son looks up to many
African American basketball players, especially Michael Jordan and Scotty Pippen. The
boy also admires many rap stars. The woman wants her children to evaluate the behind-
the-scenes lifestyles of celebrity heroes to decide whether these men are really worthy of
respect. She advises her son:
‘Even if you choose Ezy-E, even if they talk about non-violence, it’s not a
responsible lifestyle. When you see these men as your role models, make the
distinction about what goes on in their life, around them, and how they carry
themselves. You can rap, but when you’re 30 years old, you’d be back out here on
the street without a job, ‘cause rap would be faded out by then.
The woman said that Michael Jordan and Scotty Pippen are worthy of respect
because they have returned to the black community to provide educational mentoring for
children and financial assistance to schools. She commented:
They don’t forget the people that they’ve left behind. That’s the type of role
model figure that you want to become. You have to emulate those values. You
don’t see very many of them telling you, ‘Oh, Dennis Rodman is the man.’ He
can do what he wants to do, and that’s good, but there has to be a drawing line.
Cultural sensitivity
The extent that an AIDS prevention campaign is sensitive in addressing cultural
norms and controversies among African Americans may predict the extent that it
effectively targets the intended audience. One key informant from the Task Force argued
that most religious AIDS prevention materials do not effectively target African
Americans because they are developed by and for whites:
When I see the AIDS messages on TV, especially the ones portraying white
people, I think that white churches might deal with these kinds of issues
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differently than a black church would. You say one word that can mean
something else. We’d say something’s ‘bad’ when it means something’s ‘good.’
A male pastor commented that AIDS prevention information should be tailored to
address stigma among African Americans. He commented:
It’s something that you can’t just limit to one community, but at the same time,
we know that education needs to address all the little typical things that the
African American community has thought, like the stigmatism of people who
have AIDS and homosexuals and drug users and a whole lot of other people.
Street language should be a primary component of an AIDS prevention message
targeting African American youth, one key informant suggested. For example, the
common use of the slang word “jump” was heard in discussions among both boys and
women during the focus group discussions. After watching the “On the Pillow” video,
one woman said Terrence “took her back to his place from the jump.” One boy said that
“jumping into it” is “like what happened in that movie, like if you want to get with
somebody’s girlfriend.”
Picha hadisi
In this study, a fotonovela was adapted for African American teens, whereas in
the past this channel has been used to target only Hispanic individuals.
Since the word fotonovela likely is unfamiliar to most African American teens
and adults, an alternative label may be needed for this audience. In the focus groups, the
moderators referred to the fotonovela as a “story booklet.” In the course of discussions,
one girl called it a “picture book” and another girl remarked that “it’s a play.”
One member of the African American AIDS Task Force suggested that the word
fotonovela, Spanish for “photo novel,” be translated into Swahili. She suggested this
approach to coordinate with the primary AIDS brochure used by the task force, titled
“Umoja Sasa,” which is Swahili for “unity now.” The Swahili translation for “photo
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novel” is “picha hadisi." Perhaps in the future, picha hadisi could be used as a name for
photo stories designed by and for African Americans.
Raps
The raps were especially popular among both girls and boys. The girls liked the
raps for different reasons. One remarked that “it’s neat,” and another pointed out that a
rap “makes it stick in your head.” When one girl mentioned that she liked the rap titled
“A limit to a lime,” several other girls joined in and recited the rap with her.
Several teens said they especially liked the raps because the lines rhymed. One of
the fotonovela evaluators said the raps were interesting, and she explained that a rap is
“just like poetry. That’s all it is — just poetry, and then they add a beat to it.”
During the youth focus groups, occasionally a participant would interrupt the
discussion just to recite a line or phrase from the booklet. The one most frequently
mentioned was the end of the first rap: “That’s the bottom line.” One girl used that line
to talk about her own life: “I ain’t gonna do nothin’ and that’s the bottom line.” Then
another girl repeated, “And that’s the bottom line.” The most quoted line among the boys
was “Don’t let AIDS block your shot at life.” An evaluator said she especially liked the
line that said, “So watch what boy or girl you call fine.”
Among the girls’ friends, the raps and the “steppin”’ were favorite items in the
booklet. One girl said her friends thought the raps were “fun.” In the late afternoons,
while the boys went to the church parking lot to shoot hoops, most of the girls would line
up on the sidewalks to rehearse their collaboratively choreographed “steps,” and every
day they would add another move. These “step shows” included coordinated clapping,
shuffling, stomping, and dancing in circles or lines, but usually no singing, music, or
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words except occasional counting or other verbal instructions. Sometimes the girls
created steps to go with rhythmic music on a cassette tape, or their friends would sing
repetitive, original, unaccompanied songs while the steppers performed.
The use of raps in the fotonovela may have been attractive to many teens because
they had access to the written version of raps in a culture where raps are usually shared
and taught orally. After the skit writing workshop, conducted on the first day, several
individual boys and girls jumped up to recite the rap in front of the entire group. On a
couple of occasions, one boy openly criticized the ones who were reading the raps.
Another boy scolded him, saying, “You’re just jealous.” Several boys in the
youth group were also members of a rap team that sometimes performed in church. One
youth leader explained that the younger boys who do not know how to rap are especially
envious of the ones who can.
The raps in the back of the fotonovela are intended to be simple and easy to read,
which could enable even inexperienced rappers to impress their friends. For example,
when asked what he thought of the raps in the booklet, one boy said, “This rap? I can do
that.” Another boy said using raps “helps make the book sound better.”
When the teens in the summer youth program were asked to write a skit or play
about AIDS, all the boys chose to write raps instead. Unlike the girls, who usually
wanted to write skits collaboratively, the boys wrote their rap verses individually and did
not want their friends to see their raps until they were finished.
Unlike the boys in the summer youth program, who exclusively wrote raps, the
boys in the pilot group were intensely focused in writing collaborative skits with other
boys. In the pilot group, the boys worked in groups of three or four and typically
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produced skits that were much more serious, morbid, and streetwise than the ones created
by the girls in the pilot group. Although the differences in writing preferences between
the boys in the pilot group and the summer youth group could be partly explained by
socioeconomic differences, the primary explanation may be the fact that most boys in the
pilot group had experience in performing various pre-written skits for radio spots.In
critiquing one of the raps, one girl commented:
I don’t like that part about respecting AIDS. You could say something, like that
you’re aware of it or something. Like ‘AIDS won’t take me ‘cause I know all
about it.’
An evaluator criticized the Scriptural implications of the first line of the rap titled
“The bottom line.” She commented that “it says, ‘They say sex is wrong, sex is not
right.’ But the Bible says there’s nothing wrong with sex, if you’re married.”
Preferred channels
The African American teens in the focus groups named a variety of media
channels they would like to use to learn more about AIDS. The girls suggested that other
effective channels for AIDS education might include television or radio commercials,
movies, and cartoons. A woman recalled seeing an AIDS prevention cartoon on local
television that was developed by older teens to reach younger teens. She remarked that
the cartoon
Had a lot of effect because it’s entertaining but it made the point, and it was very
understandable. This cartoon got their attention.
One girl suggested a television mini-series because “that’s something you can
watch with your family.” A woman argued that movies, educational videos, and
television spots “really do help a lot.” She observed that on television, “they’re
beginning to really educate people more with showing the effects and stages. I mean, I
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would really like to see more videos like that.” A boy said he has learned about AIDS by
watching movies. He commented:
I know a lot about AIDS. I keep watching videos. Somebody have sex, and
every time after that, they say something about AIDS.
Occasionally, teens made comments reflecting their awareness of educational
techniques used within traditional health communication campaigns. When asked how
they might make an AIDS awareness video, one girl commented that “probably at the
end, they might have a message with all the people in the cast saying it, something like
safe sex.” Another girl added that “they’d probably tell the amount of people who have
AIDS, in the millions.”
Several boys recommended that AIDS testing could serve as an effective
education tool among African American teens. While testing itself is not a channel, it
provides an opportunity to educate individuals using interpersonal counseling, pamphlets,
or videos.
Fotonovela vs. traditional media
Although most focus group participants were aware of tools and strategies used in
traditional AIDS prevention campaigns, some believed past approaches have not been
effective in changing behavior. Pessimism about traditional strategies, however, might
prompt a positive reaction to a novel strategy such as a fotonovela intervention. For
example one woman observed:
If you look, the pregnancy rate is going up instead of down, so we still must not
be doing enough. Sometimes we just have to change the way we’re doing things,
and re-strategize so that we can reach them. Because right now, it’s not helping.
Another woman observed that the fotonovela is different from traditional AIDS
prevention campaign materials because “it’s real children. That’s what they’re going to
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relate to. It’s not that parent on the television that they always show.” The fotonovela is
more attention getting, another woman argued, because the message is presented by and
for teens, rather than by adults. She observed that if
A grown person’s telling them something, sometimes they’ll rebel. This is the
whole thing I like about the pamphlet. Because children, they can relate only one
on one with another child. It’s the kids’ point of view. It may not fully get all of
them attention, but it will get somebody’s attention.
One woman enthusiastically supported the strategy of having teens
collaboratively create AIDS education materials for their peers. She remarked that
“when you have teen kids coming together, they team up with some of the best ideas you
ever want to imagine.”
Another woman observed that the fotonovela project is similar to a youth
newsletter project in her church. All teens are asked to contribute material to the
newsletter, and the pamphlet is distributed during church every Sunday. She explained:
Some of them just write their name. They’re like, ‘Oh, we know these kids. This
is what they think. ’ It’s about anything they’ve went through, about things they
have to deal with personally. It’s like, ‘This could really happen ‘cause I know
this person.’ And it makes them wake up. A lot of kids want to pray or come
forward right after testimony.
A couple of the girls thought the booklet did not contain enough information
because it contained so many photos instead. This evaluation could have been based on
their comparison of the fotonovela with traditional AIDS brochures they may have seen
in the past. For example, one girl remarked that the booklet “ain’t nothing but pictures.”
One woman observed that the length of the fotonovela made it unique, when
compared to other kinds of AIDS prevention materials. She remarked that “even in its
brevity, it was different.”
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A fot onovela evaluator said the booklet should offer more statistics and other
information because “I see a lot of things like that.” One boy suggested the fotonovela
should have a video to go with it. Another boy suggested that the fotonovela be modified
so that it more closely resembles a traditional AIDS prevention brochure. He explained:
For the beginning, they could have put ‘How to prevent AIDS.’ And then, have
like pictures of people in color pictures, and have like a longer strip.
The perceived need for more condom information may be based on a comparison
of the fotonovela with traditional AIDS brochures or materials used in the school
curriculum. For example, one girl commented, “Oh, everybody think people need to
know more about condoms.” One boy said he wanted to see more pictures of condoms in
the booklet and complained that “they only got three, four condoms on the book.”
Another boy suggested that a condom be given out with the booklet.
Future dissemination offotonovelas
When asked to suggest some ideas for future distribution of the fotonovela, the
girls group came up with a number of strategies: mailing them to people who request
them, placing one in every mailbox, mass mailings, handing them out in stores and other
public places, and distributing them in the schools. One boy also recommended
distribution in the schools, suggesting that “you need to give the teachers at school like a
lot.”
Specific distribution strategies, as suggested by the women, included placing the
booklets in pediatrics waiting rooms and distributing them to employees of various
offices, stores, companies and other businesses. Many women said they liked the
accompanying sheet that provided tips for sharing the booklet with teens and
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recommended that this sheet be included with the booklet when distributed to adults. The
possibilities for sharing the booklets are numerous. One woman commented:
You could go so many ways with this. You know, how sometimes you go to the
pool, and you see kids talking to the boys, ‘cause they have like after-school pool
things. You could use that. You could be like, ‘OK, now, You see this thing?
Go over here and read this.’
Although some ministers likely would be reluctant to take an official role in
promoting the booklet in their churches, several women recommended that the booklets
and accompanying materials be distributed to church youth leaders first. One woman
commented:
Maybe where the pastor may not deal with it or whatever, a lot of them have
youth leaders who do a lot with youth, and they know where the youth are. So
they know how important it is to get out this information.
Several women recommended that the booklets be distributed to adults before
they are given to teens and that the adults be trained in how to discuss AIDS and
sexuality issues with their children. Another agreed with this suggestion, and added:
It’s easy to give them to the kids if you take them to school, but you should get
the adults to introduce them to the children.
A valuable aspect of the booklet, one woman argued, is that it can open a door for
conversation between a parent and child after the parent receives in-depth and current
information about AIDS in a workshop setting. She explained:
The parent gets the information in a class and furthers herself in the knowledge of
what’s going on and about the disease itself. When she does, when her child
comes to her and asks different questions, she’ll have the ammunition to answer
these questions.
Another woman recommended that adults organize groups of teens to “start going
out into the neighborhoods” to initiate discussions about AIDS and other health risks.
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She plans to organize a boys’ discussion group in a low-income housing area and to
promote the event with fliers, refreshments, and door prizes:
I’d be willing to talk to the boys about any sexual thing they like. We really need
to sit down and have a group session to teach them about these diseases.
Cognitive Processes
Figure 19 below depicts the overarching framework for this study, highlighting
the cognitive processes, as identified by research participants, that help explain how
individuals engage in AIDS dialogue or comply with AIDS prevention advice.
/ Cognitive Processes \
f
Comprehension Motives
Learning Attitudes
Sexual scripting Sexual revenge
Health beliefs About AIDS
Susceptibility Prosocial attitudes
Susceptibility
Threat
Severity
Benefits of abstinence
V Perceived consequences
\ of unsafe sex /
Normative
Processes
INDIVIDUAL PROCESSES
Predisposing
Factors
BEHAVIOR
CHANGE
MESSAGE
Enabling
Factors
Environmental
Factors
-> OUTCOMES
Potential
Barriers
CULTURAL CONTEXT
FIGURE 19: Cognitive Processes, Identified by Research Participants,
that Influence Individual AIDS Preventive Behavior
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Reading comprehension of the fotonovela
All the teens agreed that the booklet was readable, and none said it was difficult to
read. One girl commented that “it’s not too much reading.” Another girl remarked,
“There ain’t no hard parts in here.” A boy observed that “it made good sense.”
One woman commented that the booklet is “not too long” and is “simple to read.”
Another woman remarked that “it’s not no big long article or something that people don’t
have time to look at.” Similarly, a fotonovela evaluator said the booklet was easy to read
and added, “I mean for middle school age, it’s really easy.”
In critiquing the language, one evaluator said use of the word “pom” was
confusing because it was a bit unfamiliar and at first, she “thought it said ‘popcorn,’ or
something.” Another evaluator said the word “flick” is familiar, but “we use the word
‘flick,’ you know, like those disgusting movies at the video store.” She suggested that a
more neutral term would be “movie” or “video.”
Apparently, one girl did not have sufficient reading skills to comprehend the
fotonovela script. Throughout the focus group, she asked other girls to tell her what the
characters in the booklet were doing. Outside the room where the girls’ group was
meeting, a youth group worker commented that this particular girl was unable to read
because of a learning disability. After the focus group session, the girl demonstrated her
interest in learning about AIDS by using colored markers to make a poster that simply
contained the word “HIV.”
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Learning about prevention
Apparently, many African American youths are attentive to abstinence advice and
knowledgeable about the consequences of sex, but they do not follow this advice. One
woman remarked about the evidence of their risky behaviors:
To me, pregnancy and all that kind of stuff -- your teacher tells them, ‘Don’t have
sex.’ They listen, and they go have more babies, even though they’re learning.
Another woman complained that AIDS prevention advice for youth usually “goes
over their heads, just like everything else.” Photos, videos, or cartoons may be essential
components of any AIDS prevention intervention targeting African American youth
because these visual elements can stimulate attention, involvement, and learning. One
woman commented
We can tell them ‘till they’re green. They hear it, but until you see it visually, it
doesn’t really affect you. I think the young people, even middle school age, need
to see videos on AIDS and find out what it is.
The “On the Pillow” video used for focus group discussions apparently made a
lasting impression on many boys. Even during a focus group session held two weeks
after the video was shown, the boys frequently volunteered remarks about scenarios
portrayed in the video, in light of various discussions. The main points they recalled,
long term, included Terrence’s rationalization that having sex with a stranger is OK
because Crystal was “a fine woman,” that she deliberately infected him, and that he
caught HIV from her because he did not insist on using a condom.
Another woman noted that “some of them don’t comprehend it just from talking
about it. Some of them are visual people. You’ve got to show it to them.”
After watching the video, one woman said she liked it “because it was more
revealing about what’s going on in the world.” A girl endorsed the video as an effective
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learning tool: “I think they should go play the video ‘cause kids will come back to it and
remember it.”
Although visually showing how a person can become infected could be disturbing
to some, it may be the most effective educational strategy. One woman commented:
It may seem like it was going into something too much, but just to get the picture
where it could be realistic enough to make you know that this is how it happens.
When asked to guess how her own church might make a video about drug
awareness, one girl said the video probably “would show people who take drugs and have
HIV.”
Sexual scripting
The way that teens conceptualize sexual action sequences, including their
strategies for requesting sex and refusing sexual advances, can reveal important aspects
of communication barriers to practicing safer sex. The sexual scripts embedded in the
comments of youth focus group participants may reflect both popular and prescriptive
norms of behavior among African American teens.
Apparently, many boys believe they are expected to initiate sexual activity with
girls and to provide protection such as condoms. Some boys expect their advances to be
seen as sexual harassment. For example, one boy commented:
When your friends go out and sexual harass somebody, before they do anything,
like you could talk to them about using a condom.
Although the sexual norm may be for boys to initiate sexual involvement with
girls, the girls often may be the aggressors. A fotonovela evaluator recalled a role-
playing exercise at school, in which a guest speaker asked the girls to act as “the
aggressive ones.” She said the boys “were like, T don’t want to do it.’ It was funny.”
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One woman said young girls constantly pursue her sons by calling her house until
3 a m. She remarked that these girls “are trying to get to the boys, every kind of way they
can, anything they can do.” She recounted one story of how two teen sisters aggressively
chased her sons, despite the girls’ religious upbringing:
Their mother was very strict on them as far as raising them up right, teaching
everything they needed to know. I knew this mother put everything that she could
into them. As soon as they hit a certain age, 12 or younger, the next thing I knew,
they were having sex. And the reason why, I found out, was ‘cause I had boys.
My son says, ‘Momma, see you always talkin’ about that’s such good little girl.
But you don’t know. I’ve already had sex with her.’
Shocked at this story, another woman exclaimed, “I’d hit the floor!”
Rape may be perceived as a particular problem and risk factor among many
African American men. One boy commented that “date rape, raping a girl - white people
don’t do that that much, ‘cause they know how to protect themselves.”
When asked, “How do you decide how far to go with a girl?” one boy in the pilot
group responded, “As far as they let me.” One 13-year-old boy bragged about a
hypothetical sexual encounter when asked what he thought about waiting until marriage
to begin having sex. He remarked, “Even though I believe in waiting until marriage, if a
girl come up to me and asked me, I’d go up in her.”
After watching the “On the Pillow” video, one boy said he would probably jump
at the chance to sleep with an attractive woman: “If a lady came in, I’d do the same thing.
But I’d have a condom on.”
The boys pilot group was asked, “How long do you think it takes before it’s cool
to ask a girl to have sex?” One boy said he would probably wait a week. To this, another
boy reacted with surprise: “A week? Boy, you gonna get dry.” Then another warned,
“Boy, you gonna give her occasion.”
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A week would not be sufficient for one girl, who remarked, “I feel like you don’t
know nobody in a day, not even in a month.” If a boy pressured her to have sex after
three months, another girl said she would tell him, “Don’t worry about me, ‘cause three
months is not enough time to know somebody.”
When asked how someone can know if they are ready to have sex, various boys
said a person is ready when “they’re in love with that person,” when they are willing to
accept responsibility for a possible pregnancy, “when it meets your needs,” when “it’s
common sense that comes to you,” when “it’s just a stage that I reach,” or “when you get
married.”
When the boys in the pilot group were asked the same question, one boy
responded, “Oh, we ready.” A boy in the pilot group said he would be in love enough to
have sex “when it comes and it’s not just a feeling, but it’s like the person. The feeling is
good, when you kiss that person.” Another boy said that a person should wait until
marriage to have sex, but he further explained:
At a point in time, it so happens to come up, when you like, you can’t get out of
it. It’s too stone cold clump (pounds his fist on his hand), and you hot, you cannot
get out of it, all right? You just drag yo up shot straight. You show you’s a man,
and you go out and drink. You go see a fine girl. You know the only way you get
off, is you protect yourself. But I believe you wait until you get married.
Although the traditional sexual script for adolescent boys may be to pursue sexual
relations at every opportunity, the boys in the focus group reacted differently when they
thought about a woman pursuing them instead. Each of the boys was asked to
contemplate what he might do if a 20-year-old woman approached him at a concert and
asked him to go home with her. One boy said he’d probably look for a place to hide or
an escape route:
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The bathroom’s got those booth things. So I’d say I have to use the bathroom.
When I come back out, I’d be trying to don’t talk to her, and I’d just walk out of
that room. You know what I’m saying?
Another boy said he’d go home with the woman, but try to limit their interaction
to just talk and no sex: “We don’t have to have sex, but I’d try to talk to her about what
she thinks about school and things like that. That’s the bottom line.”
The sexual scripts among African American adults may not be much different
than those for teens. Apparently, many African American men and women have a
reputation for “trying” a Christian to see what it will take to make their religious friend
“give in” to their sexual advances. One woman commented:
So many times men do try women and women try men, because they feel that
they’re not any different. They feel like it’s a game. It’s a challenge. OK, she
told me no this time, but how many times can I keep on doing what she wants
done before I can get her?
A cultural norm of sexual behavior appears to be that African American men are
not expected to resist pressure to have sex. One woman remarked, “Most men don’t put
up a fight. A few of them out there that do, but it’s a lot of them that don’t.” Among
women, however, the norm may be to expect mutual emotional involvement before
having sex with someone new. Even when she was “out there in the world” having sex,
one woman expected a minimal level of commitment in a relationship before she would
go to bed with someone. She said:
It wouldn’t have happened to me in one night, because I wouldn’t allow that.
‘Cause I would not have that. If you couldn’t go along with me further than one
night, then you got to keep on walking.
Perceived susceptibility
Lack of perceived susceptibility can be a more powerful predictor of risky
behavior than “immorality” or lack of rational thought. One woman argued that she took
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risks in the past not “because we didn’t have a conscience,” but because “we just didn’t
think it would happen to us.”
Among African American boys, perceptions about the susceptibility of others
were revealed when they were asked to evaluate the “On the Pillow” video. One boy
commented that the video scenario could actually occur locally: “It could happen in
Gainesville,” he said. Then another boy argued that even though it could happen in
Gainesville, probably “it could happen to some bums.” A third boy came to the defense
of the first, contending that “it could happen to anyone.” Then to justify his statement
about “bums” being the ones at risk, the second boy said, “Oh no. It’s the right and
wrong.” In other words, while some boys believed that any Gainesville resident may be
at risk of HIV infection, one maintained that only the “bums” who do “wrong” are really
susceptible.
Similarly, a boy in the pilot group implied that in Gainesville only prostitutes and
social outcasts are likely to become infected. He remarked that AIDS is most common
among “especially them desperate, ugly men ~ they always get AIDS. ‘Cause you know
them prostitutes probably give everybody AIDS. They open their legs, house to house to
house.”
One boy in the pilot group said he thought that black teens in Gainesville
probably could get AIDS because “anybody can.” However, several girls indicated that
no one in their social networks is susceptible to HIV infection. When asked to think of
someone who is not at risk of getting AIDS, one girl responded, “Everybody I know. At
least, I hope.” Then another added, “Everybody. ‘Cause they ain’t gonna be doin’ all
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that.” A couple of girls disagreed. One argued that “anybody can get AIDS” and another
commented that among African Americans in Gainesville, “they playing with AIDS.”
When asked whether most African American teens are actually worried about
AIDS, most girls indicated that many teens are concerned about others but not worried
about themselves. One commented, “Yeah, they’re concerned, but they don’t pay much
attention to it. It doesn’t really hit close to home.” Another added that “until it hits really
close to home, then they’ll open their eyes.” One girl contended that African American
teens “should be more worried” than they are. Several girls indicated that none of their
friends seemed worried about getting AIDS.
The same held true for most girls when they examined their own beliefs. All the
girls indicated that they are concerned about AIDS, but most did not feel they would ever
become infected. One said she is concerned, but commented that “I feel like I know
enough for now.” Another agreed, adding that “I’m concerned but I’m not as concerned
because I know I’m not going to have to suffer and die from AIDS.”
Several other girls did express a sense of vulnerability to infection, with one
remarking that “I don’t want to die early,” and another commenting that “I don’t know as
much about it, and I feel like I need to know more.” Another emphatically remarked,
“Yeah, I’m concerned. I don’t want no disease.”
Many women may believe they are immune to HIV infection because they are
married or because they are already educated about the disease. But one woman
addressed this belief by recommending that
We get educated as much as possible so that we will be aware of not just it
coming by sex or whatever it is, and how silly it may seem, but knowing that this
is a possibility. Regardless of how wonderful I might think I am, I still need to be
educated.
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Perceived threat
Most African Americans in Gainesville do not talk about AIDS, several women
argued, because they believe the disease does not pose an immediate threat -- that very
few people within their social networks have been infected with HIV. Several women
made comments reflecting this lack of perceived threat among their peers:
Half of us probably - if we not in a hospital or some kind of work like that - you
don’t know. You hear about it. You read about it. But you don’t really know.
It hasn’t hit home. Nobody around them have it.
It’s like something that hasn’t hit home close enough to them.
I mean, that might be one person that you actually see, that you know has it. But
what about all the ones that you’re eating with, and going to lunch, and you’re
doing all these different things with, that may have it?
The prospect of AIDS continuing to spread may increase perceived threat. One
woman commented that “you’re wanting it to go away, but it’s not going to go away.
And AIDS is going to get worse.”
The extent that church members perceive AIDS as a threat may be associated with
whether their minister has personally counseled with a person living with AIDS. Jean
Tapscott, an administrator with the national Agency for HIV/AIDS, commented that
African American churches in Washington, DC, usually begin to address AIDS issues
when their ministers “have experienced firsthand, in their church, the dying process.”
She added that “the church is moving. It’s not where the general community is. The
church tends to move more slowly.”
When African Americans die of AIDS, and the cause of death is euphemistically
called “a long illness” or simply attributed to cancer or pneumonia, it is difficult for local
residents to ascertain how widespread HIV infection has become in their own
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community. The actual threat is veiled by euphemism and secrecy. As one woman
commented:
A lot of people don’t own up to it, a lot of people who have AIDS. People don’t
know how widespread it is here in Gainesville because most people, they’ll say,
‘I’m in the hospital with cancer or pneumonia’ or something like that. So people
have no idea that they have AIDS. A lot of people are dying of it, but they’re
telling people it’s something else that they have so they don’t have to go through
being rejected.
Perceived threat may be partly based on an individual’s perceived threat about
health risks other than AIDS. For example, one woman explained the roulette nature of
risk-taking behavior by comparing AIDS risks with an example familiar to women who
struggle to reduce the amount of fat in their diet:
It’s just like a person that has heart disease, and the conscience tells him not to eat
certain things ‘cause it could kill you. Then they say, ‘Oh well, this one time.’
And that be the one that take you out. Realizing that this thing exists enough that
I don’t care who you are, that one time that you take the chance at anything in life
really, could be the one that take you out.
Perceived severity
Most focus group participants indicated that they knew AIDS is fatal. A woman
remarked that “a lot of kids think you get it and you just die. Not so. You suffer. You
hang in there a good while.” This observation was reflected in the youth focus group
discussions as well. All the teens knew that AIDS is fatal. For example, a boy in the pilot
group warned that “if you get it, you gonna die from it. I’m not sayin’ when, but you
gonna die.” However, none of the youths talked about the suffering of AIDS patients.
Comparing the fatal consequences of HIV infection with the inconveniences of
unwanted pregnancy, another woman commented:
AIDS is something that takes you out of this world. It takes your health away,
you know, and you die from it. So it’s even more fatal than someone goin’ out
there, messing up and getting a child. That’s something that they have to deal
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with for 18 years or whatever, but with AIDS you not sure that you’re going to be
here 18 years. And the majority of the time, they’re not.
Although they may tend to feel invincible, teens lack the freedom to leam from
their mistakes in an age where one mistake could end their lives. A female pastor argued:
They’ve got to know, OK, if for one minute you let your guard down and you do
this, these are the consequences you may face - putting the picture out there that
it’s OK to make mistakes, but certain mistakes that you make now may take your
life. I think that’s the best message we can send.
Given that neither a cure nor vaccine for AIDS has been discovered, the publicity
about new AIDS treatments may lower the perceived severity of the disease among many
individuals. For example, an African American woman in Gainesville who has lived
with HIV for more than a decade has dramatically improved since she began taking “the
cocktail,” a combination therapy that includes AZT and two other medications. After the
first month of taking the cocktail, her viral load dropped from 46,000 to less than 400,
while her CD4 count rose from 484 to 750. A CD4 count of 500 or less is a clinical
definition of full-blown AIDS, while a normal, uninfected individual would be expected
to have a CD4 count of 1,500 or higher. After doctors informed her of the promising
news, she was ecstatic. She recalled:
I started screaming and they said, ‘Now, wait a minute. You still have to take
your medicine,’ but I said, T don’t care. That’s some good news.’ They said it
could become undetectable, but they need to do more tests to see if a person can
actually get off the cocktail. They don’t know if it goes somewhere else in the
body and hides. But I don’t care. It’s gotta be a miracle.
After receiving this news, she said “all the aggravation is gone now” and she said that
above all, “I just feel good about myself now.” However, she is afraid that news about
success of “the cocktail” will hurt AIDS prevention efforts among youth:
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I almost think with the cocktail and all this stuff that’s coming out now, they’re
not going to care. ‘Cause they’ll say, ‘We’ll go ahead and do it, ‘cause we can go
get the cocktail.’
Perceived benefits of practicing abstinence
When the boys were asked why some people wait until marriage to have sex, the
reasons cited were disease prevention, financial support for a child, and the opportunity
to advance their education:
Boy 1: If they’re gonna have a baby someday, then they can afford the situation.
Boy 2: Babies - they are very, very expensive. You’re the parents, so you’re
going to have to go to work and pay a lot of money for the day care and
stuff like that. It gonna take a whole lot.
Boy 3: They might want to get their education.
Boy 2: If they have sex and mess around, they may not.
One woman said she advises her daughter to hold on to her virginity:
because once you give it away, it’s not no renewal. No matter how long you wait
before you go again, it’s not no renewal ‘cause it’s old.’ After they’ve gotten
married, then she can lose that to him, but not before.
Perceived consequences of unprotected sex
In this study, AIDS prevention is the behavior change goal, and the postponement
of sexual involvement is the recommended behavior in the application of the model.
However, the perceived consequences of non-compliance with the recommended
behavior are not limited to HIV infection. Many perceived consequences besides HIV
infection could be more predictive of compliance and thus more useful in designing an
effective AIDS prevention intervention targeting African American teens.
The emotional pain that can result from premarital sex was vividly described by a
16-year-old girl who said she had recently lost her virginity. Although the sex was
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consensual, the girl’s mother had the man arrested and sent to jail on statutory rape
charges. The girl reflected:
If you’re a virgin, you’re gonna feel that you gave your virginity away to that
man, and if he leaves you, you’re gonna feel awkward. I’m feeling depressed,
‘cause it just happened that one time. And you feel like it’s all on you. And then,
it’s like you start to relive the incident over and over in your mind after it
happened. Even if it’s good, I mean, you still relive it afterwards.
Another focus group participant remarked that the girl’s feelings were hurt
‘“cause that man take advantage of you.” However, a woman in the focus group said she
counseled this girl after the incident, and recalled:
She said,‘Well, I just did it.’ No reason at all. Out of the blue. And this girl is a
very smart, intelligent young lady. She could have gotten AIDS.
When asked what they would do if a friend encouraged them to have sex with a
girl, all the boys argued that having sex would be wrong but that even if they did have
protected intercourse, they might still face the risk of HIV infection or unwanted
pregnancy. One boy commented, “They say all you gotta do is use condoms. But
something may go wrong.” Another argued that “if you’re not married, you cannot have
sex. You can have sex, but one of the things is that if they not married, they could go
have sex and get pregnant.”
Other than the girl who discussed her statutory rape situation, the other non-virgin
was a 13-year-old girl who was close friends with the first. The girls’ focus group
moderator commented, “I don’t know if she was pressured, but I know the way she was
talking, I don’t think she wants to do it anyway.”
In addition to naming AIDS and unwanted pregnancy as consequences of
unprotected sex, boys in the pilot group also listed herpes, date rape, paternity suits, child
support, sullied relationships, and jealousy as other consequences of premarital sex. One
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boy commented that “it can kind of ruin a relationship. You’ve had that experience with
that person, so you can’t go back.”
Uncertainty about pregnancy or disease transmission could be a perceived
consequence of having sex. One boy admitted, “I’d feel worried afterwards.” Several
boys in the pilot group suggested a variety of scenarios illustrating the consequences of
unprotected sex that apparently are commonplace situations that happen to others in their
social networks:
Boy 1: That person might be dating another person besides you. And the other
person like finds out you’ve been doing it.
Boy 2: Say you just datin’, right, and you have a baby. But that’s not the person
you want to marry. Then you go out and marry somebody else. And then
I’m gonna say that’s my baby, and they’re gonna say that’s my wife.
Boy 3: And one of them is gonna find out you’re spending more time with the
other.
Boy 2: You’d have to pay child support, like pay for an apartment. The court can
come give you a bill.
Sexual revenge attitude
The “On the Pillow” video portrayed Crystal, an HIV-positive African American
woman, as seducing and deliberately infecting Terrence, a Christian African American
man who was engaged to be married. This plot provoked much discussion about why a
person might deliberately infect others with HIV. The idea that an HIV-positive woman
should seek revenge by infecting other men as restitution for her plight may be a
widespread attitude among African American women. A women’s conversation that
examined this meta-perception was prompted by the question, “What do African
American women think about AIDS?”:
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Woman 1: I’ve heard some tell me, ‘If I get it, I get it, but I’m taking somebody
with me.’
Woman 2: Bad attitude.
Woman 1: They have a negative attitude towards it. You know, I’m like,
‘Excuse me? If I get it, me and that brother, we gonna have to throw
down. That’s my point of view.’
Several women also speculated about what a woman’s motives might be for
deliberately infecting others with HIV. One woman theorized that “some people just lose
touch. They don’t have no kind of guilt or remorse or nothing.” Although some women
felt that the revenge motive might be a popular norm among infected African American
women, no one indicated that this attitude was acceptable. Another added that a woman
in this situation might try to get revenge because a man hurt her, either emotionally or
simply by giving her the virus:
There’s not a good reason, but I feel that sometimes it’s because if a woman finds
that a man hurt her in that way, she feels she can get back at men by giving it back
to them. In some ways, it was the hurt that drove her to that type of bitterness.
They have it, and they know they’re gonna die. They want to take as many with
them. It’s reality. And a lot of times, because of them feeling deceived, they feel
that all men are bad. ‘See, I can get him to do it because he’s not faithful, and
he’s gonna jump in the bed and do it anyway. So let me just go ahead on and give
it to him.’
The revenge plot was the only aspect of the video that the boys said they didn’t
like. This may be an indication that sexual revenge is both hated and feared among
African American males. For example, one boy said he disliked “that idea, if I’m going
down, I’m gonna take everyone with me.” When asked if they thought the girls in the
focus group next door would react differently to the video than they did, several boys
instead implied that the girls would behave like Crystal, the HIV-positive woman in the
video:
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Boy 1: They’ll leave you, you feel great, and they write you a note.
Boy 2: So you’ll feel great, and they’ll write you a note. Bye-bye. It’s like she
got what she wanted.
Motives
Teens’ motives for having sex often may be irrational, based on the need for
physical gratification. For example, one boy explained that they do it “because they hot.”
Another boy, a participant in the pilot group, commented that “when you’re in your teens,
when those urges are strongest, maybe you can’t afford to say no.”
When people are aware of everyday health risks other than HIV infection risks,
they may be more likely to attend to AIDS prevention messages as well. For example,
one woman commented:
Something is going to happen, one way or the other. If it’s not AIDS, it could be
something else. We’re always eating things with fat, and people are dying,
having strokes and heart attacks, high blood pressure. People are trying to teach
us.
For many Christians, a primary motive to abstain from risky behavior is to avoid
the eternal damnation believed to be the final punishment for sin. One woman warned
that “God says if you’re an adulterer, you’re going to Hell because you’re sinning.”
One woman with a history of “partying” said she identified with Terrence, the
main character in the “On the Pillow” video. She argued that Terrence’s motive to “get it
out of his system,” rather than his alcohol consumption, was the key influence upon his
decision to have premarital sex with a stranger:
What happened to me - it wasn’t the alcohol as much as it was getting caught up
into something he know he had a problem with. He thought he could get it out of
his system, for this one last time, and when he got married he would be faithful.
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Normative Processes
Figure 20 below depicts the overarching framework for this study, highlighting
the normative processes, as identified by research participants, that could influence
whether individuals engage in AIDS dialogue or comply with AIDS prevention advice.
INDIVIDUAL PROCESSES
Normative Processes
Diffusion of innovations
Popular norms
Prescriptive norms
Pastoral norms
Peer pressure
Church influence
Parental influence
“Watching for the signs”
Predisposing
Enabling
Factors
/ Cognitive \
Factors
BEHAVIOR
CHANGE
MESSAGE
Environmental
Factors
CULTURAL CONTEXT
Potential
Barriers
OUTCOMES
FIGURE 20: Normative Processes, Identified by Research Participants,
that Influence Individual AIDS Preventive Behavior
Diffusion of innovations
At the time this study was conducted, no official AIDS ministry existed within
any African American church in Gainesville. Thus, it is assumed that starting an AIDS
ministry within African American churches would involve radical change in religious and
institutional norms.
The African American churches may have failed to initiate AIDS discussion
because the perceived need simply may not exist. Very few church members have
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publicly admitted that they or their family members are infected with the virus. One
woman said:
I think like right now, nothing’s really gonna go on. But in the future, you’ll see
more demand, because there’s gonna be more of it in their churches. Then they’ll
wanna do something about it.
The African American AIDS Task Force likely could serve as a change agent to
initiate programs promoting AIDS-related dialogue because this organization has the
resources and credibility to initiate change. The innovators could be visible leaders
within the churches, such as deaconesses and Sunday school teachers, who could serve as
liaisons between the change agent and the church members.
Several women in the focus groups volunteered strategies for initiating AIDS-
related ministry among African American churches. One woman suggested that the first
step would be to “get to someone who really cares about their people.” According to
diffusion theory, this person or small group of individuals could be considered innovators
or early adopters, depending on whether they continue to “spread the word.” The woman
went on to explain:
It’s just like anything else. You may get to certain places, and you have to deal
with the people who actually want to hear about it. So once you find the area,
maybe it’s in one church out of 10. Usually out of 50 people, you’ll get one
person that come up, and they’re really interested in what you talked to them
about. And they’ll go, T want to get more involved in this.’ That might be their
ministry, something that they really want to deal with. With the others, it might
not hit home right now, but later it may. And that opportunity will arise that they
will be able to actually use it, even if they don’t feel like they need it right now.
According to diffusion theory, these innovators would be expected to begin
engaging in conversations that promote AIDS awareness and dialogue among friends and
family within their social networks. As the innovators “spread the word” to various
members of a particular church, more members would accept and adopt the “innovation”
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of AIDS dialogue in that context. Eventually, a consensus would be reached among most
members - a consensus that either asserts that talking about AIDS is beneficial or that
this kind of dialogue is unnecessary or potentially harmful. At the same time, however,
the AIDS dialogue would continue to spread through a multitude of other social networks
outside that particular church, depending the types of social ties that each person has
within the larger community.
African American ministers could serve as innovators by launching AIDS
prevention initiatives within their churches that could spread to individuals throughout
the community. A male pastor argued that ADDS prevention efforts should begin at the
grassroots level and then branch out through various social networks:
We should get some form of communication out to every home. It could be
literature, PSAs, some type of community workshop, or forums that can be done
for a number of social organizations like fraternities, sororities, and schools.
One woman witnessed the diffusion phenomenon within her own church, which
recently had begun initiating outreach and evangelism to the underprivileged throughout
the black community. She explained:
In my church, they go out and feed the people and minister to them. But you
don’t have that many. You may have one church out of 10 that does that. But if
you work with that one church and they get educated, then they can help educate
other people. And through that, it keeps traveling and it may go to that church
that maybe you couldn’t reach. So I think by meeting with groups outside of the
church as well as inside of the church, the ones that you can’t come in and
actually deal with, then you just try to deal with other groups.
Network diffusion of AIDS information could be a far more effective tool in
changing community norms, as compared with mass mediated campaigns that target
individuals with a behavior change message. One woman commented:
Word of mouth really does travel fast. A pamphlet could be laying here for years,
and somebody could walk by and won’t pick it up. But you put it in somebody,
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and if that person really is interested enough, like she was saying, then they gonna
tell somebody else, and somebody else gonna tell somebody else, and they’ll be
saying, ‘They really got an AIDS thing going.’ And then this person gonna get
interested. It really goes by word of mouth, more so than any other thing.
The “word of mouth” strategy not only promotes dialogue within organizations
and institutions, but also appears to promote intensive dialogue between individuals who
are actively involved in personal community outreach and others who would be
considered weak or non-existent ties within that person’s social network. For example,
one woman explained:
I’ve been wondering about how I can actually let people know that I’m there for
them. So by word of mouth, a lot of times people do end up coming to me, and I
talk to them or whatever.
Popular norms
Popular norms involve perceptions of which behaviors are typically or
customarily performed. Among African American teens, popular norms about sexuality
include perceptions about virginity, aggression, and promiscuity. For example, a boy in
the pilot group said that some of his friends “brag” about having sex. He remarked that
“some people say it, but you know they lying. You know they lying.”
One woman speculated that teens probably would react differently to the “On the
Pillow” video than the women did:
They’re like, T wouldn’t do nothing like that. I wouldn’t have run out that way.
You know. I would have at least got checked out first before I did something like
that.’ But with the younger ones, they’d be like,‘OK. Man, she’s fine. She’s
ready to give it up. I’m going for it.’
Another woman added, “Most of the younger ones would think that. ‘If
something fine and pretty like that come to me, yeah, I would do that, too.’”
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In guessing about the sexual behavior norms among the girls in the focus group,
the moderator remarked that she “didn’t actually see any hoochies there. The ones that I
feel were virgins were wearing pants and baggy-looking shirts.” She further speculated
that all but two of the girls were virgins. She commented:
I could probably point out two of them that are not virgins. And that was about it,
out of all those girls. Two of them basically said they weren’t virgins. The rest of
those girls, they have no experience whatsoever.
One woman suggested that adult women are less likely to become infected
through sex than teenagers: “But us, on the other hand, we’re more alert about things,
and we care about our body.” Despite this awareness, many focus group and interview
participants considered infidelity among African Americans to be widespread in their
community. One woman commented that “we have to know that it’s a lot of that going
on. It’s a lot of people just going out there.” Infidelity also may be commonplace within
the social environment of many African American teens. When asked how the characters
in the video were like people she knows in her own life, one girl commented that “the
man is like people I know, ‘cause he cheated on his wife.”
Although all the boys said their friends are unlike the characters in the video,
several said that the people they know, other than their friends, really “ain’t different.” A
couple of boys said they are “smarter” than the characters in the video, and conversely,
one remarked that “those people retarded.” However, one boy wondered aloud why
being smarter or less smart really matters when “nobody can even see you do it.”
The youth moderators’ participant observations of the teen focus groups indicated
that girls may be far more focused, attentive, and interested in discussions about AIDS
than boys of the same age. While moderators conducted the youth focus groups, adults
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were not allowed to enter the rooms. This strategy was used to encourage greater
spontaneity and openness in the discussions among the youth. However, it also
prevented the investigator from observing the participants during the sessions. After the
sessions ended, the youth moderators offered comments about behaviors and themes that
they noticed during the sessions.
The fact that the girls knew each other, the girls’ moderator argued, helped
facilitate discussion because it probably made many girls feel more comfortable sharing
personal feelings. She speculated that in a group where girls do not know each other,
I think they won’t speak up. If I didn’t know them, I’d just sit there. I’m just
saying when you have a new group of people in a new class, and you don’t know
anybody and nobody knows your face, I don’t think anybody would talk. I think
it’s best that they know each other, and they also feel closer to the person.
Girls also tend to volunteer only the opinions perceived to “fit” with the opinions
of their peers, especially when talking about sexuality and other personal issues. The
girls’ focus group moderator noticed a social desirability effect among the girls when
they were discussing personal sexual issues. She observed that several girls
kept changing their minds when they were talking about whether they want to
have sex. I feel like most of them were just listening to people.
Physical aggression and yelling appear to be normative behaviors among pre-teen
boys in situations where they are supposed to pay attention to an adult or other non-peer.
During all focus group sessions, most boys tended to be disruptive, inattentive, and loud.
During the first focus group session, a hyperactive 11-year-old boy began antagonizing a
much taller 13-year-old boy by calling the older boy’s father derogatory names. The
altercation ended with the older boy shoving the younger one into a door, and an ensuing
din of yelling erupted among the other boys. Several weeks later, it was determined that
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the older boy’s father was in prison, and his stepfather had died of AIDS three years
earlier. During the second focus group session, the same younger boy repeatedly yanked
the protocol and tape recorder out of the male moderator’s hand. A youth group leader
said this boy frequently misbehaved because he was not given his Ritalin as prescribed.
Prescriptive norms
Prescriptive norms involve perceptions of which behaviors are societally
sanctioned or customarily approved. A prescriptive norm among African Americans may
be one of taking personal responsibility to halt the spread of AIDS. For example, one
woman commented that Terrence, a character portrayed in the “On the Pillow” video,
was mature because he “didn’t do like she did and pass it on.”
Monogamy may be another prescriptive norm, even if individuals are not
expected to maintain a long-term monogamous relationship. For example, one woman
argued that a couple should not become physically intimate if either of them is already
involved with another person, and each person should ask the other about outside
involvements or commitments if the information is not volunteered. The woman
commented that the video character Crystal “didn’t even ask if Terrence was dating
anybody else. And he didn’t say anything. But I would go further. I would ask.”
Casual sex with strangers was considered irresponsible by most focus group
participants, regardless of age or gender. One woman commented on Terrence’s
behavior in the video, saying:
Regardless of if he was drinking or not, he never seen that person before and he
never have should went took her back to his place from the jump, you know.
Many prescriptive norms about sexuality may be created by adults for
adolescents. One woman argued that it is easy for married adults to sit on the sidelines
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and criticize the young people who struggle with sexual dilemmas. Referring to the
tragedy portrayed in the video, she commented that “we can sit and say what they should
have done and how much they should have done it.”
Getting married appeared to be a prescriptive norm among the African American
teens, even if most adults in their lives are not married. When asked why people get
married, one girl simply said, “because of babies.” However, another believed the
primary reason should be emotional involvement.
She explained:
People get married because they feel that their relationship, if they be going for a
while, they love each other so much they want to go to a higher level.
Various participants within every focus group argued that couples should get an
AIDS test before taking their vows. One boy in the pilot group said he plans to do this
when he meets the “right one”:
Right before I get engaged, I’m gonna be like, ‘Come on.’ She might think I’m
sick, but what if the doctor tells me she’s got AIDS?
Pastoral norms
The prescriptive norms that apply to ministers, as perceived by teens, may be
important to ascertain before designing an AIDS ministry targeting youths with
prevention initiatives. These perceptions may indicate the extent that ministers can serve
as credible, respected role models, teachers, and counselors in promoting AIDS-related
dialogue.
Apparently, some teens expected their minister to hold certain attitudes and use
particular counseling approaches that they consider to be appropriate and conducive to
open, helpful dialogue. A good minister is assumed to think and communicate on the
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same level as teens, except that he also is expected to dole out moral or spiritual advice.
For example, when asked how her minister might react to the “On the Pillow” video, one
girl said she thought he “would probably agree with us.” But another girl added that
“they’d try to convince us not to do it and everything.”
Several prescriptive norms for pastors emerged through focus group discussions
about the portrayal of a minister in the video. One girl said she did not like the minister
in the video ‘“cause he didn’t seem like a pastor to me.” Another girl added, “Yeah, like
the part where he cursed.” Her comment refers to the end of the film, when the pastor
shouts, “What the hell is wrong with this world?” One girl said she respected the young
man going to his pastor but did not like the pastor’s forceful demeanor, such as “where he
made him open the note and said he should have come out and told him in the first
place.” Another girl explained:
It seemed like he didn’t show enough emotion, and like he was yelling at the guy
trying to get him to talk about it. He was forceful. He didn’t take his time in
trying. He was too mean to him. He got on my nerves.
Several girls said this attitude was not appropriate for a pastor, particularly in
comparison with their own pastors. One added that “he was putting in more of his own
emotion instead of trying to be a pastor,” while another said that she “could see it if it
was his child or something, but this was a person that was coming to him.”
Peer pressure
When a teen tries to gain the respect of friends or save face, these behaviors can
be evidence of peer pressure, and they may be motives for initiating sexual involvement
or pretending to be sexually experienced.
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Several boys in the focus groups said that teens have sex to avoid the
embarrassment of being labeled a virgin. “They want to fit in with the crowd,” one boy
commented, and another added that “they don’t want to be like a virgin.” A female
pastor said many African American boys and men are promiscuous because they want to
prove their masculinity:
A lot of them are like, ‘Well OK, I’ll sleep with this one. Hey, that’s what makes
me a man. ’
Despite this peer pressure, one fotonovela evaluator said a lot of the sex talk
among boys is just bluffing and bragging. She remarked that “those guys sit around
talking about sex and stuff, and a lot of them tell lies because I bet you about half of them
are virgins.” Another evaluator added that “a lot of my friends tell me a lot of boys talk a
whole lot about it. I mean, they don’t even have girlfriends or anything.”
In some cases, peer pressure may have little to do with sexual behavior among
teens. For example, one boy said that “the reason virgin children have sex is not because
of the crowd. It’s because they have a girlfriend.” A boy in the pilot group said his
friends’ comments do not play a role in whether he pursues a girl: “If I see a fine girl, I’m
going to try to walk up to her myself and her lady friends.”
Girls may be more likely to give in to sexual pressure from a boy if he plays
football or basketball, one woman speculated. When a boy has this kind of social status,
she said, “all the teenage girls wouldn’t mind having him as a boyfriend.” The thrill of
being “singled out” by an attractive or seductive person in the presence of peers, may
create an even riskier situation. Recalling how this scenario was depicted in the “On the
Pillow” video, one woman commented:
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So, let’s think about the picture for a minute. Just think, she walked into the bar.
She looked all around. All the other guys are there. But she chose him. All he
had to do is say no. It was directed to him.
Terrence was in the company of his beer-drinking friends when he decided to give
in to a stranger’s seduction. After watching this video, one woman theorized that if “a
child’s in a group of guys, girls, they’ll do the same thing he did.”
Several girls cited peer pressure as the main reason that teens drink, including
attempts “to be cool” or the desire “to prove to their group that they cool.” Other girls
argued that some teens are not pressured to drink, but just do it because “they don’t have
anything else to do” or just “‘cause they want to.”
Some teens believe that standing up to “the crowd” is not impossible, even if it is
difficult. If her friends pressured her to become sexually involved with her boyfriend,
one girl said she would not agree with their advice and added that “they are your friends,
but they just don’t understand you.” Another girl commented that she would tell them
her relationship with her boyfriend “is between me and him.”
One woman suggested that a person’s gender or age doesn’t have much influence
on how they respond to peer pressure:
If it would have been a teenager or it would have been a man, because of who
they was with, or either a woman or a girl - they would probably react the same.
I don’t think there would be too much difference, because of peer pressure.
Teens may often become sexually active when virginity is considered a stigma. A
female pastor observed that “now virginity is something to be picked at. So most kids
worry about what the other kids are thinking. They’ll try to show them every time that,
‘Oh, I’ll do this.’” An incident involving several church-going African American boys
convinced her that peer pressure motivated them to engage in risky behavior:
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I actually overheard three kids talking that they went to the pool and girls that
they didn’t even date - they had sex with them right there in the pool. And these
were kids that are in the church, in somebody’s church. I was like, even though
we’re teaching it, we’ve got to find another way to actually get it out to them.
The desire to be seen as an adult may motivate many teens to succumb to peer
pressure. A female pastor said she tries to appeal to this motive in her abstinence advice
to teens:
They all want to be grown, but what makes them grown a lot faster is being able
to not let someone entice you into doing something you shouldn’t.
The quest for higher social status may be another common form of peer pressure
among African American teens. A female pastor said she has heard boys frequently
complain that
‘I’ve got to have 500 tennis shoes because they’re going to pick at me.’ We run
across that all the time -- Tf I don’t get another pair of tennis shoes, I don’t want
to go to school.’
One mother said she sees evidence of the pressure to conform in the way her 13-
year-old son often dresses for school. The woman said she tells him that ‘“it’s no
comfort in wearing your pants below your buttock line, acting like you’re so cool.
Where’s that going to get you?”’
Church influence
Socialization in the church may help reinforce prevention advice among youth. A
fotonovela evaluator recalled hearing a preacher’s sermon about sexuality that “was like,
it’s summertime, and you guys are feeling hot, but it’s not the temperature.” One
participant in the second women’s focus group, a Sunday school teacher and summer
youth program assistant, said she discussed sexual negotiation with her class during the
fotonovela project. She recalled that the class talked about
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being alone with a guy, and he’s trying to get you to do something that you’re not
ready for and you feel uncomfortable with and stuff. You tell them you say, ‘No, I
don’t wanna have sex,’ and he still trying to force you into that situation. But he’s
gonna do like, ‘I love you’ and ‘You fine.’ I told them that you simply don’t
know what’s wrong with him, and it could be the AIDS virus. And when I was
reading it to them, we just had a good Sunday.
During this Sunday School lesson, she also asked the teens to talk about how well
they communicate with their parents. She asked them a series of questions, such as:
Are you able to sit down and be open with your parents and talk about sex and
different things? Can you talk to them? I wonder if I’m doing it, will I let my
momma and daddy know? Maybe I’m doing it sometimes just to do it?
The key to living a good life, one girl said, is to obey God. However, religiosity
apparently can lead to inner conflict among many church-going African American girls.
One girl reflected that even though she goes to church and tries to be a good Christian,
“it’s really hard to be a virgin.” Another girl commented that she is postponing sexual
involvement “because the Bible says it’s a sin, and if you’re a true Christian you’re not
going to do it. You’re going to do it, but you’re going to try not to.”
When asked whether it is OK for a Christian to have sex before marriage, the girls
unanimously said no. The reasons included avoiding hell, following the Bible, and
avoiding a mistake. One girl speculated that non-religious people probably do not abstain
from sex because they do not receive this kind of advice: “If you’re not in the church, you
really don’t care about it.”
All the boys seemed well aware that the church condemns premarital sex. One
strongly argued that “it’s a sin to have sex before you’re married. It really is. You can
have sex after you get married.” However, none of the boys really knew why this is
taught. When asked this question, one boy responded, “I don’t know. ‘Cause it’s in the
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Bible, I guess.” Another boy challenged the teaching, using an example from the Bible
itself: “Adam and Eve had sex. They had Cain and Abel.”
Talking about sex in church, however, may not always discourage teens from
engaging in risky behavior. In the “On the Pillow” video, Terrence’s fiancee, Alisha, was
presumed to be infected because Terrence had a one-night stand with HIV-positive
Crystal, a stranger at a bar, and then slept with Alisha before getting an AIDS test. One
woman observed that the Christian upbringing of Terrence and Alisha did not ultimately
prevent their exposure to the virus:
She may not have been sleeping with anyone but him. And it seems like to me
both of them had the right start. They were both in church. So it wasn’t like they
didn’t know anything about what they shouldn’t do, you know, about sex outside
of marriage. And still yet, she had sex with him before marriage.
A key informant from the Task Force argued that African Americans who seldom
or never attend church and church members who have “backslidden” are most at risk of
contracting HIV. She argued that outreach efforts should target these people first:
Some churches just don’t want to discuss AIDS because then they might have to
face up to the fact that somebody in their congregation might not be living the
way God told them to - backsliding, tip-toeing around, whatever. That is a
problem. The people who aren’t living right aren’t in church. We should reach
out to get them.
A male minister argued that even people with high social standing or a good
reputation need to hear about AIDS in church. He explained:
I can’t assume that because you are so-and-so’s daughter or your mother’s been in
church for years or your father’s been a faithful worker that I don’t have to
discuss this with you. We need to talk about everything that’s out there. We need
to talk about possibilities that it can knock on your door.
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Church attendance and involvement in organized religious activities can help a
Christian maintain a healthy lifestyle. When ministers present advice based on Biblical
interpretation, it can reinforce lasting behavior change. One woman commented:
When we go to church, the pastor’s always preaching about the things you
shouldn’t do, the things God will not allow you to do. Eventually, if you hear it
long enough, some of that’s going to soak in. If you utter that Word daily, I
mean, every week and Wednesday night prayer, it’s eventually gonna sink in, if
you wanna live like this.
Parental influence
Several boys indicated that abstinence advice has primarily come from their
parents. When the boys in the focus groups were asked to indicate whom they would
prefer to talk to if they had a problem or question about sex, several said they were
comfortable talking to their mothers or to both parents. However, most said they would
prefer to talk to their fathers, and they perceive their fathers as more down-to-earth and
knowledgeable. One boy said his father is more open and understanding. He
commented, “I’d talk to my dad. He talks to me about everything. He always talks. He
understands me.”
Another boy agreed, saying he would rather talk to his father even though the man
might lack the sexual experience that his friends have:
I talk to the ones that’s more experienced about it. Man, I be like - see I talk to
my dad too, you understand. But my dad is old, and he ain’t havin’ none of that
no more, you know what I’m sayin’?
Some boys preferred to talk to siblings or friends rather than their parents, when it
comes to talking about sex. One boy recalled having a discussion about sex with his
brother but added, “I can’t really tell you how it was started.” Another boy said that if he
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ever had concerns about sex or relationships, he would probably just talk to his sex
partner.
When asked to tell the least favorite person to talk to about sex, one boy named
his mother. Another boy said he hates talking with his mom about sex, but added that
“now my daddy, he knows about sex.” Another boy disagreed, saying that he does “talk
to my momma about sex.”
Most boys in the boys pilot group also said they would probably go to their
fathers or older brothers before they would talk with their mothers about sex. One
commented, “I like, talk to her, but she fuss with us. But my father I’d ask a problem.”
A couple of boys, however, said they would prefer talking with their mother. One said he
would probably call an AIDS hotline instead of talking to a parent.
The women were asked what they would do if one of their children admitted to
being sexually active. Most said they would try to begin talking to their children before
they became sexually active. One woman said:
That’s where that open line of communication comes in. A lot of kids who can
talk to their parents are extroverts. I could do that. I was very open with my mom
and my grandmother. I was ready to be sexually active. I was like, ‘Hey, Mom.’
‘What’s up, girl? We going to the clinic.’
Another woman argued that setting up firm rules for her children helps them
develop long-term decision making skills. She explained:
There are certain rules, certain regulations, certain disciplines that you must
maintain in order to be a responsible person. I can speak for the rules in my
house. If you honor that, then I’m sure when you’re on your own anywhere - if I
allow you to go spend a week at camp for the summer - you will be responsible in
your thought patterns, what is right for you and what is not.
In a study of AIDS dialogue between parents and their middle-school aged
children, Whalen (1996) found that parents tend to be more mutual with daughters and
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more directive toward sons. In the present study, one boy recalled a piece of directive
parental advice: “They go like, T don’t want you doing this ‘til you married.’” Another
boy related that his parents do not forbid him from having sex but insist that he does not
do it under their roof: “My parents say if you’re gonna get it, you want it, then you take
it outside and leave it out there.”
Another focus group participant, a mother of two, said she tries to help her
children cope with peer pressure by using a directive approach. The woman said she
already has told both her children, ‘You ain’t ready for something like that. I’m your
girlfriend. I’m your boyfriend. Until I say you’s ready.’” If one of her children insisted
that he or she was ready to become sexually active, the mother said she would probably
ask, ‘“Are you sure it’s not pressure? If it’s pressure, then you can always say no to
pressure.’
An example of a parent using a mutual approach to sexuality dialogue was the
case of one mother who said she fostered open communication with her 10-year-old
daughter by offering to play the role of a friend. She said she tried to put aside her
parental role for a while to help her daughter open up:
She has like something she wants, and she say, ‘Mom, can we play friends?’ And
I’m like, ‘Sure.’ You know, ‘friends’ is I’m her friend, but I’m not her mom.
She’s discussing things that’s bothering her. And as a friend, I’m giving her
advice. You know, what I would do if it was me. We’ve been doing this ever
since she’s about 4 or 5 years old. We’d get us a little tea party, and sandwiches
and stuff. It gives me the chance to take my mind off what’s pressuring me and
get down and think as a child and to play a child’s role with her. And she feels
more secure with me playing a friend than coming straight out and talking to
Mom, even though she’s talking to Mom.
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“Watching for the signs”
During the second women’s focus group, a piece of advice repeated many times
was the parental warning to “watch for the signs.” Throughout the session, several
women related their own parenting stories and reiterated this advice. The “signs” are bits
of subtle evidence suggesting that a teen may be engaging in risky behavior. In
describing her own parenting challenges, one woman explained:
We’ve got to pay close attention to our children ‘cause a lot of them will get in
situations. We can’t put it all off on the children, we got to put some off on the
parents, ‘cause I’m a parent myself. I was a working parent and when he was in
school, he was in the hands of somebody else. But when I was home, I was with
him. But still, I made mistakes ‘cause I was a single parent. I couldn’t keep an
eye on him 24 hours, but I tried to. I had to get rest sometime. Still, I tried to
raise them as good children.
Other African American parents should be taught how to watch for the signs as
well, one woman contended. Many parents do not look for signs because they believe a
religious home life protects their children from trouble. But given the influences of
peers, this woman warned, parents cannot afford to
feel like, ‘I’ve taught my daughter, so I know she’s not going to do it.’ You can’t
go by that. It only takes one guy to switch it. A lot of people have taught their
kids all their life not to go and have sex.
Another woman, a prominent leader in the church, admitted that she had
overlooked signs of her son’s drinking problem:
My oldest son has always been real private. I have found out he was drinking and
stuff while he was going to school. We had no idea. This was our good child.
That was that one we told no, and he didn’t do it. But he’s not the one who does
it in front of your face.
Being a good listener is the best way to watch for the signs, one woman argued.
She explained that “they’re gonna give you the key. If you listen, they’ll give it to you.
We’re responsible for when those signs come, for us to stop right then, and do whatever it
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takes to try to work it out.” Another woman asked for clarification of the group’s
consensus: “Everybody sayin’ watch for the signs. But what are the signs?” To provide
an example, a woman related a story about how her instincts were right on target when
her daughter became pregnant:
My daughter was getting big in her bust and her hips, and I’m like, ‘OK, you sure
you’re not pregnant?’ ‘No, Momma.’ I’m just talking to her and talking to her.
She got sick, and I gave her Advil ‘cause I thought she was having bad cramps.
And then when she was still sick, I took her to the hospital and they told me she
was getting ready to deliver. They told me her son was not too big, and that she
was going to miscarry because she was too small. She had a full-term baby. It
weighed five pounds, eight ounces. She had no prenatal care or anything. I’m
here to tell y’all, when you say watch for the signs, let me tell you - really watch
for the signs.
Another woman related an example showing how “good” teens from prominent
families sneak behind their parents’ backs to engage in risky and forbidden behavior:
A pastor friend of mine said they had a garage, and she wanted to put a bed out
there. They was like letting some people come and stay with them. She and her
daughter went out there to clean it up together. And she kept seeing the signs.
Every time she was talking to her, she says, ‘No. I’m not doing anything’ and all
that. Next thing she knew, she put a bed out there, not thinking her good 16-year-
old daughter that she’s got in the church, raising her just right, would do anything.
And all of a sudden one night, the Lord said, ‘Be quiet and listen.’ And next thing
she know, she heard something in the garage. And He said, ‘Don’t go running out
there. Just wait.’ She waited, and after a while she heard a man’s voice. And
next thing she knew, she seen her daughter sneaking out of there, trying to go to
the bed outside to that room where the guy was. And then when she went out
there, come to find out she had been bringing friends there all the time, guys and
everything. And she threatened the other kids in the house, but they said they’re
not telling anybody.
Enabling Factors
Figure 21 on the following page depicts the overarching framework for this study,
highlighting enabling factors, as identified by research participants, that could help or
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encourage individuals to engage in AIDS dialogue or to comply with AIDS prevention
advice.
FIGURE 21: Enabling Factors that Facilitate Individual Compliance
with AIDS Prevention Advice
Self-efficacy
Locus of control is a key element of self-efficacy, because individuals must
perceive that they can control their own behavior and the factors that influence behavioral
outcomes before they can gain self-efficacy. One woman argued that adults need to take
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control of their own lives, to convince youth that they too are capable of overcoming peer
pressure to follow through with prevention advice. She remarked:
I guess to get kids, you have to take charge of yourself as an individual. Don’t
worry about what the pastor’s doing. Don’t worry about what your friends are
doing. You need to know that even though it happened to them, it could happen
to you.
The perception that learning about AIDS is an effective weapon against infection
is a form of response efficacy. One girl’s question highlighted the belief that knowledge
and awareness about AIDS will slow the spread of the disease. She asked the other girls,
“When we have our children, is it gonna be worse for them, or is it gonna be better?”
Another girl answered, “I think it’ll be better, ‘cause we know more than they did.”
Realism of the fotonovela
Apparently, the booklet successfully depicted typical, everyday situations among
African American teens. For example, one girl remarked, “That’s how most people get
together. They go to a friend’s house, watch a movie and chill, and stuff like that.”
Another girl added that “it what goes on every day. Like the story.” One girl said that
some of these situations have actually happened to people she knows.
One woman said the title of the fotonovela, “Afternoon Delight,” was “very
dynamic” and describes a common scenario among many African American teens. She
added:
For kids, that’s exactly what it is. Because the national Gallup Poll’s already told
us that’s the time that kids have the most time to themselves - the TV, and Mom
and Dad is not home.
Although several women argued that the fotonovela was not hard-hitting, one
noted that the story instead portrayed typical, familiar situations among African
American teens:
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You know, it was mild, but this is such a typical scenario. Somebody goes to
school, and you go home in the afternoon just like she was saying.
Another woman agreed that a fotonovela should “use their own scenarios, the
things they go through on a daily basis.”
All the girls agreed that the booklet looked and sounded realistic. One girl
volunteered that “they put our everyday language in there.” However, one fotonovela
evaluator said she did not like the use of improper grammar and slang in the booklet. She
remarked, “I don’t like the way they talk. I just really don’t care for that kind of
English.”
One girl commented that “the stuff that she had wrote on the way that they
lookin’ and stuff like that, the way they actin’, they look real.”
The boys also agreed that the story was realistic, but none said that any of the
situations had happened to them in the past.
Perhaps some boys thought the story was completely true, rather than a
dramatization. When asked if his friends thought the story was real, one boy responded,
“I know everybody know it’s real. It ain’t no movie.” Similarly, when asked what type
of story was used in the booklet, one boy said, “A true story,” and another boy remarked
that “it could really happen.”
A concern in developing the fotonovela was the possibility that the story’s actors
might be seen as people living with AIDS. Even if some teens perceive that the
fotonovela actors have AIDS, however, the booklet presenter can turn the
misunderstanding into an informed and focused discussion about AIDS risks. For
example, one woman recalled a conversation she had with several boys in her
neighborhood, after they read the booklet:
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Boy: These kids got AIDS?
Woman: No, they don’t have it. They just doin’ a role.
Boy: They don’t even look like they have it.
Woman: See, that’s the problem. You don’t look like you got it, but you have it.
You could look all healthy, fine, and sexy.
Boy: Yeah, that’s true.
Apparently, the boys thought Kevin’s sexually aggressive approach in the story
was typical. The title of the adult video pictured in the fotonovela may have illustrated
this social norm. One boy remarked that “he ran and got himself ‘mo booty.’ And that’s
what happens all the time.”
One boy argued that a booklet should depict the realities of street life because that
is where many people become infected. He commented:
You just need to go to like a store, and show ho’s roughing around, ‘cause
sometimes you’ll have AIDS. ‘Cause they like walking around.
Apparently, a character in the fotonovela may have been perceived as fake. When
asked what his friends said about the story characters, one boy said, “One guy was like,
lying.” A situation that might not be realistic, for one girl, was the fotonovela's scene in
which Tatiana became uncomfortable with the romantic situation at her friend’s house
and found a way to escape her predicament. The girl who played Tatiana’s character
remarked, “I wouldn’t get out of it by walking the dog.” A young girl with HIV was
portrayed in the fotonovela as presenting her personal story in church. One girl in the
focus group thought this scenario was not realistic:
I don’t think people would tell the truth if they had AIDS, in front of other people.
And some people don’t feel like they should tell that, if this person really did have
it.
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Fear appeals in the fotonovela
Given that previous research has shown that high fear appeals are less effective
than milder fear appeals in leading to attitudinal or behavioral change in individuals, the
fotonovela story used low fear appeals. The information conveyed the severity and
seriousness of AIDS, but the story was not the typical “scary” tale of a young person
dying as a result of a mistake. However, many focus group participants said the tone of
the story should have been more tragic and less “everyday” and typical.
One woman argued that the fotonovela should have graphically depicted the tragic
consequences of AIDS in order to make a persuasive impact on teens. She remarked:
I think it’s too mild. I think it really should have had a little more punch to it. It
should show that AIDS is going to kill. I’m trying to see the effect, what it’s
going to do to people. I want them to see how they have sores on them, sore
throats. Give them something to really picture in their mind.
The tone of the booklet was appropriate for its purpose, one woman argued:
I think in its mildness, it leaves room for you to talk. I mean, this isn’t supposed
to do everything. This is just a tool for you to open a door.
The message that teens die of AIDS was found in both the fotonovela story and
raps, and the facts listed on the back provided AIDS death statistics. However, none of
the teens perceived that fear appeals were used in the booklet. One boy remarked that
“nothing was scary. Just trying to tell you what to do and what not to do.” Another boy
believed that teens will not change their behavior unless the fotonovela is “scary.” He
explained:
If it was scary, and it was about AIDS, then most people would stop what they
doing and read it. And when they read it, instead of going out and then doing
what they want to, then they try to stay out of it, instead of going out and catch
AIDS at an early age.
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In characterizing the mood of the fotonovela, one boy remarked that “it’s kind of
sad, but not a lot.” A few boys complained that the everyday tone of the booklet was not
appropriate for a subject as serious as AIDS. One boy remarked, “We just going outside
playin’. We can catch the basketball and all that. But we talking about AIDS.”
Teens will probably put the booklet down, another woman argued, “if you don’t
keep bringing them back to this, ‘My God. Man, I didn’t know these things happen.’” A
fotonovela evaluator agreed, arguing that showing the consequences of risky behavior
may elicit enough fear to discourage teens from engaging in risky behavior. She
remarked, “I mean, you scare them half to death with all this AIDS and STD stuff. They
ain’t gonna want to do it.” However, one woman disagreed with the fear appeals
strategy, arguing that some teens will refuse to read any AIDS prevention material even if
it is designed to scare them.
The only reason his friends might become involved in learning from the booklet,
one boy argued, would be if they were already afraid of contracting the virus. Otherwise,
he contended, they would ignore the prevention advice because their behavior would be
driven by lust. He explained:
Like some people in school now scared of AIDS, so if they don’t want to catch it,
then they need that book. But some people just don’t care what they do. They
walk around, in sexual arousal, and people don’t know what they doing, and go
around harassing people. Then when people do it, and they catch AIDS. And
they all wonder why people did it.
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Using fear appeals among African American boys might backfire because a fear
response might threaten their self-perceived image of toughness and lead them to
challenge each other to prove their fearlessness by engaging in the dangerous activity.
Modeling
Social modeling has been used in AIDS prevention campaigns to encourage
individuals to imitate a respected person. This form of modeling also could be used in
interpersonal contexts as well, where opinion leaders can set a positive example for teens.
For example, religious leaders could serve as role models for young African Americans,
but danger could arise if the role model engaged in behavior that is seen as hypocritical.
One woman commented, “Looking at people that you think are up here that won’t fall -
mistake number one.”
The desire to imitate an attractive person could confound the intended outcome of
an AIDS prevention message if the character engages in risky behavior. For example,
one girl commented that the video character Crystal was “a little tiny bit” similar to
herself. She explained that Crystal “was like seductive when she first came out. When
she slept with him, she was aggressive.”
For other teens, however, an attractive person may need to gamer respect or be
homophilous with audience members before he or she could be seen as a role model. For
example, one girl said she did not admire Crystal’s behavior, arguing that the character
was “different from me ‘cause she’s the wrong age. And she was too nasty.”
An awareness of potential “slip ups” can be learned through seeing consequences
of others’ mistakes. For example, the tragedy portrayed in the “On the Pillow” video
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caused many focus group participants to reflect on situations that could lead to a fatal
mistake in their own lives. One woman commented:
Seeing how this mistake happened to this one woman who actually had given
herself to him, that he received AIDS, and now she could have it and the baby
could, too. It makes you more aware of it, and then you’re going to be more easy
to say, ‘Wait a minute. I cannot have a slip-up, because it could take my life.’
Heritage reminding
Heritage reminding can be a tool for enabling African American teens to follow
AIDS prevention recommendations. When a significant other advises a teen of his or her
racial background, in order to promote a sense of pride in black roots and the need to
appreciate it, this guidance can connect racial pride to issues addressing protection of self
and others.
A key component of black heritage is the church. AIDS prevention projects
targeting African American teens should include “a spiritual basis,” one woman argued,
“because the African American heritage starts in the church, and it will always be in the
church.”
One girl speculated that church is “more important in the black community
because that’s what our ancestors were brought up on.” Another girl suggested that
African American teens are more religious than white teens because their Christian
values have been passed down from their African ancestors who endured slavery. She
added that “during slavery, they had some Christian songs, and they read the Bible.”
Another girl suggested that the African slaves’ faith in God during their struggles
for freedom could show African American teens how to cope with difficult situations in
their own lives:
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I learned in African American history that we used that as a way of dealing with
situations, letting God lead the way of getting out. ‘Cause slavery was bad, and it
was always an escape.
When slaves worshipped God, another girl added, it was “how they let their
emotions out.” Worship, then, may serve as a spiritual connection to a higher being, an
intellectual connection to slave roots and form of heritage reminding, and as an emotional
connection to an individual’s own everyday struggles. These connections, in turn,
possibly could help empower African American teens to postpone sexual involvement or
to otherwise protect themselves from HIV infection.
The concept of “protecting the blood” has been used in national AIDS prevention
campaigns targeting African Americans. It implies that African Americans of all ages
should look out for one another because of their racial ties and shared heritage.
Warning others if they are in immediate danger of contracting the virus is one
way of “protecting the blood.” Several focus group participants said if they got AIDS,
they would publicize the HIV status of the person who gave them the virus. For example,
one woman said she
Would have it broadcast, have it printed, anything - this man has it. You know, I
was ready. He gave it to me. You know, that way, the next woman he hit at say,
‘No, no, no. This girl said you got that. Uh-uh, I don’t want that.’ And like,
‘They was showing us both the rumors.’
African Americans should unite to protect and comfort their black brothers and
sisters who suffer from the disease as well. One woman commented, “You’ve got to say
it, ‘They’re black. They’ve got this. We’re going to help them.’”
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Achievement orientation
Talking about future plans for success is one strategy that adults can use to
encourage teens to protect their health while they are young, argued one woman who
does not have children of her own:
I guess if I had a kid, I’d probably be like, ‘Is this what you really want to do?
Why do you want to do it? Why is so important to do it right now?’ I think I’d
probably hit career, future. I mean, that’s a chance to tell them about AIDS and
other things that are out there.
Giving teens a vision for the future also can help them make more rational
decisions while they are young, a key informant said. She contends that when youth are
given “the vision and the dream of where they’re going, the decisions about themselves
will be automatically clarified.” When talking to her own children, the woman explains it
this way:
‘If you don’t have a degree, you might not get any further than $5.25 an hour.
You’re going to have a hard life, all of your life. You cannot look at the cars
driving along the road. You’re looking at it now. But when you become a full
adult, there may be cars floating in the air. Envision what your children will be
doing and how they will live their lives. If you can’t visualize them living in
space, then you can’t make it there now. ‘Cause that’s where we’ll be. In order
to be a part of that, you want to live. So you have to make the right decisions now
that will affect how you live in the future.’
When asked what they wanted to do when they were older, most boys and girls
said they wanted to earn a graduate degree in order to have a professional career. A
professional basketball career was a common aspiration among the boys. One boy in the
pilot focus group commented that he wanted to be a doctor, lawyer, or a professional
football player.
Most girls said they wanted to become professionals. Their career choices
included that of doctor, teacher, nurse, lawyer, veterinarian, and judge. One said she
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wanted to be the first woman president. Among the few girls who named non-
professional choices — mother, spiritual dancer, model, and cosmetologist -- all listed
these vocations as alternatives to a professional career.
“Making it real”
The use of intense imagery or personal contact with patients may be a necessary
but not sufficient factor in persuading youth to practice AIDS preventive behaviors. A
woman living with AIDS, whose infected daughter died several years ago, said that
bringing youth face to face with a person living with the disease is not too intense for any
age group, “not when it’s dealing with life. But I can say that ‘cause I’m dealing with
this.” However, she questions why her own 17-year-old daughter became pregnant
through unprotected sex after witnessing the suffering and death of her younger sister:
She’s seen it intense. She’s seen my daughter in the hospital with tubes and all of
this, and she knows I’m HTV, and she still goes out and gets pregnant. How could
she do that?
A number of women nevertheless argued that AIDS prevention efforts will not
“hit home” unless they show how people suffer from the disease. Several women
recommended taking teens through an AIDS ward to show them the seriousness and
severity of the disease and to promote compassion toward people living with AIDS. One
woman commented:
I think that you should take them through an AIDS ward and let them see how
people suffer - not trying to scare them, but to let them know what reality really
is. If you took some teenage kids, starting middle school age, and let them see
how people suffer from AIDS and everything, I think that would hit home.
This strategy might prompt criticism from some parents, who do not want their
children to be frightened or physically exposed to a diseased person. One woman
defended the hospital visitation idea, saying:
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Some people might say taking them through a hospital is too hard on them, but
it’s harder for them to go out there and get it and then have to find out all of this.
It’s better to educate them. I don’t care what the cost is.
A female pastor said she plans to invite a person living with AIDS to speak to her
congregation to let them “know this is not just something you see on television or in a
movie. This is real life.”
One woman said her three teenage daughters learned about AIDS firsthand by
experiencing a cousin’s death from the disease. She commented:
I let them see the point where she had to go into intensive care with an aneurysm
on her brain. I mean, they went through the whole thing with me. My kids got to
actually be there to see the things it put my cousin through. It lets them know it’s
real. It’s like teaching them about alcoholism by taking them to a morgue to see
kids who were killed by it.
“Making it real” for teens involves showing them how others like themselves
have contracted the virus, one woman argued. She explained:
Even if you and your friends are talking about sex, but you’re not actually doing
it, you still don’t think, ‘It can happen to me.’ ‘How can you tell me I can get
AIDS, when I don’t even know anybody that has AIDS? I know other kids who
are having sex, and I’ve never seen anybody that had AIDS except a gay person.’
It’s gonna have to be real to them. It can’t always be just us sitting there telling
them.
Many teens and women argued that the most effective way to educate others
about AIDS is to bring them face to face with a person who lives with the disease. Many
individuals who secretly live with AIDS may want to come forward to educate others
about the disease but fear the consequences of stigma. One woman observed:
Those are the main ones who can be the most effective. They’re the ones they
can see, that can speak and say, ‘This is happening to me. Look at my body, look
what’s happening to me because of this.’
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A male minister said he uses true stories to address AIDS in his sermons. For
example, he once told a story about an acquaintance who committed adultery, contracted
HIV, and then infected his wife. He said many people relate to true stories because
this is live, this is documented, this is true. I’m not telling you a fairy tale or
something make-believe. It makes you more aware of a situation when there are
actual events. We’re not talking about someone in a magazine, but someone
standing before you who’s really lived through this experience.
Dialogue about AIDS
Education is a necessary but not sufficient condition to promote preventive
behavior, and open dialogue about AIDS may be more important than education in
sustaining healthy behavior patterns. One woman remarked, “There’s a lack of
education, but communication lines probably need to be open more.” Even though none
of the families in his church appear to be directly affected by AIDS, one male minister
said he has a responsibility to deal with AIDS, because this kind of discussion is
Another way of saving lives, not so much spiritually but physically. To not
address it or talk about it or discuss it could put somebody else in jeopardy. So, to
skirt over it or hide it or pretend that it’s something that’s not going to really
affect our church -1 think that minister or congregation would be doing them a
big injustice. That would be a big mistake for them to not talk about it.
Even though none of the families in his church have been touched by AIDS, this
minister said he has mentioned the disease in his sermons
More as information, not so much as a scare tactic, but as preventive teaching -
that it’s the result of something that can happen if you’re not careful. It’s almost
like you’re going to be faced with the bad if you release yourself to the dangers
out there.
Although his congregation is generally open to discussing AIDS issues, the
minister said they do not talk about it enough:
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We don’t talk about prevention enough, things you can do to educate people. We
are aware of the disease, but I don’t think we talk about it among ourselves
enough. I don’t think any church would say this is the focus of discussion.
In a follow-up interview, conducted six months after the research ended, a key
informant said that her involvement in the study led her to conclude that
If AIDS isn’t brought to the whole church, they may not see it ‘cause people don’t
take it seriously. Every church should have a focus group to discuss these issues.
There’s a great need for it.
In the girls’ group, the only people they recalled talking to about AIDS were
parents, most frequently their mothers. One girl said her mother “told me a true story
about a girl that got AIDS,” and this conversation occurred after the girl told her mother
that “we were learning about AIDS in school that day.” Another girl said her mother
initiated a conversation about AIDS “one night when we were talking about the human •
body and sins and everything.” The girl recalled that her mother “just talked to me, to be
aware and to watch what I’m doing.”
None of the boys said they talked about AIDS with a parent. One boy said he has
had many discussions about AIDS with others, including talks with his friends, cousins,
parents, and pastor. Another boy remembered that his pastor had talked to him about
AIDS. Although most boys did not recall having a conversation about AIDS with
anyone, many remembered hearing a classroom presentation by an HIV-positive woman.
Another form of open dialogue about AIDS is discussion in the context of a
romantic relationship. Couple dialogue has been promoted in several different national
AIDS PSAs, including the CDC’s “Know Your Partner” and “Respect Yourself, Protect
Yourself’ campaigns. One boy was aware of this advice, commenting that a person is
more likely to get AIDS “if you do it without having a conversation.”
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Dialogue about sexuality
Many youths may find it too difficult to initiate a conversation about sexual issues
with an adult. For example, if given the chance to talk to her pastor privately, one girl
said she would prefer to discuss family conflicts rather than sexual issues:
I’d probably talk more about a problem I’m having with my mom. Me and my
momma be having an argument.
When youth do muster the courage to start a conversation with a parent about
sexual issues, often the parent responds with shock or disapproval. Often the first
mother-daughter discussion about sex occurs when the daughter wants permission to
begin using birth control. One woman recalled her shock when her daughter brought up
the subject of birth control pills:
My daughter came home, my baby girl said, ‘So-and-so giving her daughter birth
control pills.’ I almost fell dead. I say, ‘Giving her birth control pills? What are
you sayin’?’ She said, ‘Well, I thought if she’s taking birth control pills, I can
take them.’ I said, ‘No, ma’am. I ain’t giving you permission to take no birth
control pills. I feel like that’s like giving you consent to have sex. It’s time for us
to really have a talk.’ By the time I hit the ceiling and panicked, I almost fell
dead. ‘Cause I didn’t quite understand it. See, when a child say something, you
need to really listen. If you didn’t quite get it, you say, ‘What are you sayin’?’
Another woman related having a similar reaction when her daughter requested
permission to use birth control, but this mother did not promote open, two-way dialogue
about it:
My daughter was sayin’ to give her birth control. But I really prayed about that. I
told her what the Bible says, and I said, ‘If you sneak and you do it, protect
yourself. ’ I don’t need to know anything about it, but you sneak down to that
clinic and get what you need, or you’ll sneak and go get a baby.
Given that teens may be reluctant to initiate conversation about sex with adults,
the adults may have to make the first move. One woman recalled how her own mother
initiated discussions about sex:
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I had a friend that got pregnant, and my mom came to me. She was just like, ‘Do
you want to get on the birth control pill now?’ And I was like, ‘You know we’ve
had this talk a million times. I’ve told you I ain’t doing that.’ I wanted to talk to
her because she wanted to talk to me.
One woman commented that being open with her children sometimes can be
“tough and awkward and weird.” Sometimes listening to teens involves willingness to
non-judgmentally accept their confessions. As a mother, one woman said she has
learned that to communicate with my kids, it’s gonna be some things that you’re
not gonna want to hear. It’s not always gonna be good. If we think back to where
we was, and some of the things we snuck and did, then we can understand.
Authoritarian lecturing and scolding are not effective methods of promoting
“correct” behaviors among teens, one woman argued. She said teens expect a parent to
give them a reason for behaving a certain way, and if the parent does not provide a
reason, “somebody else will.” Another woman commented:
What’s wrong with a lot of parents now is how much you stuff things down them
and tell them they cannot do it and what they’re not supposed to do, all the time.
Showing love and acceptance is a better approach in the long run, one woman
argued. Reflecting on her own childhood, she recalled that her mother
didn’t shove it down all the time about ‘Don’t have sex.’ And some people
thinking it’s just by saying, ‘No, no, no’ that that’s what it takes. It’s not so
much the ‘no’s’ but it’s all that love and the other things that’s planted in you that
help.
Parents must deliberately establish relationships with their children and work to
maintain those relationships, a male minister argued. Keeping an open line of
communication between parent and child is an essential means of preventing a child from
making serious mistakes. The minister commented that “someone may be pressuring
them to do certain things, and you’ll want them to come and really talk to you about it.”
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He said he tries to communicate to his children the message that “I don’t want you to
make a mistake because you feel that you have to do these things.”
Given that communication styles among youth vary widely, parents must adapt to
these individual differences. One woman observed that “it’s not so easy for everyone to
be open. You know, every child is different.” Regardless of individual differences
among youth, however, a supportive approach will be effective
as long as you’re trying to be open enough that come what may, you’ve been
there, and you’re not gonna kick them out of the house. You know, ‘Use your
head like I taught you, and I’m here for you, whatever.’ I think that’s so
important in the long run.
Talking about behavioral intentions may be an essential part of an effective
discussion about sexuality. One woman suggested that “one thing we need to talk to our
children about, is they can have good intentions but if they don’t go all the way with it, it
doesn’t mean much. They intend to do something, but they don’t do it.”
Telling “our stories”
Many African American women are key resources for carrying AIDS prevention
messages to youth through the oral tradition. A key informant recalled that when she and
an AIDS network outreach worker conducted an AIDS workshop for a Christian
women’s convention, all the participants were grandmothers. When the two workshop
leaders presented information about AIDS to the group, the response from these older
women was overwhelming:
You would not believe the energy they had. They were so excited. They heard
stories about AIDS, testimonials, and they asked questions. They are an untapped
resource. We were really excited by doing that with that group, and we’d like to
see more of that. They are the real teachers. Children have a way of really
wanting to know, to learn, to understand their boundaries. And they listen.
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Sharing personal stories about the challenges of growing up is often an essential
part of open parent-teen dialogue about sex. In reflecting on her own experiences in
helping her daughters, one woman commented:
Sometimes, and not just sometimes, we need to tell them our stories. Not
necessarily that they’re going to broadcast it. They’re not going to do that. But
you need to tell them your story. But you know, ‘Momma got pregnant when she
was 12, but I know I could not do this. And I should not do this, and this is how
my parents raised me.’ That sticks, believe it or not. That really pulls them
through, if they’re 16 or 17 years old - the stories that you have. So it’s very
important that we tell the stories to our daughters that will help and aid them.
Another woman said that when she was young, her mother shared stories about
becoming pregnant at 16. The woman said this kind of parental honesty really helped her
make sense of her own circumstances, such as “when you share what you’ve been
through, and even how, ‘OK. I did it, and I messed up.’”
Sharing personal stories as a tool for counseling young people is not limited to
parent-teen dialogue. A woman from a low-income housing area said she often walks the
streets so that she can tell young women about her own past mistakes. She explained her
strategy this way:
When they come up to me, they say, ‘Girl, let me tell you something.’ They think
I’ve never really been out there, and I don’t know what they’re going to come to
me for. It’s an old game. I just tell them, ‘Let me tell you a little something. I
used to be just like you, walking around with my big hand on my hip. Well, look
at me now.’
This strategy is not only valuable from an adult perspective. One girl said she
appreciates adults talking about their past experiences. If presented the opportunity to
talk to her pastor in confidence, she said, “I’d want to know what they went through.”
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Communication skills training
To help address barriers to effective parent-child communication, many
participants in the second women’s focus group discussed the idea of initiating a
communication skills workshop for parents. An argument in favor of this idea is that
many African American mothers are single parents who must work to support their
families, and this situation leaves many children unsupervised and free to roam with their
friends most of the time. Time spent apart can widen a rift between children and parents,
especially when parents try to enforce discipline.
One woman explained that since she “had nobody to teach me,” she reaches out to
young mothers to “tell what I’ve been through.”
The focus group itself was suggested as a model for a parenting class. One
woman suggested that “if you bring a parent into a group just like this here, it helps the
parents know exactly what to tell their youngest children.” Another woman suggested
focus group sessions in the public schools, in which parents and children could meet
together for discussion and training.
One woman pointed out that many African American women living in housing
projects are beginning to enter the work force through a government-sponsored
transitional program. She suggested that these women be required to take a parenting
class or AIDS communication class in order to qualify for assistance through this
program. She explained her rationale:
It needs to be part of that channel, during that approval time, to teach them that
type of communication so they can interact with their children. ‘Cause those are
the younger ladies that have the kids, that just throw them out there and go on to
work. It might be a beginning point to teach mothers how to talk with their
children, even as young as 2 or 3. We could also get their input.
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A male minister said many adult church members can serve as role models and as
friends for youth, and many adults have the resources to “offer some other outlets to the
kids so they won’t think that ‘Well, I don’t have anything else to do.’” He said serving in
these roles requires a person to be creative, involved, organized, and active:
You’ve got to be willing to hang out when you get older because kids stay up late,
they want to talk, so you can’t shut them off and say ‘It’s time for me to go to
bed, I’m tired.’ You’ve got to do some things to keep them going and let them
have their space where they can enjoy themselves. You have structure.
A male minister suggested that role playing could help church members of all
ages learn how to communicate with each other about AIDS prevention issues, so that
“children won’t be so naive and gullible, thinking ‘What’s going on here?’” He said
adults have a responsibility to think about their child’s sexual development, and
sometimes he asks parents questions such as “What are you going to do?” and “How are
you going to handle it when you are approached?”
The “right atmosphere” must be created before open communication can occur
between adults and teens in his church, one male pastor observed. For example, one day
a year the girls in the church are invited to join fathers from various churches for an
outing called “Daddy’s Day Out.” This event is designed to create an atmosphere for
girls to talk to men who can serve as their role models or father figures. After the
minister forms several small groups, he explains to the girls
The focus of why we’re here - that we want to be here for you. ’ They can ask
those questions that they’ve always wanted to ask but maybe were afraid to and
have a heart-to-heart talk. Their dad may not be the one who’s leading the group,
so that makes it easier for them to open up. Sometimes kids have a hard time
opening up to their own fathers.
The minister observed that some youth in his church do not have fathers at home,
even though most have regular contact with their fathers. The “Daddy’s Day Out” event
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helps fathers learn to communicate with children by approaching dialogue from the
perspective that ‘“if anything comes up, we don’t want you to ever be afraid that you
cannot come and talk to us about what you’re going through,”’ the minister explained.
Dialogue tools
Although the focus groups in this study were used to gather data about attitudes,
beliefs, ideas, and behaviors, the groups themselves appeared to serve as a tool for
promoting thought, awareness, and continuing dialogue in a non-threatening setting. The
moderated, semi-structured focus group also might be used within churches as an AIDS
prevention tool. One woman commented:
I’d just like to see if there could be something done in the church, where you
wouldn’t have to point the individual out. Just like we’re doing here now -
making people aware of it, and how it can happen, and how easy it can happen.
You know what I’m sayin’? And it don’t have to be any special individual that it
can happen to.
Despite her initial resistance to come, one woman reflected on her new level of
AIDS awareness and knowledge that she had gained through participation in a focus
group:
Tonight my sister told me we’re going to this AIDS thing, and I said to myself,
‘Oh, I don’t want to go to that.’ And I actually looking for reasons to get out of
this. I’m really glad I came, ‘cause I really never went to discuss or learn too
much about AIDS, no more than looking at TV, you know, when they talk about
it in church and stuff like that. This is actually my first time ever being out to
discuss what you should do. Like I’ve got five boys, so I really do need to be up
to date with everything. And I’m really glad she got me to come out tonight. It
do put a lot of thoughts in your mind - what would you do?
In addition to the “Afternoon Delight” fotonovela, the “On the Pillow” video was
used to promote focus group discussion through raising awareness about AIDS-related
issues. One woman commented that after seeing this video,
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It makes a difference to me. It made me more aware that it’s not just an unfaithful
person that does this all the time. All it took was one time. And that was enough
for me to know that we need to show people, to let them know.
Empowerment of African American adults
African Americans must be empowered through unity, concern, and a common
vision if they are to help protect youth from HIV infection, one woman argued. This goal
will require long-term effort. A key informant from the Task Force contended that
African Americans in Gainesville need empowerment because many
feel like they’ve been left out of the system. They need to know and feel the
support of family and community. They need the basic tools to survive, but often
they’re too proud to ask.
One woman remarked that “we’re going to have to work at empowering African
American women in doing more.” In response to this call to action, another woman
examined her own efforts in light of others’ needs:
That’s why 1 work as hard as I do. I know I’m saved. I’ve been baptized, but I’m
still reaching higher for myself, too. I feel like if I need help, I know that
somebody else out there got to need more.
In exploring the concept of empowerment, one woman suggested that African
American women put aside pride and defensiveness and participate in the kind of
community parenting seen in many African villages. She suggested:
If we do like they did do over yonder, where there was the community raising up
the children, then we will watch out for other people’s kids instead of saying,
‘Now see, that’s just a bad young lady,’ and not say anything.
Building on that idea, another woman quoted the old cliché, “It takes a village to
raise a child,” and requested the assistance of her African American sisters:
I need you to help me. We have to go back to the realization that that’s the way it
must be, that you can go and talk to my daughter when you see her prancing
around with a little boy, ‘Well sweetheart, I know this is not you.’ And know that
the mother is not going to be offended.
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Finally, one woman proclaimed: “Let’s take the neighborhood for our mothers!”
Watching out for others’ children does not imply that all parents are negligent,
one woman argued. Rather, community parenting is a way of assisting parents with the
impossible task of monitoring children when they are not at home:
Let’s help that parent by us watching out, us looking out. Their parents might be
doing all they can to tell them, but maybe they can hear it from somebody else or
hear a testimony about something you did. Once that becomes a reality to them, I
found out a great tool is just being able to listen to them, because we get so busy
and we don’t listen. All they want, the majority of them, is someone to sit down
and talk to them.
The empowerment to stop the spread of AIDS does not necessarily depend on
collaborative efforts, one woman argued. She recommended that every person
just reach out and do what we can as one person, and not waiting until, ‘OK, we
gonna wait ‘till we start this big group up to do it.’ Let’s do it before then. If it’s
not going on in school, or it’s not going on in the churches, we as individual
persons can do a lot more than trying to wait until you got a group to do it.
This woman said she talks to many girls individually about their personal
concerns. She recommends that other women develop a sensitivity to “signs” of trouble
that girls sometimes show and reach out to help:
We can stop, and every time we see a sign, we see a young lady in church, we see
them things, we can sit down and show them we care.”
When one woman was growing up, her mother became a godmother for many of
her friends who could not communicate with their own parents. “It got to the point where
my friends, my cousins couldn’t talk to their momma. And they’d be like, ‘Can I come
talk to your mom?”’ A barrier to this commitment to community parenting is a common
mothers’ attitude that their children have had superior upbringing that will protect them
from harm. One woman observed this widespread attitude:
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In our churches, homes and community, most people have gotten to the point
where, ‘My child is better than yours.’ Or ‘I don’t have to worry about this,
because it’s my child.’
Empow erment of teens
While women need to be empowered to protect each other’s children, the youth
need to be empowered to make their own decisions about sexual involvement, one
woman argued. Reflecting on her own childhood, she commented:
My mom wasn’t always saying, ‘Don’t do it, don’t do it, don’t do it.’ ‘But you
have a mind of your own, and this is not going to make or break you. You gonna
be up for this at some point in your life.’
A female pastor said she tries to help teens cope with peer pressure by talking to
them in small groups. She said a primary lesson is “how to be your own person and not
be a follower.” She tells them that “it’s OK that if you don’t like something you don’t
have to go along with it. You don’t have to let people persuade you into doing different
stuff.” A related lesson she emphasizes is that teens should have the courage to stand up
for their beliefs:
It’s just as well as it is for a person to have their own religion or to say, ‘I don’t
want religion. I want to live this way.’ You have just as much right to say, ‘Well,
I don’t want to live the way you’re living.’ I say, ‘What about the drug addict
that’s selling drugs? He’ll come tell you all about it, and that’s something that’s
going to kill you.’ So you should learn to be not ashamed of who you are and
what you believe in, in standing up for that. Learn how to read and get educated
for yourself about whatever you believe in.
Teens are the best suited to educate their peers, argued one key informant,
because they are well educated about the risks, but they also understand the curiosity and
urges that motivate youth to try risky behaviors anyway. She observed that most teens
want to know all the risks, the consequences of their actions. It’s available to
them. They know they can reach out and touch it. Yet, there’s a component of it
that’s just being a teenager - they must try the risk. And we have to understand
that they will try it.
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Compassion
The behavior change strategies used in compassionate Christian outreach could be
effective in promoting AIDS preventive behaviors among the African Americans who are
most at risk of infection. This approach to behavior change involves social support,
helping individuals improve their perceived self-efficacy, and promotes open dialogue.
One female pastor argued that Christians must foster a non-judgmental attitude
towards non-Christians before they can engage in effective outreach. The people targeted
for outreach must be supported and validated, even if their behaviors are sinful or
unhealthy. The pastor said that she and others in her church invest much time and energy
visiting residents of low-income housing areas to help them overcome bad habits:
We don’t believe in a lot of different things that people do that are wrong, but we
deal with them because it’s life. They don’t fit in, so that’s why they hide it. A
lot of times we get people to open up about things that they usually wouldn’t open
up to other people about because they know that we’re not going to judge them.
We’re actually going to go from where they’re at and see what we can do to help
them. It’s not that we accept it, but we accept them and then we try to help them
to grow above those problems and minister to them instead of just saying ‘OK,
you’re not a Christian if you’re like this’ and then throwing them out the door.
This kind of outreach reinforces the message that Christ’s love and healing can
empower individuals to overcome their problems, the pastor said. Many people approach
her for guidance after they have experienced a personal tragedy. She said that showing
unconditional love proves to people “that we’re legitimate and that we’re not just trying
to get numbers for our church and different stuff like that.”
When she visits the residents, she tries to create honest dialogue with them about
their problems and concerns. The pastor described her approach this way:
Once you sit down with them, they begin to talk. All they want to know is they
got somebody that cares and also that they can be confidential with us and know
that it’s not going to go out, but that we’re going to sit here and we’re gonna pray
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as long as it takes for them to get better or whatever, and not just throw them
away. What happens is once they get to know us, then that’s when a lot of this
stuff comes out.
A key informant said her church is accepting of unwed teenage mothers, even
though most African American churches in the past would not have been so supportive.
She told the story of a high school senior who became pregnant, and her church helped
the girl graduate and become a successful university student:
People surrounded her with love, and she brought that baby along because that
baby’s not a sin. That mistake didn’t stop her life. If there was no love and
compassion, she would be a casualty on welfare. Churches have come a long
way, and we’ve done a great job not being so judgmental when a young lady does
have a pregnancy. She is not told she cannot come to church because she can be a
productive part of the group. If one life is strong, then two lives are strong.
The woman commented that she would not be able to assist people living with
AIDS if she did not foster a spirit of forgiveness toward them. She said:
I’m not judgmental, but I don’t think I could work with them. There’s a bumper
sticker that says, ‘I’m a sinner, saved by grace.’ But in our weakness, we have to
help each other and feel compassion for each other and love each other to build
that person up.
Reinforcement of religious values
A key informant argued that AIDS prevention efforts in the black community may
ultimately fail without leadership within the churches:
Our main background in the African American community is our churches. And
it appears that if we don’t have the leadership of our churches, we cannot fall on
the background of our family. Because it’s just inherent - our family and
churches are connected.
Parents who want to help protect their teens against consequences of peer pressure
should show trust in their children and teach them Biblical principles that can guide their
behavior, one woman argued. Reflecting on her own upbringing, she said:
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I know that my mom, she did not tell me all the time, ‘No, don’t have sex’ and all
that. But she gave me the Word of God, she told me what God said, and that was
it. And she trusted me. My friends, I was with them every day. Their parents
were Christians and had told them they couldn’t do it. But as soon as they went to
bed, they were sneaking out the window. And I went right along with them, but I
would not let a boy touch me. I was a virgin before I met my husband, and I was
proud of it.
Instilling Christian values through open dialogue and Biblical training may help
prepare younger teens to rationally and confidently cope with peer pressure. One woman
explained:
If they learn those values, it will help them to understand, even when they get old
enough for peer pressure, they will feel strong enough that they can stand and say,
‘Well no, I’m not going to do that without feeling like I’ve got to be persuaded.’
Because they’ll know the reasons why they’re not.
The religious norm of confessing sin to a minister can support a system of
accountability among individuals, such that a minister can help a person involved in risky
situations to make behavioral decisions in a more rational or moral way.
In evaluating the “On the Pillow” video, one woman commented that although
Terrence made a mistake,
At least he went to someone in authority to confess. And he didn’t just keep going
on, like it could have been a chain reaction if he had not went to his pastor. So to
me, I thought that was a good point of view — that he was mature enough to do
that.
If spiritual counseling can reinforce individuals’ religious beliefs, it might
persuade them to avoid risky behavior. For example, one woman argued that counseling
“makes you aware of how much that one mistake as husband and wife or whatever could
not only hurt them.”
Finding theological commonalities among various African American churches, in
terms of how those beliefs could support open dialogue about risky behaviors, could
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encourage many concerned members of the larger community to rally behind the AIDS
prevention banner. A key informant suggested that the dynamic power of uniting the
African American churches to fight AIDS could help strengthen a broader community
campaign.
Female opinion leadership
Six months after the study ended, a key informant commented in a follow-up
interview that an important aspect of a church-based AIDS prevention program would be
to “let the women in church know that they have to take responsibility” to help
themselves and their children. She said she’s heard some women say that they wish they
had been involved in the study because they wanted to be involved in the problem¬
solving efforts of the women’s focus groups.
A male minister commented that many women in his church are influential and
willing to talk to youth about sexual issues. Although the girls likely would benefit from
this kind of dialogue, he said, “I don’t think the boys would feel comfortable going to a
lady.”
However, when he was a boy, this minister sometimes sought advice from women
in the church, especially the “older people who were like role models.” He said that
sometimes he “felt more comfortable talking with men, especially if there were things
you might call sensitive.” The minister said he looked for role models in the church
because he was not comfortable discussing sensitive matters with his father:
Not to a point where I could go and sit down with my dad and say ‘Such-and-such
is the case.’ I’d probably get it out eventually after walking and pacing the floor.
It wasn’t an easy transition.
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Although African American pastors tend to be reluctant to discuss AIDS
prevention, the women who participated in focus groups and interviews and those
observed in AIDS education settings were eager to leam more and frequently asked for
resources, tools, and strategies to help initiate prevention efforts in the community. The
following are typical remarks made by female focus group participants:
We need to know what’s the best way to be able to approach it.
Now that we know about it, I think maybe we need some more tapes, some more
literature. So how do we stop it in the church? How do we tell our young
people?
A female pastor who attended the AIDS breakfast commented that the other
ministers at the event “had a hard time dealing with it.” She argued that if the ministers
“don’t want to deal with it,” then African American women must realize that
It’s our job. If the head people do not do it, we’ve got to take it upon ourselves to
look out for that young girl or young man that’s going the wrong way.
Even if ministers refuse to talk about AIDS from the pulpit, women can take a
stand to promote church-based AIDS education. Suggestions for AIDS ministry projects,
offered by various women, included Bible studies, an AIDS missions night, discussion
groups, video showings^ and literature distribution. One woman commented:
We need more people talking about it, more movies, more literature put out in the
churches. It’s gonna help not only the kids. But we need to reach the adults.
They need to speak up.
Forging inroads
Although these kinds of church projects can be launched by influential women
and other individuals, a comprehensive AIDS ministry is not likely to be initiated in most
churches unless the minister perceives an urgent need that outweighs the possible
political consequences. One woman remarked that “if we were able to employ the
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ministers to take a more expectant viewpoint of the AIDS epidemic, then we can really
get the program in the church.”
“Inroads,” a buzzword mentioned during numerous African American AIDS Task
Force meetings, often referred to the group’s quest for networking and innovative
strategies for targeting hard-to-reach youth with AIDS prevention messages. A common
comment by Task Force leaders was “we’re looking for inroads” -- primarily inroads
into churches, schools, volunteer groups, and other organizations.
The co-founder of the Task Force recommends that the group promote AIDS
awareness through youth skits, videos, and community workshops. She suggested the
idea of raising money for a college scholarship as an award for the best AIDS prevention
proposal submitted by an African American teen.
According to a brochure describing AAATF’s primary goals, the organization is
“seeking inroads to serve the church community through culturally sensitive AIDS
programs and seminars, tailored to address moral and religious standards, which foster
care, compassion, education, HIV prevention, training, information, and referrals.”
In their attempts to forge inroads within African American churches in
Washington, DC, AIDS prevention specialists from the national Agency for HIV/AIDS
have developed a basic outreach strategy. Jean Tapscott, an administrator with the
national Agency for HIV/AIDS, explained:
First, you need a core of ministers who are receptive. Many people don’t want to
be identified with AIDS. So instead of addressing AIDS head-on, you can have
seminars that cover teen sex, health or violence, or have general health fairs with
AIDS awareness as an element or component. You can only give them as much
as they can handle, but you have to find out what they can handle.
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The mission of an AIDS ministry should theologically dovetail with the
traditional mission of most African American churches, Tapscott argued. In describing
the approach to AIDS ministry promoted by her agency, she commented:
The philosophy of this office is that churches should do what they usually do -
minister to physical needs and spiritual needs, provide compassion and caring and
a message of prevention. Sick people should be treated the same, whether they
are HIV positive or not.
Tapscott has observed that African American churches are more likely to
collaborate with an AIDS organization when someone within the agency has strong ties
to the religious community. She commented:
There are issues of church and state, but there can be a good marriage between
church and state. Right now, many churches and agencies seem to have pieces of
the whole, through their individual efforts, but where do you pull it all together?
Her agency met resistance when it attempted to introduce literature about
condoms and sexual issues within various churches in the city. Tapscott said the
Religious Roundtable “didn’t want to use words about condoms and sex. So we took
those words out. If that’s palatable for the church, then that’s fine.”
The nature of inroads for AIDS ministry depend upon whether initiatives are
intended to function as education or ministry for people within the church or as church-
based community outreach. The political climate within a particular church may
determine which initial approach is most appropriate.
While most African American churches are not willing to promote condom use
within their congregations, some apparently are willing to distribute condoms to
prostitutes or other at-risk populations as part of an outreach ministry. This irony was
observed by one key informant, whose church is theologically conservative:
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Here’s the Litmus test: you could interview other people from my church and ask,
‘Did you pass out condoms?’ and they’d say, ‘Yeah, I passed out condoms.’ ‘Did
you give one to your own son?’ ‘My son? No. He ain’t going to be doing that.’
Or here’s a good one: ‘Did you give some to your daughter?’ ‘No.’ They’d go
down to the Salvation Army or Saint Francis House to pass out condoms. By all
means. Going down to where the prostitutes hang out --1 call it the zone for
prostitution over there — fine, pass them out. Over there by the Greyhound bus
station, they ought to be passing out condoms every night. But pass them out in
church? I doubt it.
A female pastor said she wants her church to be the first in Gainesville to develop
an AIDS ministry. She wants to start by hosting an AIDS week that would include a
guest speaker who is an African American person living with AIDS, a healing service,
and possibly a benefit concert. Her church, an interdenominational, Pentecostal,
independent congregation, recently purchased a school bus to pick up residents of
housing projects for transportation to church services and other events. Given that many
church members and visitors “probably have been drug addicts and alcoholics and stuff
like that,” AIDS awareness events should be designed to “let them know why they don’t
want to go back out there to that, because of what can actually happen.”
In recruiting people living with AIDS to serve as community speakers, churches
and AIDS organizations must sensitively and strategically consider the personal
consequences that the speaker likely would endure as a result of going public. For
example, an African American woman living with AIDS recently decided she would like
to serve as a speaker, but she is afraid to take the first step in Gainesville for fear of
verbal attacks upon her and her children:
As far as getting on TV or something, that would give me a heart attack. I’d have
to go to a whole different county ‘cause my children have a problem. One time
the AIDS network asked me about going into the schools, and my oldest daughter
said, ‘Momma, no!’ ‘Cause they had some other people come to speak, and the
children asked them all kinds of crazy questions that made no sense.
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Reflecting on her own experiences, she suggested that a starting point for an
AIDS ministry in some of Gainesville’s black churches could be a simple information
campaign:
The best thing possible that can be done right now is to let people who have HIV
or AIDS know that the ministries are there. It’s up to the person to actually come
to them with it, ‘cause a lot of people are sitting in the closet. Put information out
there for people with HIV, so they’ll know where they can come if they need to.
The churches just have to sit back and wait for those people to come in. They
need to say, ‘Come here and let us pray for you. Come here and let us help you.’
Community education is another form of church-based AIDS outreach. An AIDS
awareness fair in Washington, DC, the collaborative effort of several African American
churches, demonstrated a level of institutional unity and compassion toward people living
with AIDS that has not been seen in Gainesville. During this four-hour event on a sunny,
humid morning in August 1995, health educators and representatives from three churches
and various service organizations manned a dozen tables on a barricaded inner-city street
within an African American neighborhood. While teens played basketball and families
shared hot dogs, lemonade and grilled hamburgers, church leaders passed out literature
and small groups discussed AIDS concerns in the midst of the festivities.
Kevin McDermott, director of the HIV/AIDS Ministry of Greater Mount Calvary
Holy Church in Washington, DC, coordinated the event. Although his church is not
involved in street outreach, it coordinates AIDS fairs that provide referrals for and from
other organizations in the city. The church also is seeking federal grants to fund
construction of a substance abuse rehabilitation center that will develop HIV education
interventions for its clients.
Greater Mount Calvary and other African American churches in Washington, DC,
have been among the first in the United States to initiate AIDS outreach projects within
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their neighborhoods. Tapscott said these projects have included church posters with an
abstinence message, church bulletins devoted to AIDS awareness and information, and
bus posters, as well as TV and talk show programs. Several churches have produced
public service announcements for newspapers, television, and radio, with messages that
promote abstinence, HIV testing, and prenatal HIV testing, as well as messages that
emphasize “the church loves you.”
African American churches can develop projects to coordinate with annual events
such as AIDS Awareness month in October or World AIDS Day on December 1.
Tapscott said African American churches in Washington, DC, have coordinated prayer
meetings, benefit concerts, candlelight vigils, and other events to commemorate World
AIDS Day. Her agency has found that an African American church is more likely to
participate in these kinds of events if an African American person living with AIDS
initiates dialogue with the pastor and congregation first. In addition, she said that “it
helps if the church gives the person a gratuity for speaking, to help them make ends
meet.”
Greater Mount Calvary Holy Church in Washington, DC, celebrates AIDS
awareness month by hosting an all-day, outdoor health fair, workshops, a Sunday evening
healing service in which a speaker talks about healing and AIDS, and a Saturday night
AIDS symposium in the church. McDermott said the symposium is a panel of seven or
eight people that usually includes a person living with AIDS, a health educator, an AIDS
case manager, a doctor or nurse, and a legal expert. On one evening every year, the
church hosts an AIDS benefit concert that highlights musical talent and inspirational
speeches from members of several metropolitan churches.
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The AIDS ministry of Greater Mount Calvary Holy Church was perhaps one of
the first in the United States to be implemented within an African American church.
McDermott said the vision for this ministry was bom in 1989, when the bishop became
“troubled because several men had died of AIDS in the church.” The bishop founded the
AIDS ministry the following year while serving as deputy director of the National AIDS
Network. McDermott remarked that the concept behind the AIDS ministry
is to bring together everyone who has to deal with HIV issues and give them a
place to get away from the pressures of dealing with AIDS, a place to be
encouraged and strengthened.
The AIDS ministry set out to address community and congregational needs within
areas of education, care, compassion, and outreach. McDermott said programs have
included peer education classes, as well as hospital and home visitation, support groups,
and prayer for people living with AIDS.
Community unity
The theme of the first AIDS prevention campaign initiated by the African
American AIDS Task Force in Gainesville was “Umoja Sasa,” which is Swahili for
“unity now.” The Task Force has distributed several hundred brochures with this theme.
The fabric of the African American community is tom bit by bit when children
are victimized by AIDS, crime, and early pregnancy, one woman argued. She called for
community action to solve these problems:
You see a child got murdered, shot down in the street. That affects us. It goes
real deep. And when we see our little babies pregnant at 11 to 12 years old, that
goes real deep. That’s something we don’t need to let go unattended. That’s
something we need to be right on top of.
One woman argued that AIDS awareness and education must occur within many
different segments of the community before the spread of the disease can be halted:
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It helps for parents, relatives, people in school to be educated. It’s not ever too
many people to help - to keep it in their minds at all times that these things can
happen, so the more people that actually know how to educate people on it, the
better they’ll stop it from happening.
In the Gainesville area, African Americans should join with Hispanics for a more
holistic approach to AIDS prevention, a key informant said. She commented:
I see more Hispanics coming in. I believe the cultural diversity will not be a long
string It will be a short one. I think we will be a more dynamic part of a total
picture and more of a bonding there.
Social support for people living with AIDS
Social support, when framed as compassion, is a basic tenet of most African
American church doctrines. When asked how doctrines of his church address AIDS
education or outreach, one male minister could not recall any official statements that
directly addressed these issues. However, he said his church is part of a network of
interdenominational congregations that promote outreach to people of all backgrounds:
We talk about reaching out to all people, all men, all women, all over the world,
but we don’t limit it and say we’ll only reach out to the people who are going to
be down the Riviera. We reach out to those who are in need. We have a song,
“The Lord is Within You” that says we are to go forth because there are millions
who are waiting for ministry. Not just African Americans. Our scope is world¬
wide, and it’s not limited to certain groups of people.
Beyond this global outreach mission, the church believes that people living with
AIDS deserve compassion. The minister remarked that “love is universal. If it was
conditional, then we’d really be messed up. That wouldn’t be church.”
Providing social support for people living with AIDS is considered a
responsibility for a true Christian. As one woman commented, “I feel like as a Christian,
the first thing that we should be able to do is to be there for them, and support them and
to show love, and not to be so scared.”
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This woman further argued that although the African American church as an
institution largely has failed to provide material assistance to people living with AIDS
and to their families, individual Christians urgently need to provide this kind of support:
The sad part about it, is it’s not just the individual but the children, the whole
family. They need to be supported. They’re in and out of the hospital. They
need money. They need food to eat with. It’s just so much that goes along with it.
And when that loss comes, it’s not just to that person. Even though they have
families, the families are not there to take the kids, and no one else is there to
clean and cook and do for them. I’ve seen them. They’re struggling, trying to
feed their kids. They’re trying to cook, and they’re trying to clean, and nobody’s
there to help them. That’s my worry more than anything. Where’s the people
who can actually be there to assist and help them?
Before effective social support can be provided, one woman argues, individuals
must personally see the situation and feel empathy toward the needy person:
The thing is, you’ve got to get people where right now they see it. So they can
say, ‘OK, I know she has AIDS, and yeah, I’ll go in there or clean her house and
cook her kids’ food and do this and that, without the fear that I may catch it.’
Given that fear of contagion is a major obstacle to providing social support for
people living with AIDS, she argues, helping people overcome this fear can be
accomplished through education about AIDS transmission:
You’ve got to get people involved, to know that you can go and hug her, and you
ain’t gonna catch no AIDS. I mean, it’s the fear of the whole situation. So
you’ve really got to sit them down and educate them. Then you’ll probably get
more help in these areas. You know, if this individual’s got it, then you can say
that ‘She’s got AIDS, and she really needs some help.’ Then you’ve got people
that will volunteer to do it.
After seeing how doctors and nurses were not afraid to touch and hug an infected
young girl, a female pastor said she was less afraid to do the same. She observed that
“some of the nurses were kissing on them and hugging them and just giving them love.
And they weren’t scared.”
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When a friend was diagnosed with AIDS, one woman said this was the first time
she had personally known someone who eventually died from the disease. Before the
friend died, the woman felt helpless because “there’s nothing you can do but sit there,
hold their hand, and share the hurt with them.” When asked the question, “How would
you react if your best friend just told you that she has just tested positive for AIDS?”
most women said they would offer comfort and share tears. For example, one woman
said:
It would be sad. You’d hug her. Y’all would shed tears. To me, it’s not the time
to talk Nothing you could say or do could change that situation. So I would just
let whatever happens, happen. Comfort her as much as possible. Or him. Make
him feel all the love and that you’re there with him through thick and thin. It just
would be a very emotional time.
One woman, however, admitted that she would not be prepared to deal with the
situation:
You wanna know what I think? I don’t know what I would do. Say, for instance
if you came to me, and you told me you had AIDS, I wouldn’t know what to do.
Developing empathy for the plight of a person living with AIDS is essential for
the helping individual to offer genuine social support. As one woman observed:
They can tell when you pull away from them, or you don’t love them or be there
to help take care of them. That hurts them more than the disease and knowing
that they’re going to die. The people.that they thought would be there for them -
everybody just disappears on them, and they’ve got to go through this by
themselves.
Church outreach to people living with AIDS should include simple, everyday
assistance, one woman argued. She said this kind of AIDS ministry begins with
Some task, like who will want to go and get his medication for him, because he
cannot get it? If you cook them one meal, they’ll eat off that one meal all week.
That mission usually goes out and ‘This group is gonna fix dinner this week for
Sister So-and-So, and if we need to go shopping for Sister So-and-So, we gonna
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do that. We’re gonna make sure she is fine until she is able to get back up on her
feet.’
A major benefit of social support for people living with AIDS is that improved
emotional well-being can boost physical immunity to illness. As one woman observed,
“I think they last longer when they have a positive frame of mind. The mind is a
powerful thing.”
Within the focus groups, about one in three women and about one in 10 youth
said they have personally known a person living with AIDS. In sharing anecdotes about
their interactions with HIV-positive individuals, these focus group participants described
their inner struggles to overcome fear of the disease and of the people carrying it. One
woman said she overcame her own fears of contagion by showing compassion to a young
African American girl who was hospitalized during the last stages of the illness:
I know more about it from experiencing a little girl dying, and being in the
hospital, and watching the nurses take care of her. That made me more educated,
enough to know that I wasn’t going to get it just because I showed her love or
hugged her or gave her a kiss on the jaw. I’ve learned the thing they need most of
all is love. Just to know that you’re not scared of them and that the love you have
for them goes deeper than whatever disease they may have.
Another woman first met a person living with AIDS at her workplace. After she
learned that she could not catch AIDS through casual contact, she began showing a
greater-than-normal amount of affection and attentiveness towards this young man while
others were keeping a certain physical distance from him. She commented:
A few years back, I worked with a young man that contracted AIDS, a gay guy.
And he’s very nice, very friendly guy. We always hug and shake hands. Now I
know that you can’t get it from shaking hands or hugging or just sitting down
having a casual conversation. So I treat him like everybody else, but yet there’s
that hurt there where you feel sorry for him. You don’t let him see it, but if
there’s anything you can do - sometimes I think I overreact. I’m like, ‘What can I
do for you? What you need? Coffee?’ But you want to make them feel as much
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love as possible. There’s so many people that are like standing a distance away
from him.
Potential Barriers
Figure 22 below depicts the overarching framework for this study, highlighting
the potential barriers, as identified by research participants, that could block or inhibit
individuals from engaging in AIDS dialogue or complying with AIDS prevention advice.
INDIVIDUAL PROCESSES
Enabling
Factors
CULTURAL CONTEXT
Potential Barriers
Lack of efficacy
Familiarity
Fatalism
Lack of parent-child
communication
Denial
Secrecy
Desensitization by drama
Lack of AIDS knowledge
Judging by appearances
Homosexual stereotype
Religious beliefs:
Homophobia
Just wodd belief
Church as protection
Church politics
Religious taboos
Divine healing
Fear of contagion
Black genocide theory
Stigma
Euphemism & labeling
FIGURE 22: Barriers to an Individual’s Compliance
with AIDS Prevention Advice
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Lack of self-efficacy
Although a basic component of a church-based abstinence message is to wait until
marriage to become sexually active, many focus group participants questioned the
efficacy of marriage in preventing HIV infection. “But it doesn’t stop it,” one woman
argued.
A lack of confidence in safer sex practices also can be a barrier to effective AIDS
prevention. One boy in the pilot group remarked that “there ain’t no protection from
AIDS from condoms.”
A female pastor said many African American residents of low-income housing
facilities have a substance abuse problem, and many also are sexually promiscuous.
Hopelessness may be a major barrier to overcoming these addictions or changing risky
behaviors. She commented
They feel bad about it. They feel guilty, you know, in some sense. But, they feel
like they’ve been doing it for so long, there’s no hope and no one else cares, or
whatever. Most of them want to get better, but they just don’t know how. And
so, that’s where we try to come in.
Familiarity
Awareness is a prerequisite for learning and involvement. However, familiarity —
as the old cliché goes — may breed contempt. The self-perception that a person has
learned enough about AIDS can inhibit interest in future involvement in behavior change
interventions.
A person’s belief that he or she is already knowledgeable about AIDS can be a
barrier to dissemination of new AIDS prevention material such as a fotonovela. One girl
commented, “I don’t have friends to give it to, ‘cause most of my friends are pretty much
aware of AIDS.”
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Another example of this phenomenon was shared by the woman who recruited
many participants for the women’s focus groups. She said:
Trying to get women to come down here, most of them were like, ‘Well, I’ve
been to an AIDS class before, the AIDS training.’ And so, if they go through
once, they may not want to learn anything else. They don’t take it serious.
Fatalism
A lack of response efficacy can ultimately lead to a sense of fatalism, since
individuals may feel that nothing can effectively protect them from HIV infection. For
others, a sense of fatalism seems to be rooted in their own fundamentalist religiosity. As
one woman remarked:
With these diseases springing up, there were 39 stripes and those stripes were for
our demons. There must be 39 diseases. They keep getting worse and worse.
They’re not getting any better. You can talk to your people, and they’ll say, ‘All
right. We won’t do that.’ And they do that. But there’s no harm in keep talking.
The ultimate fatalism, the desire to die, may be pervasive within the social
networks of some African American teens. Prevention advice would be expected to have
little influence on a person in this state of mind. One boy explained:
Some people, they suicidal, they don’t care what they do. They’ll go out and do
anything just to kill themself. Like they in a hospital, and they don’t know why
they did it to themself.
The belief that AIDS might one day be cured may prevent hopelessness among
many African Americans living in the current situation. One girl said she believes AIDS
will be cured within the next five or ten years, definitely “by the time we have our kids.”
But another girl argued that “even if it was found, I mean, it would be very hard that
everyday people could go and get some medicine.”
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Lack of parent-child communication
A barrier to effective parent-child communication is parents’ lack of knowledge
about AIDS or their resistance to learn about the disease. One woman remarked:
A lot of young parents are very independent and were not taught for different
reasons. Maybe they were rebellious, and that information wasn’t passed on. So
we have generational problems of communication.
A parent’s lack of knowledge about child development can be another barrier to
effective communication with youth. One woman commented:
A lot of times it’s just an awkward situation, or they don’t know exactly what to
tell them when they’re 5, how much to tell them when they’re 7. Some children
are asking questions. Some are not asking questions. They’re talking to their
friends at the playground. If you’re a parent, and in some cases nobody talked to
you when you were a child, how are you going to talk to your child and educate
them? Especially if nobody talked to you, then you don’t know how to do it.
Another possible barrier to effective communication is a parent’s
misunderstandings about a child’s sexual curiosity. When young children are involved
in sexual experimentation, she said,
That’s just misguided curiosity. They didn’t just wake up one day and just start
doing something. They have reached out or tried to find out, and they can’t. The
parent has to be equipped to deal with that, even when they’re 3 and 4 and 5 and
talking about their pee-pee and their wee-wee.
When youth see their parents as too strict or old-fashioned, this perception may
indicate a need for more open dialogue between the parent and child. For example, one
woman related the story of her 13-year-old son who called her “old fashioned” because
she would not let him go to the mall by himself. The boy reacted to the rule by
comparing her to his father:
He sat down and drew a column for his mom and a column for his dad, and he
talked about the way we view life. Is my mother strict, or is she cool? He
checked strict. He checked his dad cool. When it came down to decisions and
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choices about things, he said his mom is old fashioned. His dad responds in a
new way of thinking.
Barriers to fotonovela dialogue
Fear of rejection could be a barrier to interpersonal dissemination of the booklet.
One boy did not expect all his friends to agree with his advice. He observed that
“everybody’s got different opinions.”
During a two-week period, a total of 300fotonovelas were distributed to African
American teens. The boys shared 11 fotonovelas, girls shared 39, six women shared 150,
and other female church members not in the focus groups distributed 100 fotonovelas to
youths (Appendix D). Although rejection or lack of interest is a potential barrier to
dialogue, most teens that actually shared the booklet said they were not afraid of risking a
brush off. One woman who successfully shared the booklet with numerous teens and
adults encountered others who “really didn’t have time ‘cause they had to go do things.”
Another barrier to sharing the booklet, particularly among African American
boys, could be a cultural norm of macho indifference. Although none of the boys
indicated that sharing the fotonovela would be a problem, they also did not seem eager.
When the boys were asked how they felt about sharing the booklet, their typical
responses included: “It’s fíne with me,” “It’s fíne to talk about preventing AIDS,” and
“It’s good to talk about stuff to make sure they doin’ OK.” An example of this
indifference was shown in one boy’s remark: “It don’t bother me. I can talk about most
anything with them. But it don’t make no difference.”
This lack of eagerness to share the booklet also could have been rooted in the
belief that their friends would probably react to them with indifference. It may be
considered “uncool” for African American boys to give advice to one another. One boy
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commented that ‘"they so hard headed, they won’t listen to it. They do the opposite of
what you tell them.”
One boy had a fatalistic attitude about sharing AIDS information with his friends.
He commented that “you can talk about it, and the same day they’ll go out and catch
AIDS. You try to help them.” Another boy, however, thought that using the fotonovela
to talk about AIDS could make a difference. He commented that “if they read the book,
they’ll know how to protect themselves. If they don’t read the book, they could go out
and catch AIDS.”
Most girls did not expect any difficulty in sharing the booklet, but a few
expressed reservations. One girl commented that “it gonna be hard to talk about it,” and
another added that “it’s not easy to come up to somebody and start talking about AIDS.”
An actual barrier to effective dialogue about the booklet was the presence of
adults and others. One girl remarked that “it’s difficult when there’s grown people
around, and I thought when there’s children outside or in the house.” Similarly, when
one boy was talking to his friends about the booklet while walking to school, his
girlfriend was walking behind him. A couple of the boys laughed about this incident
during the final focus group session.
Although talk is generally considered a beneficial activity, too much of it by one
person can become a barrier to focused conversation. When asked if it was hard to talk
about the booklet, one girl remarked, “Yeah, ‘cause she was talking most of the time. I
told her to stop talking, ‘cause she talk too much.”
One girl said she was a little worried about “whether they liked it. I was worried
about the pom in the story, or something.”
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The topic that was most difficult to discuss, for one girl, was “the sex part.”
However, another girl disagreed, saying, “What’s so bad about that, talking about sex? I
talked about it.”
Just world belief
A key informant from the Task Force said she became involved in the
organization because she was disturbed that many African Americans in Gainesville
believe that AIDS is a curse from God. Similarly, another key informant commented:
AIDS is not retribution from God for people who have done something wrong. I
mean, how do you explain an infected newborn baby, or someone who’s gotten
AIDS from a transfusion?
Ministers often talk about “innocent victims,” commented Jean Tapscott, an
administrator with the national Agency for HIV/AIDS. However, she argued that a
theological rebuttal to that position is that “we’re all sinners.”
The belief that AIDS is divine judgment could be a barrier to perceived threat.
Most African American churches need to prepare to minister to people living with AIDS,
one key informant argued, because the number of church members affected by the
disease will continue to increase. She said:
As we get closer to the year 2000, we’re going to see a lot more people coming
back to church for very dire reasons. I think some people, after they get AIDS,
might be more concerned about their eternal souls because they might believe
they’re going to meet their maker a lot sooner than they expected. Church is one
place where people come sometimes hoping to get a miracle. If you think they’re
under punishment or a curse, you’re not even going to bother to try to get them
there.
One elderly woman suggested that the AIDS epidemic is a fulfillment of Biblical
prophecy. She remarked:
The Bible said such a long time ago, if people keep sinning and doing the same
things over and over, there will be a disease that come over on this earth that they
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can’t cure. And I hear in the news that they’re giving them shots, but the shots
don’t take effect on them. So if people keep doing the things that God say don’t
do, it’s going to be forever. It’s not going to stop. It’s going to go on and on and
on until God get tired and wipe it off. Or they get saved. I hope they get saved. I
really do. What’s happening now has already happened, and it’s been happening
ever since the beginning. The crooked things will not be made straight until He
calls for anybody who believes in the word of God.
Another woman said people must realize that AIDS is a fulfillment of Biblical
prophesy so that they can avoid infection by living righteously in