Challenge, Vol. 13, No. 2
African American College Students’ Attitudes toward
HIV/AIDS: Implications for Historically Black
Colleges and Universities
_____________________________________________________
Sandra E. Taylor
Department of Sociology and Criminal Justice
Clark Atlanta University
Tara Jones
Department of Medical Sociology
University of Alabama – Birmingham
_____________________________________________________
Abstract
This paper investigated African American college students’
responses to a set of interview questions selected from a larger survey
instrument in an exploratory study of basic attitudes about HIV/
AIDS. Forty-two participants responded to an interview schedule in
an investigation of student attitudinal domains regarding the HIV/
AIDS epidemic. Results show that while most students’ attitudes
were consistent with expectations, a number of students expressed
attitudes that are counterproductive in the fight against HIV/AIDS.
Given the epidemic within the African American community,
such findings appear ominous and implore strategies, in particular,
from the institution whose primary function is the education of its
populace. Unless aggressive steps are taken to address the problem
across college and university campuses, there can be no lessening
of the epidemic’s impact within this community, and thereby no
positive impact toward the goal of U.S. lowered rates consistent with
recent global trends.
______________________
Please direct all correspondence to Sandra E. Taylor, Department of Sociology
and Criminal Justice, Clark Atlanta University, 223 James P. Brawley Drive, S.W.,
Atlanta, GA 30314 or email to: staylor@cau.edu.
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Introduction
While HIV/AIDS cases have declined worldwide, ironically,
the leading world superpower is not experiencing this optimistic
trend. According to the World Health Organization (2007), 33.2
million people were estimated to have HIV in 2007 compared to 39.5
million who lived with the virus in 2006. In the United States, the
HIV/AIDS epidemic has not hit a similar leveling, in part due to the
high numbers of cases affecting the African American population.
And within this particular population, a further irony is the number
of black college students infected with HIV. While black college
students represent only a very small proportion of HIV/AIDS cases
overall, the significance lies in the African American numbers versus
those in the Caucasian community, and in research showing gaps
in knowledge between these two groups. In one study of ethnicity
and sex differences in AIDS-related variables of knowledge, fear, and
homophobia, the authors found that African American students had
significantly lower scores on these measures (Waldner, Sikka, & Baig,
1999). Moreover, and irrespective to race or ethnicity, one would not
expect such disparities from a sector focused on higher education.
It is too often presumed that college campuses, replete with readily
attainable informational resources, insulate their students from
health-related risks, including HIV/AIDS.
The daunting statistics indicating an increase in HIV
infections among African American young adults do not exclude
the college populace. One might reason that at institutions of higher
learning, students are somehow more “educated” about risk factors
associated with contracting HIV, and thereby, less likely to engage in
high-risk behaviors. However, cases of new HIV infection (84 male
college students, 73 of whom were African American) revealed in an
epidemiologic investigation involving 34 schools in North Carolina,
show that college status is not an insulator. Rates of newly reported
HIV infection among African American college student men who
have sex with men were similar to their non-student counterparts
(CDC, 2004). This research further showed that the majority of
study participants did not perceive themselves to be at risk for HIV
infection despite the elevated rates of high-risk behaviors.
Related literature on HIV/AIDS and college students indicates
that while this population is knowledgeable about prevention
measures and risky behaviors, students tend to underestimate
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their vulnerability. In one sample of 649 African American male
and female college students (aged 18-25 years) attending various
4-year institutions in a major southeastern metropolitan area,
inconsistencies in knowledge and behavior were observed. Data
indicate that while this population overall adheres to certain HIV-
preventive behaviors, they nevertheless violate other important HIV-
prevention practices (Taylor, Dilorio, Stephens, & Soet, 1997). For
example, while the college women were more likely than college men
to use measures that help prevent HIV transmission, both groups
reported practices that expose them to risk, including engaging in
sex without knowledge of a partner’s sexual history. In an earlier
study of African-American male college students, only 26% of
respondents were steady condom users despite knowledge of the risk
of not taking precautions (Johnson, Hinkle, Gilbert & Gant, 1992).
Hence, a significant gap emerges between students’ knowledge and
their actions resulting in new cases of HIV infection.
Reasons for the failure of African-American college students
as well as young African-Americans in general to follow safer
sex guidelines tend to center around their perceptions of being
invincible and somehow being disconnected from the reality that
they might contract HIV. However, other studies suggest that the
gap between student knowledge and behavior might be attributed
to factors outside of the invincibility/invulnerability explanation.
Included among these other factors are lapses in judgment (often
due to alcohol or other substances), and believing that physical
characteristics and appearance can inform one about their partner’s
HIV status. In light of the fact that college experiences can include
experimentation with mind-altering substances, education and
training campaigns attempt to appropriately emphasize the high
risks involved with consumption and dating. Much of the literature
has stressed the need for prevention and information messages that
are tailored to the populations that appear increasingly vulnerable,
including African American college students.
While empirical evidence in accounting for the gap between
student knowledge and behavior has not been consistent, also
inconsistent are factors explaining the gap between HIV rates of
black and white college students. Research by Waldner, Sikka, & Baig
(1999) show that AIDS knowledge scores were significantly lower
for African American university students compared to Caucasian
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students. African American students demonstrated higher rankings
of homophobia as well. Davis et al (2007) found that although it
appeared that white students were more aware of HIV facts than
African American students, this effect could be explained through
sexual status (sexually active students versus abstaining students,
with the sexually active students reporting less knowledge).
A possible factor in the disproportionate number of black
students contracting the virus is the increase of HIV/AIDS in certain
U. S. regions. Reif, Geonnotti, and Whetten (2006) document that
a substantial increase in AIDS cases in the Deep South occurred
from 2000-2003. In contrast, other regions experienced more
stable rates for this same time period. Given that black students
are disproportionately located in the South and data suggesting
colleges as potentially high transmission areas in the rural southeast
(Hightow, Leone, MacDonald (2003), the regional hypothesis
becomes a feasible one.
An epidemic of infection occurring in some North Carolina
college students involving African American men who have sex
with men is described by Hightow et al (2005) in terms of an at-
risk, accessible population deserving further HIV prevention
interventions. In this study of state surveillance records examining
new HIV diagnoses in men 18-30 years old, risk behavior for HIV-
infected men enrolled in college was compared with HIV-infected
male non-enrollees. Newly diagnosed HIV infection was found in
men in 37 colleges located in North Carolina or surrounding states
and a sexual partner network investigation linked 21 colleges, 61
students, and 8 partners of students (Hightow et al, 2005). As a
result, the authors describe an epidemic of HIV infection occurring
in North Carolina college students that has captured the attention of
both researchers and practitioners as well as college and university
officials. The study clearly reveals that college students can no longer
be viewed as a categorically low risk population, in part due to the
nature of developmental stages associated with this age group.
The culture of late adolescence (including the college
population) and the accompanying thought processes do not
necessarily nor consistently coincide with the wider culture. That
is, this population may tend to view sexual phenomena in ways
different from other groups. Specifically, they may hold different
views on what constitutes sex or particular sexual behaviors. For
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example, while penile-vaginal intercourse is viewed as “having
had sex,” oral-genital or penile-anal intercourse is not viewed as
constituting “sex” as perceived by certain college students (Sanders
& Reinisch, 1999). Similarly, Bogart et al (2000) found that vaginal
intercourse and anal intercourse were considered sex by a group of
undergraduates (n=233) under most circumstances. However, this
same group categorized oral intercourse as sex contingent upon the
gender and viewpoint of the actor, and whether orgasm occurred.
This specific study by Bogart et al (2000) assessed the impact of four
factors on respondents’ judgment of whether hypothetical actors
would consider a particular behavior to be “sex.” The subjects read 16
scenarios featuring a male and female and judged whether each actor
would consider the described behavior to be sex. The views of the
subjects indicate the realm of differences related to what constitutes
sex for this population. These findings suggest, as pointed out by the
authors, that items in behavior surveys need to be clearly delineated
to avoid subjective interpretations by respondents. Many studies on
HIV/AIDS and adolescent/young adult age groups have repeatedly
illuminated the inconsistencies that abound in defining “sex” for the
college population.
The training of students in alleviating attitudes and behaviors
that run counter to controlling the HIV/AIDS epidemic is certainly
the purview of the education sector, but also begs for the input of
the religious/faith sector. In light of the stigma and fear associated
with HIV/AIDS, strategies to combat the epidemic within both
sectors have been severely hampered. These key social institutions
within the African American community represent crucial sectors
in impacting the problem, but have only recently begun to engage in
more aggressive initiatives toward addressing the problem.
Given the increased numbers of African American college
and college-aged students who have contracted HIV, and in light of
knowledge and attitudinal gaps, efforts toward understanding the
nature of this population’s psyche relative to the epidemic would
seem feasible. Within this context, an investigation into specific
domains of HIV/AIDS was conducted in illuminating themes that
adversely affect safer behaviors.
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Methods
This research included a sample of African American college
students (n=42) who regularly attended a series of HIV/AIDS
education and prevention activities at a Southeastern historically
black university. Activities ranged from awareness seminars and
forums to health fairs showcasing innovations in HIV/AIDS, with
a major focus on training and education for prevention. Although a
total of 166 participants responded to the larger survey instrument
from which subsequent interview questions were extrapolated,
complete interviews were conducted with forty-two students in
comprising the content analysis for this study. Of the 42 respondents,
the average age of the sample was 20 .2 years with a median of 19
years and a range of 18 – 29. They ranged from freshmen to seniors
and all self-identified as black or African American. A majority of
women in comparison to men were included (26 or 61.9% and 16 or
38.1% respectively).
The larger research used a survey instrument consisting of
open-ended and structured questions to ascertain basic thoughts
and actions of college students. These questions represent part of
an extensive instrument designed to collect an array of measures
on college students’ attitudes and behaviors toward HIV/AIDS.
Specific items were selected for content analysis in order to more
closely investigate the students’ attitudes on critical issues related
to combating HIV/AIDS. The intent was to examine the students’
overall disposition toward HIV/AIDS (i.e., whether internally-driven
(including the expression of accurate information and knowledge
of prevention indicative of high self-efficacy) or externally-driven
(including the expression of inaccurate information and/or responses
indicative of low self-efficacy).
This analysis uncovered in-depth data on three important
domains related to college students’ thoughts and feelings regarding
HIV/AIDS and involve statements alluding to 1. fear, 2. conspiracy
theories, and 3. a gay disease. Questions that showed significant
unexpected responses (e.g., assuming you had put yourself at risk,
would you consent to testing if convenience and confidentiality
were guaranteed?) were extrapolated for the interview schedule.
This follow-up to responses resulted in the dichotomy of internally-
driven students (those who would be expected to engage in safer
sex/risk reducing behaviors, and thereby contributing to combating
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the epidemic) versus externally-driven students (those who would
be expected to attach lesser importance to these same behaviors,
thereby exacerbating the problem).
The three specific themes that emerged from the interview schedule
including 1. students’ fear of individual HIV/AIDS test results,
2. students’ belief that the epidemic is part of a conspiracy, and 3.
students’ association of HIV/AIDS with the gay population indicate
a need for enhanced programs that teach education and prevention
within a culturally-specific context.
Results and Discussion
The domains related to college students’ thoughts and feelings
regarding HIV/AIDS and the resulting themes provide insights
as to how African American college students might be inclined to
violate risk reduction and safer sex practices. For this population,
perceptions appear to be their reality. Hence, messages about HIV/
AIDS prevention must be centered in situational contexts, in an
effort to reach these students based on their experiences, views,
and ways of life. The themes unveiled corroborate past findings
indicating the need for enhanced HIV/AIDS education for an array
of populations.
The theme of “students’ fear” captures sentiments of how
afraid some students are to be tested even in the face of grave risk.
For example, one student explained, “If I find out I have it, then
what? So I would just rather not know.” While the overwhelming
majority of students (78%) stated that they would be tested if they
had put themselves at risk, this leaves far too many behind still not
understanding the importance of HIV testing. Additionally, a few
students who alluded to the “what you don’t know can’t hurt you”
syndrome made statements indicative of their experience with a
large burden of other concerns that would appear to place a concern
about their possible contraction of HIV as a minimal priority. For
example, one student stated, “Right now, I’m dealing with trying to
stay in school and keep my place . . . I just don’t have time to do all
these things that might give me another problem.” While this student
represents a minority view of the total population studied, the finding
shows the myriad of complexities involved in the development of
strategies for HIV/AIDS education and prevention.
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The “conspiracy” domain is particularly interesting but
perhaps is best understood from an African American historical
context. Still, given persons who feel that they are helpless to control
their HIV status because of a master plan, consistent preventive
measures are unlikely. Bogart & Thorburn (2005) show that HIV/
AIDS conspiracy beliefs are a barrier to prevention and may represent
negative attitudes about condoms among black men. While only six
of the 42 respondents for this analysis discussed the epidemic in
terms of a conspiracy designed by the “powers-to-be,” five of the six
had very strong opinions on how the virus emerged. One response
captures the expressions of this group: “I do think that genocide is
being committed to rid society of certain people.” Another student
stated, “I believe it is a plan to wipe out all black people because
it mysteriously surfaced in Africa to a large extent recently, and
the worst effects are on Africa.” Still another stated, “I have proof
that there was a plan . . . we need to know what they did and what
they are still trying to do.” These statements indicate how attitudes
and perceptions shape behaviors; hence, HIV/AIDS training and
education specialists must consider the sentiments of this group in
designing effective prevention messages.
Although HIV/AIDS awareness and prevention campaigns
have done much to educate society in general about the epidemic,
there still tends to be an association of HIV/AIDS almost exclusively
with the gay community. This is particularly disturbing when college
students make such blanket associations. This third domain, “gay
association” surfaces as a theme from the content analysis in that
students do not necessarily view all groups as being at risk. For
example, 8 of the 42 students (or 19.0%) indicated “gays” to the
question, “what populations or groups of people are most at risk for
HIV-infection?” (The expected responses and those which had been
communicated via training seminars and forums center around the
point of “any persons who put themselves at risk or engage in risky
behaviors.”) While the vast majority of student respondents answered
in the expected direction, unacceptable numbers continue to believe
that they are not at particular risk, when in fact (according to self-
identified behaviors), they are indeed. Several students’ responses
can be interpreted in terms of their inability or unwillingness to view
HIV/AIDS as an equal opportunity disease. Overall, in addition to
uncovering consequential attitudes, results from this analysis pose
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an important question: If students who are motivated to attend HIV/
AIDS awareness and prevention activities show adverse attitudes,
do those not attending harbor even more severe attitudes? This and
similar questions are posed for further study.
The fact that college and university students are at particular
risk for the transmission of HIV has resulted in a number of
programs and activities to address this problem. Across America,
historically black colleges and universities as well as majority-
serving institutions of higher education, have housed an array of
projects initially including awareness efforts. More recently, however,
these efforts have begun to focus more on prevention initiatives,
acknowledging the platforms that have been made during the early
nineties addressing awareness.
Given the seriousness of the HIV/AIDS epidemic within the
African American community generally, and the numbers of HIV-
infected African American college students in particular, specific
strategies can be suggested. First, the major social institutions
within the African American community must bolster their efforts
in addressing the problem. The sector of higher education has a
direct opportunity to do this and should take advantage of such
to incorporate HIV/AIDS teaching and learning across various
curricula. The importance of education as the primary response of
higher learning, and the various issues surrounding HIV/AIDS on
college campuses, point to this sector as a natural ally and collaborator
in the fight toward curtailing the epidemic. Other institutions and
community sectors are also critical in this fight, namely the religious
sector or faith community.
The religious/faith community has come a distance in
confronting the HIV/AIDS epidemic, but it has to now compensate
for a stagnant period by taking bolder and more aggressive steps
toward combating the problem. These institutions hold enormous
potential for impacting the problem, as both education and religion
have historically played a major significance in the African American
community.
Secondly, measures that directly capture and sustain the
attention of black college students would seem to make a difference.
For example, given the popularity of hip-hop and rap music to
this group, researchers, practitioners, and activists should greater
explore the relationship between this genre’s appeal and combating
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HIV/AIDS. Previous literature has discussed a model for using hip-
hop music with young adults as having heuristic value in promoting
HIV/AIDS prevention (Stephens, Braithwaite, & Taylor, 1998.)
Recognizing the potential of this genre of music to mobilize the
targeted population, and implementing subsequent catalysts for
change, can be a monumental strategy.
Lastly, reminders of risk to this target population at every
viable opportunity cannot be overemphasized. Because of gross
feelings of invincibility or invulnerability to HIV-infection, college
students too often act as if they were magically insulated from
becoming statistics in the epidemic. Persistent admonitions on risky
behaviors from all socialization agents, but especially the media,
can at a minimum, be a forceful reminder of the epidemic as a
nonrandom culprit.
Ongoing HIV/AIDS education is undoubtedly one of the best
mechanisms for stemming the epidemic within African American
communities. Given an epidemic with no cure and no vaccine,
accurate and timely information is indispensable to the ultimate
goal. Specifically, within the context of African American college
students, studies allude to the importance of increasing the specific
knowledge level of this group regarding the subtleties of sexual
transmission (Bazargan et al, 2000) in empowering them to better
understand their risk.
Conclusion
This research illuminates barriers to alleviating the HIV/
AIDS epidemic among African American college students relative
to their thinking about the disease and how it affects them. While a
number of implications can be gleaned, a primary one is that until
the most likely players (colleges and universities) step up in ways
that only they can, improvements are not likely to occur within the
black college populace.
Although it is difficult to predict specific interventions that
would seem to bring the HIV/AIDS epidemic under greater control,
it appears obvious that the sector of higher education can lessen
the deleterious impact via the very means of its basic function. In
broadening students’ knowledge of the epidemic and in serving as
a catalyst for them to be proactive, historically black colleges and
universities (and all institutions of higher education) across the
country can be a powerful force in the fight against HIV/AIDS.
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References
Bazargan, M. Kelly, E. Stein, J. Husaini, B. & Bazargan, S. 2000.
“Correlates of HIV risk-taking behaviors among African-
American college students: the effect of HIV knowledge,
motivation, and behavioral skills.” Journal of the National
Medical Association 92(8): 391-404.
Bogart, L. M., Cecil, H., Wagstaff, D. A. & Abramson, P. R. 2000. “Is
It “Sex”/: College students interpretations of sexual behavior
terminology.” Journal of Sex Research 37 (2): 108-116.
Bogart, L. M. & Thorburn, S. 2005. “Are HIV/AIDS conspiracy beliefs
a barrier to HIV prevention among African Americans?”
Journal of Acquired Immune Deficiency Syndromes 38(2):
213-218.
Centers for Disease Control. 2004. “HIV transmission among black
college student and non-student men who have sex with men
– North Carolina, 2003.” Morbidity and Mortality Weekly
Report 53(32): 731-734.
Davis, D., Sloan, M., MacMaster, S. & Kilbourne, B. 2007. “HIV/
AIDS knowledge and sexual activity: an examination of racial
differences in a college sample.” Health and Social Work 32
(3): 211-218.
Hightow, L., MacDonald, P., Pilcher, C. Kaplan, A., Foust, E. Nguyen,
T. Q. & Leone, P. A. “The unexpected movement of the HIV
epidemic in the Southeastern United States: Transmission
among college students.” Journal of Acquired Immune
Deficiency Syndromes 38(5): 531-537.
Hightow, L., Leone, P., MacDonald, P. et al. (2003). “Are colleges
high transmission areas in the rural southeast? Insights from
acute HIV surveillance [Abstract WO-L305].” Presented at
the National HIV Prevention Conference, Atlanta, GA, July
27-30.
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Johnson, E. H., Hinkle Y., Gilbert, D. & Gant, L (1992). “Black
Males who always use condoms: their attitudes, knowledge
about AIDS, and sexual behavior.” Journal National Medical
Association 84: 341-352.
Reif, S., Geonnotti, K. L. & Whetten, K. 2006. “HIV Infection and
AIDS in the Deep South.” American Journal of Public Health
96 (6): 970-973.
Sanders, S. A. & Reinisch, J. M. 1999. “Would you say you had sex
if . . .?” Journal of the American Medical Association 28: 275-
277.
Stephens, T., Braithwaite, R. L. & Taylor, S. E. 1998. “Model for
using hip-hop music for small group HIV/AIDS prevention
counseling with African American adolescents and young
adults.” Patient Education and Counseling 35: 127-137.
Taylor, S. E., Dilorio, Colleen, Stephens, T. T. & Soet, J. E. 1997. “A
Comparison of AIDS-related sexual risk behaviors among
African American College Students.” Journal of the National
Medical Association 89 (6): 397-403.
Waldner, L. K., Sikka, A., & Salman, B. 1999. “Ethnicity and sex
differences in university students’ knowledge of AIDS, fear
of AIDS, and homophobia.” Journal of Homosexuality 37 (3):
117-133.
World Health Organization. 2007. “Global HIV Prevalence has leveled
off: Improvements in surveillance increase understanding of
the epidemic,resulting in substantial revisions to estimates.”
Geneva, November 20, 2007. (http://www.who.int/
mediacentre/news/releases/2007/pr61/en/index.html)
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HIV/AIDS Perceptions, Attitudes and Behaviors
Among HBCU Students
_____________________________________________________
Michael Hodge
Morehouse College
Bruce H. Wade
Spelman College
_____________________________________________________
Abstract
College environments are typically considered somewhat
protected zones--protected from the “sins” of the general community.
However, a recent report from CDC placed considerable attention
on the resoundingly high rates of HIV infection among African
American students attending predominately African American
serving colleges and universities in North Carolina. In the “outside”
world, data show that African Americans lead the nation in the rates
of HIV/AIDS infections. This research turns on the light to view
more clearly an oft-shielded group in an effort to identify and assess
the exacerbating or ameliorating social forces that these campuses
imbue. This project uses quantitative and qualitative methodologies
to examine how college age young adults attending HBCU’s respond
to the pandemic / epidemic. In the general African American
population typical intervention approaches have had little to no
positive effects on reducing the persistently high rates of infection.
An in-depth look is taken into the lived-experiences of students
at Historically Black Colleges and Universities as it relates to their
sexual risk taking in the age of HIV/AIDS.
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Introduction
The HIV/AIDS pandemic is a significant social problem at the
global, national and regional levels. It impacts persons regardless of
gender, race, ethnicity, sexual orientation or age. This scourge may
even have reached communities thought to be relatively immune to
such incursions—college campuses. A recent report from the CDC
placed considerable attention on the resoundingly high rates of HIV
infection among African American students attending predominately
African American serving colleges and universities (HBCU’s) in
North Carolina (MMWR, August 20, 2004/53(32): 731- 4). One
CDC official states that there is no reason to think that we will not
see this same trend on other campuses as well (see Hightower, L.,
MacDonald P, et al., 2003). This research was motivated by the gaps
in the literature on the sexual risk behaviors and attitudes at HBCU’s
(historically black colleges and universities).
The importance of this project is found in the attempt to
identify the sociocultural aspects of the student populations at
HBCU’s that may place them at greater risk of HIV/AIDS infection.
By socio-cultural context, we mean the ways in which people’s
behaviors are linked to their social settings such as group membership,
race, class, and gender. For example, there are gender dynamics
that fuel the health disparities between black men and women.
Consequently, while black men and women overall account for 40%
of the cumulative AIDS cases through 2005, black females drive 60%
of this rate (Division of HIV/AIDS Prevention, National Center for
HIV/AIDS, Viral hepatitis, STD, and TB Preventions June 28, 2007).
Additionally, for 2005, black women constituted 66 percent of the
female cases of HIV/AIDS (CDC HIV/AIDS Fact Sheet, June 2007).
Although Black men have the highest rates of HIV/AIDS for any
of the racial or ethnic groups in the U.S., HIV/AIDS is the leading
cause of death for Black women aged 25–34 (CDC HIV/AIDS Fact
Sheet, June 2007).
Studies of social context situate health-related behaviors
within the framework of the social meaning, social relations and
transactions of people’s lives (Abel 1991). It is critical to focus on
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understanding the social and cultural components of developing
healthy lifestyles. Williams, et al point out that African Americans
have the highest overall HIV prevalence, HIV incidence, and HIV
mortality as well as the greatest number of years of potential life lost
to this disease (2003:66). Sero-surveillance reports suggest that the
HIV incidence among African American men 25-44 continues to
increase and is particularly problematic for men who have sex with
men (MSM). Within this group the HIV incidence is 16.7% per year
compared to an incidence of 2.5% per year for white MSM in their
twenties. (MMWR, Valleroy et al. 2000).
Few health behavior surveys have been conducted at
HBCU’s. Notably, however, Taylor, DiLorio, Stephens and Soet,
(1997) reported that only 35% of students in their study reported
using condoms on a regular basis. Until the recent North Carolina
survey the only sero-prevalence study among college students was
published in 1990 (Gayle et al.). College students were considered
to be low risk although at least one publication suggested that
African American college students may be the next group affected
by HIV (Duncan C, Miller DM, Borskey EJ, Fomby B, Dawson P,
and Davis L 2002). For instance, Black females diagnosed between
ages 13 to 24 are twice as likely to contract HIV/AIDS through high
risk heterosexual contact as their male counterparts. Black females
diagnosed in this age group and risk category constitute 17.3% of
new cases compared to 7.7% of men. It is important to understand
the lived-experiences of these students as they negotiate a complex
array of choices within their social settings.
Within the past decade, programs designed to stem the tide
of this epidemic among African Americans have made little to no
significant headway (Williams, Ekundayo, Udezulu, and Omishakin,
2003; Smith, Gwinn, Selik, Miller, Gaitor, Maat, DeCock, and Gayle,
2000). In the African American community, positive results are
slow to be realized. Clearly, there are barriers to these efforts that go
beyond the individual biological and psychological considerations
of most intervention/risk reduction programs. Myers, et al (2003),
for example, point out that “[T]his underscores the need for more
aggressive and targeted risk reduction interventions for African
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American men . . . because they do not seem to be getting the
message about the need to be more sexually responsible” (p. 75). The
scope of these risk reduction programs has not been broad enough
in the African American community where, perhaps, cultural issues
are more likely to impact people’s willingness to participate in open
discussions of sexuality and sex, participate in support groups, and
other treatments that appear effective in other communities. Even
when these programs are focused on ‘community’ issues, the efforts
are directed toward individuals.
The National College Health Risk Behavior Survey (Fact
Sheet CDC, 1995) revealed that 79 percent of college students have
ever had sexual intercourse and only 37 percent reported having
used a condom during their last sexual encounter. However, this
same study found that black students take fewer risks than their
white counterparts. For instance, while about 10-percent of whites
fail to use seatbelts when driving, only about 8-percent of blacks fail
to use them. Additionally, about 31% of whites and only 15% of
blacks report that they drink and drive. Focusing on sexual risk-
taking, the national Youth Risk Behavior Survey of pre-college
students revealed that 62.5% of whites used a condom during their
last sexual encounter compared to 72.8% of black students – even
though black students were reported to have been more likely to
have had sex during high school than Whites. Based on an ongoing
health behavior survey first conducted of 1,302 first year students in
the Atlanta University Center (AUC) by the Morehouse School of
Medicine in 2004, 64% of female and 73% of male first-year students
reported having had sex at least once in their lives. Only 48% of the
females reported using a condom during their last sexual encounter
along with 54% of the males. We will explore this rather counter-
intuitive finding later in this paper.
Methods
The findings herein are based on a multi-modal data
collection strategy, including qualitative interviews and survey
research. We briefly describe these techniques. The Internet is an
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emerging research tool that is proving to be very useful in the social
and behavioral sciences. Most of the studies using the Internet rely
on quantitative survey methods. There are a few that have used it
for qualitative analyses. Focus groups and chat rooms are typically
the choice for qualitative data collection and analyses (see Burgess,
Donnelly, Dillard, and Davis 2001; Bowen, Williams, and Horvath
2004; Hudson and Bruckman 2004). The use of interviewing
strategies, such as the technique described below, is still in its nascent
stages of development (Davis, Bolding, Hart, Sherr, and Elford
2005).
The findings of this research are based on the collection
of data from five (5) predominately African American serving
institutions within a large southern metropolitan area with diverse
student bodies (hereafter called AUC) utilizing secure internet “chat
room” sites. The data reported herein is based on surveys and in-
depth chats with 37 students. Each interview averaged 2.25 hours.
Respondents were paid for their time and potential costs of internet
connectivity. Respondents are interviewed “one-on-one” by a trained
researcher using the Internet as the medium of communication. This
method assures complete anonymity for the respondent, thereby
encouraging open, honest, and frank discussions of material that
potentially could create an uncomfortable setting for the respondent.
Focus groups and dialog sessions were also held with students.
Additionally, more systematic data were collected by survey
methodology. The findings discussed below are based on an
annual survey completed by first-year students within the AUC.
The research protocol was approved by the Institutional Review
Board of the Morehouse School of Medicine. The questionnaires
were voluntarily completed in large “convocation” settings. While
the actual convocations were required, students were given the
opportunity to “opt out” if they did not want to participate in the
study. The majority of students completed the questionnaires;
however, the lack of privacy and the large group setting undoubtedly
had some impact on the quality of the data. The analysis below is
based on data from the first two years of administration (2004 and
2005). The number of students who voluntarily participated in the
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survey (2004 – 2005) was 2,021. The patterns of sexual involvement
correspond to other data from large surveys of college students. The
number of full time undergraduates at the five colleges (according to
published fact books from 2004 – 2006) is 8633. Of this group, 44
percent (3805) is male.
Results
Our multi-method approach yielded several key findings from
the survey analysis as well as important themes related to HIV/AIDS
risk reduction among African American college students. We will
give a brief overview of the survey findings then turn to our more
qualitative aspects.
We compiled data from surveys conducted of first year
students in the AUC in 2004 and 2005. These data are shown in the
tables below. Table 1 shows that males were significantly more likely
to report having had sex than their female counterparts. Overall,
about 63 percent of these first year students indicated that they
had had sex at least once in their lives (56% of females and 71% of
males).
Table 1
Have you ever had sexual
intercourse? Female Male Totals
NO 420
(44.4%)
245
(29.3%)
665
(37.3%)
YES 527
(55.6%)
590
(70.7%) 1117 (62.7%)
TOTALS 947 835 1782
X2 = 42.735, df = 1, p=.000
These data indicate that while a greater percentage of males begin
having sex at slightly younger ages than females, there was no
statistically significant association between gender and the reported
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age of first sexual intercourse. However, Tables 2 & 3 reveal that males
report a higher number of sexual partners than females (lifetime and
last 3 months).
Table 2
# Lifetime Sex
Partners Female Male TOTALS
1 partner 162 (22.6%) 90 (14.9%) 252 (19.0%)
2 partners 174 (24.2%) 122 (20.2%) 296 (22.4%)
3 partners 99 (13.8%) 87 (14.4%) 186 (14.1%)
4 partners 124 (17.3%) 90 (14.9%) 214 (16.2%)
5 partners 68 (9.5%) 71 (11.7%) 139 (10.5%)
6+ partners 91 (12.7%) 145 (24.0%) 236 (17.8%)
TOTALS 718 605 1323
X2 = 38.936 (df = 5) p= .000 / Gamma = .213 / p= .000
Table 3
# Sex Partners in
last 3 Months Female Male TOTALS
No partners 302 (43.1%) 199 (33.4%) 501 (38.7%)
1 partner 118 (16.9%) 134 (22.5%0 252 (19.5%)
2 partners 198 (28.3%0 154 (25.9%) 352 (27.2%)
3 partners 69 (9.9%) 57 (9.6%) 126 (.09%)
4 partners 9 (1.3%) 22 (3.7%) 31 (.02%)
5 partners+ 4 (.6%) 29 (4.9%) 33 (.03%)
TOTALS 700 595 1295
X2 = 45.008 p= .000 / Gamma = .149 / p= .000
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Interestingly, Table 4 indicates that males are more likely to report
having used a condom during their last sexual intercourse than are
females.
Table 4
Condom use the last
time you had sexual
intercourse Female Male TOTALS
NO 246 (34.8%) 193 (28.8%) 439 (31.9%)
YES 461 (65.2%) 478 (71.2%) 939 (68.1%)
TOTALS 707 671 1378
X2 = 5.770, df = 1 p=.016
We wanted to explore this finding a little more deeply. We
analyzed the responses to a 13-item Condom Attitude Scale (DeHart
and Birkimer 1997). The 13-item Condom Attitude Scale had a
mean of 29.69 and a Standard Deviation of 13.412. The Cronbach’s
Alpha coefficient was .9214-demonstrating very good reliability.
This analysis indicates that males, surprisingly, show more positive
attitudes towards condoms than those of our female respondents.
Additional analysis was conducted using multiple linear regression
to ascertain which variables impacted condom attitudes (see
Table 5 below). Surprisingly, neither the mother’s nor father’s level
of education nor parental income had a significant influence on
condom attitudes in this sample. Age at first sex and number of
lifetime sex partners significantly (and favorably) impacted attitudes
towards condoms. This finding reveals that men and more sexually
experienced students are more favorable towards condoms and
condom use. This may be the result of the socialization of males
to favor condoms as a means of disease protection in this collegiate
setting. Gender attitudes probably also help to explain this difference
as females are socialized to emphasize intimacy and closeness in
their relationships.
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TABLE 5
Condom Attitudes Beta Coefficients Significance
Sex (female = 1) B = -4.915 P = .000
Age of first sex B = 1.566 P = .000
Number lifetime
partners B = .820 P = .043
For women, this may prove to be a dangerous attitude given the
nature of the HIV/AIDS epidemic in the U.S. While the greatest
numbers of Blacks that are diagnosed with HIV/AIDS are between
the ages of 35 to 44, Blacks between the ages of 13 to 24 constitute
60.1% of all recent HIV/AIDS diagnoses. The Centers for Disease
Control and Prevention surveillance data reveal that the primary
modes of transmission among Blacks include MSM (men having sex
with other men, 30,154 new cases), high-risk heterosexual contact
(having unprotected sex with a person who is HIV+, 14,698 new
cases) and injection drug use (10,415 new cases). Black females
diagnosed between ages 13 to 24 are twice as likely to contract
HIV/AIDS through high risk heterosexual contact as their male
counterparts (CDC, 2002). Black females diagnosed in this age
group and risk category constitute 17.3% of new cases compared to
7.7% of males. The primary mode of transmission for Black males
diagnosed at ages 13 to 24 is MSM behavior (19.9%).
These quantitative findings are closely linked to the evidence
provided in our qualitative analysis of students from these campuses.
Careful analysis of indepth interviews, focus group sessions, and
student dialog sessions yielded a number of interesting themes that
provide contextualization of the findings expressed above. These
themes are important determinants of the socio-cultural context
of the AUC. Our findings are also consistent with other research
findings that examine traditional gender roles (see, for example,
Hill-Collins 2004; Cole and Guy Sheftall 2003; Roberts, McNair &
Smith 2004; Sobo 1995). Unpublished data from surveys conducted
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by one of the co-authors over the last two years also indicate that
“serial monogamy” and low or inconsistent condom use are common
among undergraduates in the AUC. This research will help to inform
approaches to risk reduction and HIV testing for young African
Americans inside and outside of the academy.
One of the main ideas promoting risky sexual activity on
this consortium campus was the popular media. In particular
these respondents focused on what they termed highly sexual
videos. They suggest that African Americans are more influenced
by the combination of the music and what is seen than their white
counterparts. These respondents see the media, not so much as
causing sexual activity, but at least promoting a carefree sexual
lifestyle. As one respondent said,
Yes, Media do influence my sexual thinking and
especially my behavior. Sex on TV is free. TOO free
sex is so simplified on TV, this makes it seem so cut
and dry. I feel that TV promotes the need and pressure
for sex….
Another respondent believes that “media encourage this behavior
and our generation is easily influenced.” An interesting conversation
centered on these videos and the movies that they [college age
students] tend to watch. They said that none of the videos or movies
ever show or suggest the use of protection in the sex scenes. They
move directly from some minimal foreplay to a naked scene in the
bed to the sleep scene or cut away to another shot.
Sex has been limited to just a normal human activity
for any age these days especially on videos and shows.
i guess its all cos of the change in the way we think and
our being able to be more outspoken than humans
were years ago. the media does influence our sexual
thinking and attitudes and behaviors in a way but then
i wouldnt put too much blame on them cos i think
each and everyperson has the responsibility to process
that information and interprete it as to whether they
want to go by what they have seen or live by statutes
that protect them.
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Another respondent makes comment on the amount of sexualized
imagery in contemporary media presentations:
There are a lot of shows on television, and in the
movies that promote having a lot of sex with a lot of
people, without having any regard to the safety of the
individuals involved. These depictions of glamorous
and desirable life stages do not present the realities of
sex and sexual encounters. Clearly, no one in these
movies gets an STI or HIV.
An important finding, captured in the students’ comments above
and that is revealed from many of these qualitative interviews is
the normalizing of risky sex. These respondents do not think that
media are setting out to increase risky sex among the viewers of these
images; however, the respondents clearly indict media for depicting
risky sex as normal. In this way, these respondents say, the media
presents sex in such a way that what would be seen ordinarily as
risky behavior is now normal, and even expected. One respondent
was particularly cogent on this point:
It encourages the thinking that promiscuity is not so
bad, and in fact is at times encouraged. And none of the
people represented with the popular media go out of
their way to promote safe sex. This heavily influences
college students, who emulate what they see more
than they would like to admit...like its nothing. Like
its money, and everyone should rush to get as much as
they can from as many different sources as possible.
These respondents point to many of the popular music videos and
some movies where there is no sense of safe sex. Actors are depicted
as having sex with multiple partners, without any indication of
condom usage. And, as pointed out by Hill-Collins (2004), the lyrics
and themes of the videos are also misogynist and patriarchal.
I think that since most young black males want to be
a “player” and try to have sex with as many women
as they can, causes diseases to be spread in our
community. I think that the media encourages this
behavior and our generation is easily influenced.
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And, as one male respondent put it, “they allow videos that exploit
sex(naked women).” Consequently, females are tacitly encouraged
and shown to be passive in sexual relationships.
Another theme that is clearly present from the data targets the
sex education received as a teen in high school and from home. We
see these focal socializing agents as integrally connected providing
both complementary as well as conflicting messages. Both agents
seem to be missing the mark on sex education of children. The
respondents agreed nearly unanimously that the standard approach
used in high school was ineffective. They said that high school sex
education tries to scare students away from sex while the realities are
not discussed.
It needs to start in the homes. I think the parents
needs to be knowledgeable about the dangers of
sexual behavior, so that they can relay the info to their
children. So there should be programs implemented
to inform the adults.
A 20 years old male respondent very directly assesses the problem:
Well, I think the fundamental factor lies in the
condition of the home. When I say family grounding,
I mean a person may lack parental reinforcement,
concerning sexual activity.
The men in the group said that the extent of the sex education received
at home was their fathers telling them do not get anyone pregnant
so wear a condom. One respondent said “my father started giving
me condoms in 6th grade.” Another respondent said that he felt his
father was telling him to have sex. His father told him that a “Viagra
erection” was somehow superior to the natural erection thereby
encouraging the use of drugs with his sexual encounters. (Note:
there is information surfacing about the use of Viagra in young men
for whom it is not prescribed and not recommended in combination
with other drugs including crack cocaine and methamphetamines).
One of the most frequently stated ideas about college life
among students is the notion of “freedom from parents.” They
indicate that college provides them with the freedom to engage in
all sorts of activities. Without a strong foundation about sex and
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sexuality, the likelihood of risky sexual behavior is enhanced.
We note that the majority of HIV prevention programs focus
on male-to-male sexual contact, male bisexual behaviors, injection
drug users, and low-income women considered “at-risk”. By default,
such efforts ignore the needs of Black college women attending
HBCU’s. Our evidence highlights that societal norms, cultural
productions, as well as the college environment itself encourage
sexual experimentation and all types of sexual negotiation. African
American women in college, many of whom arrive from inner cities
and single-parent households, are part of a most recent hip hop
generation that is besieged by misogyny, materialism and sexual
risk-taking. Many African Americans strive to overcome their
ascribed and inferior social status by constantly struggling against
widespread stereotypes and assumptions regarding their very being.
Their patterns of racial identity formation and maintenance influence
how they respond to such representations, even within intimate
relationships. The research herein reveals patterns of thinking
among students, both men and women, which need to be addressed.
A female freshman student reveals her thoughts in a focus group
setting:
It’s hard being a Black woman, you’re fighting off
negativity at every moment. You gotta be strong,
when you’re in the bedroom setting you don’t want
to fight anymore. You become submissive. You relax
and let things flow.
Findings in the AUC corroborate those of Foreman (2003). She
suggests that students used certain strategies to create philosophical
and emotional rationalizations for their behaviors. Women also rely
on a perceived level of commitment in their romantic relations to
determine safer sex practices. Forman also finds that students had
difficulty discussing condom use with sex partners and that many
perceived that they had low levels of HIV knowledge. Our findings
differed from those of Foreman in the area of HIV knowledge.
Respondents had relatively high levels of knowledge even though
many did not use condoms consistently. They were also less likely
than those in the Foreman (2003) study to cite material reasons for
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having unprotected sex.
A disturbing circumstance was noted in discussions with
many of the respondents. The main thrust of the issue centered on
attitudes towards risky sexual activity. When the question was asked
why college students might engage in risk-taking behaviors, the
respondents began a type of rational choice process in their responses.
They believe that they weigh (accurately) the risks and determine
that the risk is worth it. Of course, this position is wrapped up with
all the other notions of their sexual activities – from seeing images
in the media, to sex education in school and home. One respondent
summed it up this way: “I’d rather have sex and take the risk and
hope that I don’t get it [HIV/AIDS] than not to have sex.” Another
added: “we continue to have sex because we are scared that we may
not be able to have sex again.” Yet another respondent states that
“disease is not something we think about, we are young and figure we
have time to fix whatever may happen [based on current actions].”
All of these themes fall squarely into the category of invincibility or a
false sense of invulnerability. In other words, these college students
feel that they are incapable of suffering harm from their actions. All
of these behavioral factors appear to be linked to the sociocultural
constraints of the college experience.
Sociocultural Findings
Many of the conversations settled on concerns of a
sociocultural nature. For example, the respondents began to focus
on topics such as what it means to be a college student (particularly
at a black school). Many suggested that college life means that you
have to be having sex, and a lot of it. If you are not participating in
sexual activity, peer groups view you as a child. As one respondent
put it: “you’re told you’re not grown until you get a piece.” Many
of these students may be trying to gain some sense of adulthood
through risk-taking behavior. The links between college culture
and behaviors of the students, no doubt, are complex. Distressingly,
these respondents seem to navigate this complexity in ways that may
enhance the probability of risky sex. The college culture provides
the first sense of independence from parental control. Peer pressure
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may lure students to engage in activities so that one will not feel left
out or be seen as an odd-ball.
One of the most interesting conversations centered on the
idea of sex as a proxy for the need to feel loved. The interesting
thing about this conversation was that it was most often discussed by
the males in the sample. The discussion from these young males is
similar to literature suggesting that one of the reasons for underage
pregnancy is the girl’s need to feel unconditional love. She is able to
give love and have that love unconditionally reciprocated through
her dependent infant. It can be intoned from this discussion that
students are using sex as a stand-in or substitute for their need to
feel loved. Females are also socialized to emphasize intimacy and
continuity in their relationships. As Sobo (1995) suggests, this
need for intimacy increases the likelihood of sexual risk-taking
among working class women. Our findings suggest that this need
for intimacy among women may also contribute to less favorable
attitudes about condoms and less condom usage - especially in on-
going (vs. casual) relationships with their male partners (see Wade
2007). More investigation is needed to understand the mechanisms
of this phenomenon.
Discussion
Gender as Cultural Context
Cole (2005) aptly describes the HIV/AIDS epidemic among
black women as “a disease of mass destruction” (2005:51). She points
out the limitations of the “ABC trilogy” of prevention. For many
Black women, providing or “teaching” the facts about abstinence,
faithfulness and consistent condom usage (ABC) are not enough to
stem the tide of the epidemic given the societal issues that impact
the broader African American community. The issues of “infidelity,
rape, incest … secret bisexuality, fears of rejection and loneliness,
and serial monogamy” (2005:53) make it necessary to supplement
the ABC model with other approaches to risk reduction. Cole
agrees that it is crucial that Black women receive tailored and
“comprehensive sex education” (2005:57) in response to this set of
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issues. Such gender specific programs must: 1) Convey the gravity of
the HIV/AIDS epidemic to women; 2) Influence personal behaviors
and notions of responsibility (abstinence, alternative forms of
intimacy, risk implications of multiple partners); 3) Enhance women’s
sense of personal empowerment (self esteem, self efficacy, condom
negotiation skills), and 4) finally, emphasize HIV/AIDS advocacy to
overcome community apathy, fatalism and conspiracy theories.
Another question related to gender role expectations
and sexual risk-taking for women and men is how to combat the
“valorization of thug life, misogyny, homophobic violence, and a
constant need to prove one’s manhood” (Hill Collins, 2004:81 – 82;
Cole & Guy Sheftall, 2003). Such beliefs, norms and “contextual
factors influence sexual risk-taking” (McNair, 2004:107). These
factors include environmental stress, relationship history, perceived
victimization status, an imbalanced sex ratio – fewer available
partners and an attenuated ability for females to negotiate condom
use (McNair, 2004). In a setting with an unbalanced sex ratio, there
is considerable pressure on women to compete for the attention of
men. Further, Black women in college are less likely to date outside
of their race than men. Consequently, more attention must be given
to these environmental pressures within the framework of HIV/
AIDS prevention for HBCU students.
Although most intervention programs target the individual,
health behaviors can illustrate how the health problems of Americans
and especially youth are embedded in the social, economic and
political structures of society. Evidence suggests that prevention
programs need to begin early in life, before risk-taking behaviors
cement themselves as a part of people’s behavioral repertoires.
Holtzman and Rubinson (1995) observed the impact of parent versus
peer communication about HIV/AIDS among high school students
in the U.S. They found that students who discussed HIV with
their parents were significantly less likely to engage in risky sexual
behaviors and drug injection than their peers who primarily discussed
HIV with other students. Other studies have found convincing
evidence linking family organization and interaction styles to risk-
taking behaviors (see Walker, Vaughn, and Cohall 1991; Leland and
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Barth 1993). Strategies that facilitate development of pro-social
environments are needed to stem the tide of risk taking behaviors.
Uncovering the social and cultural elements of the lived experiences
of specific at-risk groups will provide much needed information for
positive interventions of their risky sexual behaviors. This type of
preparation for a productive life style may hold the most promise for
reducing unhealthy life choices and the negative outcomes that seem
to be endemic to many communities (see Stokes and Hodge 2000;
Harris, Duncan, and Boisjoly 2002).
Youth and Sexuality in the Age of HIV/AIDS
A study sponsored by The Kaiser Family Foundation/Children
Now initiative (1999) surveyed 348 children between the ages of 10
and 15 in an effort to understand where youth receive information
about subjects such as sex and AIDS. What the survey revealed was
that youth between 13 and 15 years rely on peers as much or more
than on parents for information on sex and sexual relations. For
example, the respondents were asked to whom they would likely talk
if they were thinking about sex. Over one-fourth (27%) responded
that they would talk to friends. When asked if they had ever talked
to their parents about a range of issues, 24% indicated they had never
talked to either parent about AIDS, 19% had not talked to either
parent about basic facts of sexual reproduction, 26% had not talked
about issues surrounding becoming sexually active, and 21% had
not talked to their parents about pregnancy or sexually transmitted
diseases. Respondents also indicated interest in knowing more
about issues concerning sex and its consequences. This and other
studies show that youth are indeed interested in issues pertaining
to reproductive health and health issues in general. Students come
to college campuses with these questions and issues still unresolved.
Many have already engaged in risky activities.
Social forces in the larger societal context operate to either
aggravate or attenuate the behaviors on the college campuses. For
instance, research indicates that African American adolescents
initiate sexual encounters, on average, at an earlier age than their
white and Hispanic counterparts (Bakken and Winter 2002). Most
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interventions, therefore, focus on information processing. The idea is
that the more knowledge students have about the negative outcomes,
the less likely they will be to participate in risky behaviors. Seminars
that provide factual information are clearly a necessary component
for reducing risky sexual activity; but they may not be wholly
sufficient. Programs that address the “cultural baggage” of students
are needed to complete the package for effective behavior change.
And, it is important that these programs are based on sound scientific
foundations. We are looking to delineate the social and cultural
structures that circumscribe the behavioral repertoires of these
actors; but, moreso, we seek to understand the inter-relationships
or interaction of the social context with the actor. In essence, we
examine the mutual interpenetration and interdependence of agent
and structure. We do not ask simply what are the social forces
impinging upon each actor; but, what are the actors’ perceptions of
these social forces as they negotiate the cultural milieu of on their
campuses.
Interaction of Culture and Individual
We believe that a major issue hampering effective
intervention on college campuses, particularly HBCUs, is the belief
that it is ultimately the individual that controls his/her behaviors and
is the author of one’s own fate. Yet, sociological theory holds that
individuality is constrained by social forces such as class, race, gender
and social institutions such as family, education, religion, and work,
among others. Factors relating to these social institutions must be
included when trying to implement behavioral change strategies.
Link and Phelan (1995), for example, demonstrate the connections
between family interaction dynamics and risky sexual behaviors.
Bakken and Winter (2002) show that there is an association between
family characteristics and age of sexual initiation as well as the
lifetime number of sexual partners (both variables that are important
in assessing sexual risk). Hence, consistent with long-standing social
science theory, the relationship between health-related behaviors,
risk and knowledge can be incorporated in studies of social structure,
social practices, and agency (Abel 1991).
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Social structure is defined as the factors involving individuals’
relationships to each other and the attendant power relations. Social
practices are the reflexive activities in which people engage to
make and transform the world. Agency is defined as the ability for
people to deploy a range of causal powers—to “make a difference
to a preexisting state of affairs or course of events” (Giddens 1984).
In-depth qualitative analysis of case studies is the only way to fully
assess the actor within the particular context of the college culture
(Burawoy 1991; Feagin, Orum, and Sjoberg 1991).
Ample evidence exists demonstrating the relationship
between social factors and effective health behavior intervention
strategies. For example, research has shown that carefully designed
interventions that take into account the socio-cultural context play an
important role in reducing risky behaviors of adolescents and young
adults for a variety of problem areas. Kirby et al. (1994) provide a
review of school based programs designed to reduce sexual risk taking
behavior among adolescents. They found that a number of programs
were able to successfully reduce risk taking behaviors. Additionally,
Frost and Forrest (1995) identified five programs that were successful
in either reducing rates of sexual initiation by young adolescents or
increasing the use of contraceptives for those who are engaging in
sexual intercourse. More recently, Stokes and Hodge (2000) examine
the effects of programs such as Upward Bound on the risk taking
behavior of adolescents. These studies and others demonstrate
the substantial influence social factors have as determinants of
health behaviors. For instance, Myers, Javanbakht, Maritinez, and
Obediah (2003) examine the behavioral, demographic, social, and
psychological factors that may be associated with high sexual risk
activities. They find that for heterosexual African American males,
social support provided significantly deacreased risk-taking activities.
In other words, for every mean point increase in social support
there was an associated 2.3% decrease in the likelihood of risky
behaviors among this population group. A recently published study
examined the influence of social context on individual behaviors
that may place people at risk for negative health outcomes (Adimora
and Schoenbach 2005). These researchers found important socio-
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cultural factors that may put African Americans at greater risk for
STIs and HIV. They find that sharply contrasting social settings for
blacks and whites, particularly in their social networks, is likely to
maintain the gap in HIV rates. They note that overlapping sexual
partners is more prevalent among blacks. A lot of this finding can be
traced to contextual factors such as incarceration rates of black males,
segregation, and poverty. The study of sexual networks on Black
College Campuses has not been done, to date. Numerous studies
of college students have explored the relationship of knowledge
about HIV and risky sexual behavior (see Parsons JT, Halkitis PN,
Bimbi D, Borkowski T; Bazargan M, Kelly EM, Stein JA, Husaini BA,
Bazargan SH 2000; Dilorio C, Dudley WN, Soet J, Watkins J, Maibach
E. 2000). In many studies knowledge of HIV is not correlated with
safe sex practices (Valentine PA, Wright DL, Henley GL. 2003; Lewis
JE, Malow RM, Ireland SJ 1997) and interventions based on social
cognition models have had limited success in changing risky sexual
behavior (Ogden 2003). Other researchers have suggested the need
to integrate social group process into cognition models for youth and
young adults (Schofield PE, Pattison PE, Hill DJ, Borland R. 2003;
Young RA, Lynam MJ, Valach L, Novak H, Brierton I, Christopher
A. 2001). Several scholars have noted the importance of social
factors and culture on sexual health behaviors of African Americans
(Plowden K, Miller JL, James T. 2000; Plowden KO, Young AE 2003).
College campuses provide an interesting social setting where lives are very
closely intertwined on a number of levels.
Conclusion
Students work, live, play, etc. in a very small space and issues
of privacy are heightened by this type of organic density. These
concerns are particularly salient on Historically Black Colleges and
Universities where there is greater density than on traditionally larger
majority campuses (literally, everyone is, at minimum, familiar to
everyone). Institutional culture develops and changes as the nature
of the interactions of its members adjust to social forces from inside
and outside the institution. The findings chronicled herein, at least,
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begin to focus much needed attention on the dynamic interplay
among students at historically black colleges and universities. Given
the cultural baggage African Americans bring with them to college,
the lack of (or inconsistent) parental information provided to youth
regarding sexual relationships and the inconsistent condom use
among HBCU and other college students, it is crucial to provide
students with culturally specific risk reduction programming that
addresses the lack of risk knowledge, erroneous and problematic
early life socialization about intimacy and relationships, and the
gender imbalances in intimate relationships.
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REFERENCES
Burawoy, Michael, et al 1991. Ethnography Unbound: Power
and Resistance in the Modern Metropolis. Berkeley:
University of California Press.
Campbell, Carole A. 1999. Women, Families and HIV/
AIDS: A Sociological Perspective on the Epidemic in
America. Cambridge:Cambridge University Press.
Centers for Disease Control and Prevention 1997. “Youth Risk
Behavior Surveillance: National College Health Risk Behavior
Survey United States, 1995.” MMWR (46): 1 – 56.
Centers for Disease Control and Prevention 2001. “U.S. HIV and
AIDS Cases Reported Through December 2001.” HIV / AIDS
Surveillance Report 13 (2).
Centers for Disease Control and Prevention 2004. “Methodology of
the Youth Risk Behavior Surveillance System.” MMWR (53):
1 – 13.
Centers for Disease Control and Prevention 2007(b). “Update to
Racial / Ethnic Disparities in Diagnoses of HIV / AIDS – 33
States, 2001 – 2005” MMWR 56(9):189 - 193.
Centers for Disease Control and Prevention 2007. “Cases of HIV
Infection and AIDS in the United States and Dependent
Areas, 2005.” HIV / AIDS Surveillance Report 17 (June, 2007).
Cohen, Sheldon; Tom Kamarck; Robin Mermelstein 1983. “A
Global Measure of Perceived Stress.” Journal of Health and
Social Behavior, Vol. 24 (4): 385-396.
Cole, Johnnetta Betsch and Beverly Guy Sheftall 2003. Gender
Talk: The Struggle for Women’s Equality in African American
Communities. New York: Ballantine Books.
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Cole, Lorraine 2005. “The Politics of HIV Prevention and Black
Women.” The Harvard Journal of African American Public
Policy 11 (summer): 51 – 62.
DeHart, D.D. & Birkimer, J.C. 1997. “Trying to Practice Safer Sex:
Development of the Sexual Risk Scale.” The Journal of Sex
Research 34: 11 – 25.
Foreman, F.E. 2003 “African American College Women:
Constructing a Hierarchy of Sexual Arrangements.” AIDS
Care 15: 493-504.
Foreman, Faith E. 2003. “Intimate Risk: Sexual Risk Behavior
Among African American College Women.” Journal of Black
Studies 33(5):637 – 653.
Hill Collins, Patricia 2004. Black Sexual Politics: African Americans,
Gender, and the New Racism. New York: Routledge.
Roberts, George W., McNair, Lily D. & Smith, Dawn 2004.
“Introduction” The Journal of Black Psychology 30(1):5 - 10.
Sobo, E.J. 1995 Choosing Unsafe Sex: AIDS-Risk Denial Among
Disadvantaged Women. Philadelphia: University of
Pennsylvania Press.
Stokes, Carla E. and Gant, Larry M. 2002. “Turning the Tables
on the HIV / AIDS Epidemic: Hip Hop as a Tool for Reaching
African American Adolescent Girls.” African American
Research Perspectives 8(2) :71 – 81.
Taylor, S.E., DiLorio, C., Stephens, T.T. and Soet, J.E. 1997. “A
Comparison of AIDS-related Sexual Risk Behaviors Among
African-American College Students.” Journal of the National
Medical Association 89(6): 397-403.
U. S. Department of the Census 2000 Table P34B FAMILY TYPE
BY PRESENCE AND AGE OF OWN CHILDREN (BLACK
OR AFRICAN AMERICAN ALONE HOUSEHOLDER) [20]
downloaded from www.census.gov February 2, 2008.
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36 Challenge
Wade, Bruce H. 2007. “The Disabling Nature of the HIV / AIDS
Discourse Among HBCU Students: How Postcolonial Racial
Identities and Gender Expectations Influence HIV Prevention
Attitudes and Sexual Risk-taking.” in WAGADU: A Journal
Transnational Women’s and Gender Studies Volume 4 (sum-
mer): 125 -141.
Wingood, Gina M., DiClemente, Ralph J., Bernhardt, J. M.,
Harrington, K., Davies, S. L., Robillard, A. and Hook, E. W.
2003 “A Prospective Study of Exposure to Rap Music Videos
and African American Female Adolescents’ Health.” American
Journal of Public Health, 93, 437–439.
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Intersection Between Race, Gender, and Sexual Risk:
Implications for STI/HIV on HBCU Campuses
____________________________________________________
Sinead N. Younge,1
Deidre Smith,2
Lawrence Young,1
Daphne Cole,2
Danielle Dickens,2
Lauren Reynolds,2
Raqiyah Dixon,2
Wilton Robinson,1
Porsche N. Buchanan,2
_________________________________________________________
Abstract
There is a disproportionate incidence and prevalence rate of
Human Immunodeficiency Virus (HIV) among African Americans.
HIV/AIDS is one of the leading cause of death among Blacks,
aged 25-44. It is likely that many of these individuals contracted
HIV while they were college aged. Black college students are an
understudied group. The behaviors of college students in general,
and the combination of environment and individual behaviors,
warrants further investigation of sexual risk behaviors among Black
college students. Furthermore, it is important to understand both
the risk and protective factors that different environments may
play. A substantial number of Black students attend Historically
Black Colleges and Universities (HBCUs), which have purported
to have protective affects on risk behaviors. This paper will give a
cursory review of the sexual risk literature of Black college students
and identify some of the risk and protective factors associated with
HBCUs.
________________________________________
1 Department of Psychology, Morehouse College
2 Departments of Psychology and History, Spelman College
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Introduction
While African Americans comprise approximately 13% of
the U.S. population, they have higher incidence and prevalence rates
of acute and chronic diseases, and overall poorer health outcomes in
comparison with other racial groups. Nowhere are these disparities
more evident than in the HIV/AIDS epidemic. Identified by the
Centers for Disease Control and Prevention (CDC) in 1981, the
human immunodeficiency virus (HIV) emerged in U.S. metropolitan
cities among large numbers of homosexual males or men who have
sex with men (MSM) and intravenous drug users (IDUs). These
early cases led individuals to believe that HIV, which was originally
coined as gay related immunodeficiency disease (GRID), mostly
affected gay White males.
Much of the early prevention efforts targeted the gay
community and despite CDC data suggesting that Blacks1 may be at
an increased risk for the disease as early as 1982, African Americans
did not become a high priority group for prevention efforts until the
1990s. This early lack of focus and prevention efforts on communities
of color may have indirectly influenced the increasing HIV incidence
and prevalence rates among people of color and specifically, African
Americans, while the rates of other groups began to decline or
stabilize (CDC, 2007). Once Blacks became a high priority group for
research and surveillance, the majority of research focused on low-
income, urban, or intravenous drug using populations despite the
fact that the risk behaviors of other segments of the Black population
(i.e., college students) placed them at increased risk for sexually
transmitted infections (STIs) including HIV, and it is likely that a
substantial proportion of African Americans contracted HIV while
in college (Ferguson, Quinn, Eng, Sandelowski, 2006). This paper
will: (1) provide a cursory overview of the current literature on the
understudied Black college student population, (2) the unique
___________________________________________
1 For the purposes of this paper, the labels African Americans and Blacks will be
used interchangeably.
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influence that HBCUs can have on risk and protective factors, and (3)
examine how previously identified factors such as gender, race, and
sexual risk intersect to play a role in the behaviors of Black college
students.
Blacks and HIV/AIDS
In 1992, 11 years after the CDC’s identification of HIV, Blacks
were 3.5 times more likely to contract AIDS than Whites and Black
women were 13.8 times more likely to contract AIDS than White
women (Jenkins et al. 1993). Eighteen years later in 2005, Blacks
accounted for 49% of the new HIV/AIDS diagnoses (CDC, 2007).
In 2005, Blacks were 10 times more likely than Whites to have an
AIDS diagnosis and Black women were 23 times more likely than
their White counterparts to have an AIDS diagnosis. Among Blacks,
men who have sex with men remain the primary risk group for HIV
followed by IDUs, and high risk heterosexuals (CDC, 2007). As of
2002, HIV was the second leading cause of death for individuals aged
25 to 44 (CDC, 2007). The majority of these individuals probably
contracted HIV when they were college age.
Moving Beyond the Biomedical Framework
Researchers have speculated about the multiplicity of risk
factors that place Blacks at increased risk for HIV. Diverging from
the biomedical model, the CDC reports that race and ethnicity
alone are not risk factors for HIV infection. The second generation
of HIV/AIDS research examines sexual risk behavior from an
ecological perspective, examining how individuals interact with their
environments and the resulting behaviors. Increased susceptibility
to HIV is a function of behaviors, environment, and predisposing
physiological conditions such as the existence of ulcerative and non-
ulcerative STIs that make individuals biologically more susceptible to
contracting HIV by compromising the mucosal barrier that normally
protects against infection (Berman & Cohen, 2006; Clan, 2006).
Despite comparable or higher rates of condom use reported between
Blacks and Whites, Blacks remain more likely than Whites to have
an STI which increases one’s chance 3 or 5 fold of contracting HIV
(CDC, 2007; Quinn, 1996). This finding of similar rates of condom
use among some Blacks and Whites, but higher rates of STIs among
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Blacks is purported to result from other social and economic factors.
For instance, Blacks have historically had less access to healthcare
including early diagnosis and treatment of STIs, mistrust of the
medical establishment, higher rates of intravenous drug use, higher
rates of incarceration, and a male-female sex ratio imbalance which
may result in serial monogamy, or shared partner networks, power
imbalances in relationships, homophobia, and risky social norms
(Ferguson et al., 2006). Combined, all of these factors place Blacks
at higher risk than their White counterparts for contracting an STI/
HIV.
The majority of early research on Blacks and HIV has
examined the proximal determinants of HIV and has taken a deficit
perspective, focusing on the individual risk behaviors. Individual
risk factors alone, to not explicate the disparate rates of HIV among
the various racial and ethnic groups. As previously mentioned, there
are a number of environmental or contextual factors to take into
account. Additionally, there are inherent strengths within the Black
community that can act as protective factors against sexual risk.
Discourse on HIV is incomplete without an examination of both the
risk and protective factors that influence sexual behavior.
Black College Students
Black college students represent only one segment of the
heterogeneous Black population. Research on Black college students
can provide invaluable information about the 14% of African
Americans over the age of 25, who hold a B.A. degree (U.S. Bureau
of the Census, 2003). HBCUs enroll 13% to 14% of all Black students
in higher education in the U.S., although they constitute only three
percent of America’s institutions of higher education. In 2001, more
than one-fifth of all bachelor’s degrees awarded to Blacks were from
HBCUs (Provasnik & Shafer, 2008). Despite the high risk behaviors
of college students in general, Black college students remain an
underrepresented and understudied group. Blacks are often indirectly
studied in small sample sizes as part of larger studies of the general
college population at predominately White institutions (PWIs). When
Blacks are the sole focus of a study, the risk and protective factors of
these community and clinical (often low-income or IDU samples),
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may not be generalizable to the experiences of other segments of
the Black community (i.e., college educated samples). Although
extensive epidemiogical studies of the general college population
are lacking, one early study speculated that the rate of HIV among
college students is 2 per 1,000 students and are purported to be
even higher among Black college students (Gayle, Keeling, Garcia-
Tunnon, Kilbourne, Narkunas, Ingram et al., 1990).
Adolescents and Risky Behaviors
The 2005 national survey of 9th through 12th grade U.S.
public and private school students known as the National Youth
Risk Behavior Surveillance (YRBS). Study reported that Black high
school students were more likely to report having ever had sexual
intercourse, having sexual intercourse before the age of 13, having
more lifetime partners, being currently sexually active, and less likely
to report using a condom the last time they had sex in comparison
with their White counterparts. However, Black students were less
likely to report using a number of illicit substances and having
had an episode of heavy drinking, than their White counterparts
(YRBS, 2006). These risk behaviors often carry over to the college
years. It is estimated that greater than 80% of all college students
are sexually active by their freshmen year, and less than half use
condoms consistently (Fisher, Spurlock-McLendon, DelGado, &
Melchreit, 1999; Lewis, Malow, & Ireland, 1997). Previous studies
suggest that college students in general, consistently engage in high-
risk behaviors including inconsistent condom use, illicit substance
and alcohol use during sex, and sex with multiple partners (Hightow,
Leone, MacDonald et al., 2006).
HBCUs in the Forefront
The current interest in HBCUs and their roles in the HIV
epidemic was stimulated in 2003 when the CDC published a report
entitled “HIV Transmission Among Black College Student and
Non-Student Men Who Have Sex With Men.” Based on the findings
from this retrospective study conducted by the North Carolina
Department of Health with the assistance of the CDC, researchers
and the general population began to speculate about the role that
men who have sex with men (MSM) played as vectors in the HIV
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epidemic among African American women. The discussion over
MSM became even more publicized in the popular media with the
2004 release of J.L. King’s book, “On the Down Low: A Journey
into the Lives of “Straight” Black Men Who Sleep with Men.” The
term downlow has been in existence in the Black community for a
number of years, but it is currently used to describe the behavior of
men who have sex with other men as well as women (MSM/W) and
do not identify as gay or bisexual. While some women have been
infected through intercourse with bisexual men, there is simply not
enough empirical evidence to confirm this claim as a major route
of transmission (CDC, 2007). Despite the misguided efforts of the
mainstream media to assist Black women in identifying or revealing
non-identified MSM/W as the main scapegoats in the contemporary
HIV/AIDS epidemic in the Black community, Black MSM continue
to have the highest risk for contracting HIV of all groups, and there
remains a lack of understanding of this “difficult to reach” and often
misunderstood group.
Black men who have sex with men
The White gay community has effectively mobilized and
organized HIV education and prevention efforts to reduce HIV
incidence rates. In contrast, the Black gay community is not as
visible and cohesive. Hence there is a significant proportion of
Black MSM who, due to racial, cultural, or religious reasons, do not
embrace a “gay identity.” Racism, cultural beliefs about masculinity,
sexual orientation, and religious doctrine (which often condemns
homosexual behavior) decrease the desire to take on the label of
“gay.” Therefore, researchers have focused on the behavior of ‘men
who have sex with men,’ rather than the identity of being gay.
With the advent of the internet including chat rooms
and networking sites, Black MSM may find it easier and more
comfortable to meet and interact with other MSM with a certain level
of anonymity and confidentiality. Consequently, the internet also
exposes individuals to a high number of potential sex partners with
various HIV risk statuses. This perceived anonymity may sometimes
cause individuals to engage in riskier behaviors-behaviors in which
they would not typically engage. Consequently, the internet becomes
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a new frontier for researchers to recruit and understand sexual risk
behaviors under different social networks.
Individuals are often first exposed to vastly new social
networks during their college years. Coincidently, college becomes
a time when individuals of all sexual orientations may attempt to
exercise their new independence and autonomy and engage in
sexual exploration and experimentation and/or practice safer sexual
behaviors including abstinence, monogamy, and consistent condom
use (Foreman, 2003).
Black Heterosexual Males
An area of research that is receiving an increasing amount
of attention is heterosexual African American male behavior.
Researchers have long claimed that men are likely to be more casual
than women in their sexual behaviors and to engage in greater
sexual risk taking (Poppen, 1995). However, research indicates that
gendered sexual risk difference is complicated and context specific.
There are a number of sociocultural factors that influence the sexual
risk behaviors of Black heterosexual males.
Traditional gender roles dictate that men be the initiators of
sexual activity and many of the HIV prevention campaigns that target
women, hold this supposition. However, there is evidence that men
will engage in unwanted sexual activities because of their partner’s
tactics (Russell & Oswald, 2002; Struckman-Johnson, 1988). The
types of sexual coercion by women may differ than the type of male
initiated sexual coercion. Interestingly, some studies estimate that
up to 44% of male college students reported being the recipient of
a sexually coercive tactic (Russell & Oswald, 2002). Moreover, male
initiated sexual coercion tactics are more likely to be viewed as
threatening or capable of doing harm than women initiated sexually
coercive tactics which may be viewed as promiscuous (Oswald &
Russell, 2006). Unlike males who may be more likely to use alcohol,
verbal, or physical strategies, women are more likely to use verbal
tactics. Black males who are sexually coerced by women may have
their masculinity questioned, and feel the need to have to prove their
manhood through sexual acts, although more research in this area is
needed to support this assertion.
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Despite engaging in high-risk activities, college students
(including Black college students) have a low subjective perception
of HIV risk (Payne, 2006). In a qualitative study conducted by
Thompson-Robinson and colleagues (2007) of the perceptions
of heterosexual (N=57) African American males’ high risk sexual
behaviors, participants reported partner attractiveness, being in
love, sensation seeking, substance use, knowing that another man
had sex with a woman and did not contract a disease, and physical
arousal as some reasons why heterosexual African American males
may engage in unprotected sexual intercourse. When asked about
cultural influences on African American males’ sexual behaviors
and practices, the participants reported that their friends and
acquaintances, media, and spirituality all influenced sexual behavior.
While religious doctrine was reported as influencing sexual decisions
and behaviors, concerns regarding pregnancy and acquiring HIV
or other STIs also acted as deterrents to risky behaviors. In a 2003,
qualitative study of Black college women (n=15), similar findings
as those of Thompson-Robinson and colleagues, were reported.
Participants reported sensation seeking or pleasing their partners as
a primary reason for not using condoms.
In a longitudinal, within group, cluster analysis of the
heterogeneity patterns of sexual risk behaviors among African
American youth, Burrow and colleagues (2007) found that patterns
of sexual risk were related to lifetime psychiatric diagnoses, which is
consistent with previous research in this age group (Shrier, Harris,
Kurland, & Knight, 2003). African American are overrepresented in at
risk populations that are susceptible for compromised mental health
due to economics, incarceration, foster care, exposure to violence,
access to health care (SAMHSA, 2008) therefore, prevention efforts
need to target these groups specifically.
Black Heterosexual Women
The HIV epidemic does not uniformly affect African
American women. Instead, the increasing incidence rates are most
commonly found among women of lower socioeconomic statuses
and hence most of the research has focused on this group. Few studies
have examined the risk factors of African American women college
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students. One sociocultural factor that transcends social strata is
interpersonal power. Interpersonal power has demonstrated to be
necessary to engage in HIV protective behaviors within the context of
dyadic relationships and there exist a number of cultural factors that
are hypothesized to intersect and predict interpersonal relationship
power in relationships that are generalizable to all women.
Wingood and DiClemente’s (1998) Expanded Theory
of Gender and Power (TGP) explains how interpersonal power
influences HIV protective behavior among African American
women, while taking into account the intersection of culture, gender
relations, and various traditional cognitive behavioral factors.
Namely, among Black college students, these power imbalances may
be less influenced by threats of violence, gender and peer norms,
perceived sex ratio-imbalance, and the desire to be in a relationship,
also known as the structure of Cathexis in TGP. Foreman (2003)
found that Black college women would rather relinquish their power
to engage in safer sex and give in to their own or a partner’s needs
or desire, than engage safer sexual behavior. In Foreman’s study,
participants reported that their longing for intimacy and desire for
a long-term relationship overshadowed or even compromised their
risk reduction (e.g., condom negotiation) capabilities (Fullilove,
Fullilove, Haynes, & Gross, 1990). This compliance with partners’
actual or perceived preferences may be a result of the gender ratio
imbalance articulated early in the HIV epidemic by Mays and
Cochran (1988) and Fullilove and colleagues (1990).
The gender ratio imbalance among Blacks exists in the
general society and particularly among Black college students, with
Black females outnumbering Black males for the last several decades.
The actual and perceived gender ratio imbalance, is purported to
result in men having multiple sexual partners and women having to
decide whether or not to accept this and perhaps knowingly engage
in the act of man sharing (Fergueson et al., 2006). An additional
consequence of the gendered sex ratio imbalance may be women
who engage in serial monogamy in hopes of securing an intimate
relationship while increasing their number of lifetime sexual partners,
and in turn increasing their risk of contracting an STI. Subsequently,
African American college women have reported being more likely to
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engage in risky sexual behaviors such as condom non or inconsistent
use, when they were in a committed romantic, sexual relationship
(Winfield & Whaley, 2005).
Gender Roles
Another influential social construct is gender roles which
set up different sexual expectations for men and women. While
biological gender differences transcend race, class, and sexual
orientation, gender roles are socially constructed and may vary
depending on cultural norms. In general, gender roles dictate that
men initiate sexual activity and women are suppose to resist or limit
sexual activity and be more concerned with romance and affection
than sex (Peplau & Gordan, 1985). Although children are socialized
to various gender role norms and expectations based on their cultural
mores, the college years are a time of exploration during which ideas
about gender are particularly salient and may shift according to the
environment. College students may be exposed to mainstream and
more common stereotypes in new domains such as generalizations
about masculinity and femininity in dating relationships.
Traditionally defined gender roles within the confines of a
relationship can have a significant impact on how individuals engage
in sexual encounters. Traditional gender roles can influence sexual
coercion or intimidation, which has been identified as a serious issue
on college campuses (Owald, 2005). Though much of the initial
research focused on men as the aggressor, recently, researchers have
begun to acknowledge that women also behave in a coercive manner
in their sexual encounters (Oswald & Russell, 2005). There is evidence
that people judge men and women differently when they engage in the
same aggressive behaviors (Oswald & Russell, 2005). Subsequently,
there is a double standard in how individuals of different genders are
perceived. Women who are sexually assertive or who carry condoms
may be viewed as promiscuous. Conversely, men who refrain from
sex or are not assertive may have their masculinity questioned. In a
recent study conducted by Shearer (2005), the more men endorsed
the idea that men should not behave in a feminine manner, the
greater their likelihood of engaging in risky sexual behavior.
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Substance Use
In addition to the psychosociocultural factors that influence
sexual risk behaviors, there are salient biological factors that place
African American youth at increased risk. There is a well established
behavioral and biological link between sexual risk behaviors and
substance use including alcohol and other drugs (AOD). Individuals
who abuse alcohol and other substances have demonstrated to be at
increased risk for STIs including HIV (CDC, 2007). This relationship
between substance use and increased risk for STIs can be caused by
using substances which impair decision making, and/or comprising
immune system functioning and in turn, cause individuals to be
more susceptible for contracting an infection.
As previously noted, college is often a time of sexual
exploration, and exploration/ experimentation with various
substance. The aforementioned 2005 YRBS also examined substance
use behavior in a national survey of 9th through 12th graders. Black
students reported lower rates of cigarette smoking, lifetime and
current prevalence of alcohol use, and all other illicit substances in
comparison with their White counterparts (YRBS, 2006). Studies
confirm that students at HBCUs and African American students in
general drink substantially less and suffer fewer consequences than
do students at predominantly White institutions (PWI). Researchers
purport that the disparity in alcohol consumption appears to
be strongly related to protective factors such as HBCUs’ general
emphasis on character development in their institutional missions
and possibly, their enrollment of many students with strong religious
values and their own religious foundations (Kapner, 2003). The
environment at HBCUs may mitigate against the “culture of drinking”
and other substance use found on many PWI campuses (Kapner,
2003). However, evidence suggests that Black students who attend
PWI, also have lower rates of substance use in comparison with their
White counterparts therefore, the protective factors may exist prior
to entering college and be reinforced on HBCU campuses.
In a 2003 study of marijuana use at two HBCUs, Bowen-
Reid and Rhodes found that 52% of their sample reported at least
one instance of lifetime marijuana use. Twenty five percent of their
sample reported starting to smoke between the ages of 15 to 17,
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while 16% of their sample reported starting to smoke marijuana
in college. Approximately 6.5% of the sample reported smoking
marijuana daily. Gender differences also exist, males were more likely
than females to smoke marijuana. The findings from this study also
demonstrated that lower rates of marijuana use were related to higher
levels of spirituality. Therefore, as previously noted, spirituality has
demonstrated to be a protective factor against risky sexual behavior
and substance use. Researchers are increasingly interested in the role
of protective or factors that buffer against adverse health behaviors.
If identified, these factors can be instrumental in developing effective
prevention interventions. Among a number of identified protective
factors are the family, social support, and spirituality and religiosity.
Role of the Family
Parents play a critical role in shaping their children’s
behaviors. “Generally, the role of the family is to act as the primary
socialization agent and provide support and codes of conduct for
social competence for children within a given network” (Younge &
McAdoo, in press). Traditionally, Blacks adhere to a communalistic or
collectivist worldview and the Black family has been identified as one
of the most enduring strengths in the resiliency of Blacks (McAdoo,
1992). Additionally, the Black family has been purported to act as
a buffer or protective factor against “menacing societal stimuli”
(Hayles, Bell, Evans, Floyd, Monteiro, Daniels & Harrell, 2004, p.
410). Previous research demonstrates that parents exert more power
on the behavior of adolescents, than previously thought (Hutchinson
& Montgomery, 2007). Parental factors that influence risk behaviors
include parent-teen closeness, social support, parental monitoring,
parental expectations, and parent-child communication (Jaccard,
Dittus, & Gordan, 1996; DiClemente, Wingood, Crosby, Cobb,
Harrington, Davies, Hook, & Oh, 2001; Li, Feigelman, & Stanton,
2000; Miller et al., 1999; DiLorio, Kelly, & Hockenberry-Eaton, 1999;
Dutra, Miller, & Forehand, 1999, St. Lawrence, Brasfield, & Jefferson,
1994).
Some studies have shown that children will refrain from
certain risky behaviors (e.g., substance use) for fear of disappointing
their family and communities (Jordan, 2001). Black parents often
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encourage their children to surpass the achievements of previous
generation and children are commonly informed of the sacrifices
made by their parents and prior generations. These expectations
can enhance an investment in future orientation. Constructs such
as future orientation or ‘planning for tomorrow,’ has demonstrated
to positively predict African American college women’s condom
frequency. “Using condoms in the present provides an individual
with a safeguard against possible negative future consequences
associated with failure to use condoms consistently during sexual
activity” (Burns & Dillon 2005:184).
Previous research has demonstrated that parental monitoring
plays a critical role in the decrease of risky sexual behavior among
adolescents (DiClemente et al., 2001). As individuals transition to
college, parental monitoring becomes inconsequential and “social
ties to family and other social institutions that promote conventional
norms” (Voisin et al., 2006, p. 72) may act as a buffer for risky sexual
behaviors. Another study examined parental influences on the
sexual risk attitudes, beliefs, and behaviors of African American,
late adolescent HBCU students (Hutchinson & Montgomery, 2007).
The results demonstrated that female students had a greater amount
of parent-teen sexual risk communication with their mothers, in
comparison with male students. As expected, male students reported
greater parent-teen sexual risk communication with their fathers
in comparison with female students yet there were no significant
differences between males and females in the total amount of
communication from parents. Students who reported higher levels
of communication also reported feeling closer to their parents
during their high school years, and a greater perceived importance
of their parent’s opinions. This research indicates that an increase in
mother sexual communication is associated with more conservative
attitudes towards sex by students and less difficulty discussing sexual
topics with their partners. Greater communication with fathers has
also been associated with more positive attitudes toward condom
use among female students and less difficulty discussing condoms
among male students.
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Media Influences
In addition to parents, the media is influential in framing
individuals’ (particularly adolescents) perceptions and images
about how relationships should and do function. Relatively little
research has examined whether exposure to sex in the media has a
long-term impact on teens’ sexual behavior. In a recent longitudinal
study conducted by Brown and colleagues (2006), researchers
assessed whether early Black and White adolescents (aged 12 to
14) who have more exposure to media were more likely than those
with less exposure to media to have more advanced precoital and
coital behavior by middle adolescence? Their findings indicated
that younger adolescents with the highest exposure to sexual media,
were 2.2 times more likely than older adolescents to have had sexual
intercourse. In their study, Black adolescents’ sexual activity was more
likely to be influenced by parental expectations and peer behavior,
than media influences. This is consistent with the aforementioned
influence of the Black family.
Currently, one of the most popular and influential
entertainment mediums is hip-hop or rap music. Although hip
hop has gone through several major iterations, the latest ongoing
debate regarding its depiction of African American lifestyles
remains controversial. Most recently, the misogynist portrayal of
women in some music videos, television shows, and movies has
been publicized and criticized. One of the major concerns of most
critiques is the youth who are influenced by certain propaganda
and ascribe to the stereotypical roles being portrayed. Thompson-
Robinson and colleagues found that the media had an impact on
the sexual behaviors and perceptions of HIV risk among their Black
male, college participants. One male participant reported that the
images of females in the music videos had an ”impact on one’s
psyche” and if a rap artist was not having sex with all of the women
in their [videos], they were “less of a man” (Thompson-Robinson et
al., 2007, p. 162). The use of certain aspects, such as sex, fame, and
glamorization of the hip-hop culture is used as a medium to promote
the sale of products and lifestyles. The inability of some young people
to discern entertainment from reality becomes even more troubling
and results in the emulation by both men and women, to behave
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in a manner which is consistent with certain aspects of some hip
hop artists (i.e., the objectification of women as being hyper sexual,
and men as abusive, the glamorization of casual sex, promiscuity,
substance use), with little attention to consequences such as the
acquisition of STIs. Another study of African American female
adolescents sought to determine whether perceiving portrayals of
sexual stereotypes in rap music videos was associated with adverse
health outcomes including substance use and sexual risk behaviors
(Peterson, Wingood, DiClemente, Harrington, & Davies, 2007).
Peterson and colleagues demonstrated a relationship between
increased perception of sexual stereotypes and binge drinking,
marijuana use, multiple sexual partners, and negative body image.
It appears that exposure to rap videos had a negative impact on the
health behaviors of African American adolescent girls. However,
these findings must be cautiously interpreted and it must be noted
that this study can not determine the direction of the relationship
such that does rap have an affect on health, or does one’s sexual
behavior influence how they perceive rap music? Given the current
age of technology, it is apparent that the media’s influence health
behavior warrants further investigation.
Conclusion
In accordance with the recognition that individual level,
proximal factors such as beliefs, knowledge, attitudes, and behaviors
alone do not sufficiently explain the disproportionate burden
of HIV/AIDS on African Americans, researchers have begun to
look to environmental or contextual factors. Additionally, rather
than overwhelmingly focusing on specific segments of the Black
population (e.g., low income, substance users, MSM), researchers
are currently expanding their investigations to other segments of the
Black population including college students. This focus on college
students despite, little epidemiological data on their actual HIV rates
is supported by the fact that many African Americans were infected
while they were college age.
Application of an ecological model of health behaviors
would lead to the examination of different environments for college
students and the risk and protective factors associated with those
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students and their environments. Differences in disease rates have
demonstrated to be influenced by the differential distribution of
risk behaviors including, smaller partner pools (e.g., small vs. large
student populations), and risk behaviors (e.g., low vs. high substance
use, IDU use versus alcohol or marijuana use). These differences
influence the higher rates of STIs and HIV in certain populations,
but also indicate that certain aspects of the HBCU environment may
contain certain risk and protective factors against sexual risk. The
college experiences of Black students vary by the type of institution
they attend. Research has demonstrated that there is a distinction
between Black students enrolled in predominantly White institutions
(PWI) versus historically Black colleges or universities (HBCU), that
needs to be further explored (Greer, 2007).
The goal of this paper was to describe how race and gender
can interact to influence the sexual risk behaviors of Black college
students with a specific interest on students attending HBCUs.
College students may not face some of the same inequalities as the
general population (e.g., lack of access to health care and education),
therefore, prevention interventions need to address the specific
challenges faced by this population. It must be noted that HIV
incidence in the United States is highest in the Southeastern region,
which is the same region of the United States which contains the
highest concentration of HBCUs. College students often have sexual
partners who are not college students; therefore, it is imperative that
risk be conceptualized from a comprehensive perspective.
The nature of college campuses dictate that college students
will be exposed to an abundance of sexual risk knowledge, but as
demonstrated in numerous studies, knowledge alone is not enough
to promote healthy behaviors. Despite the increased levels of self-
report risky sexual behaviors, college students in general and Black
college students inaccurately do not perceive themselves to be at
risk (Braithwaite, Stephens, Sumpter-Gaddist, Murdaugh, Taylor,
& Braithwaite, 1998; Payne, 2006). It is important to examine the
reasons why Black college students still participate in risky behaviors
despite their knowledge of the HIV/AIDS epidemic within the
Black community. Some studies indicate that these personal fables
of the consequences of sexually risky behaviors may be culturally
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influenced. In order for prevention researchers and practitioners to
be proactive and prevent Black college students from being the next
leading group in the HIV/AIDS epidemic, more research and effective
interventions are critical. Lastly, it is not enough for researchers to
take conceptual models developed on White college student samples
and simply generalize them to Black college students. Instead,
the nuances of this group should be understood from a culturally
congruent perspective.
Future Directions
A large multi-site epidemiological study should be conducted
on college campuses with adequate samples of Black students. There
is an increased need for more accurate estimations of the STI/
HIV incidence and prevalence rates of Black on college campuses.
Second, in order to test some of the questions raised in this paper
(i.e., protective/risk factors of HBCUs), the environments of Black
students attending HBCUs and those attending PWIs should be
examined and compared. Lastly, those individuals who are practicing
healthy behaviors and in turn lowering their sexual risk, should
be examined in depth. Correlates of protective behaviors can be
identified and implemented into effective interventions.
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Wright, J. (1997). “African American Males and HIV: The Challenge
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Promoting HIV Vaccine Research in African American
Communities:
Does the Theory of Reasoned Action Explain Potential
Outcomes of Involvement?
_________________________________________________________
Paula M. Frew1,2,3,4
Matthew Archibald5
Nina Martinez1,3,6
Carlos del Rio1,2,3,6
Mark J. Mulligan1,2,3
_____________________________________________________
Abstract
The HIV/AIDS pandemic continues to challenge the African
American community with disproportionate rates of infection,
particularly among young women ages 25 to 34 years. Development
of a preventive HIV vaccine may bring a substantial turning point in
this health crisis. Engagement of the African American community is
necessary to improve awareness of the effort and favorably influence
attitudes and referent norms. The Theory of Reasoned Action
(TRA) may be a useful framework for exploration of community
engagement outcomes including future attendance, community
mobilization, and study participation. Within the context of HIV
vaccine outreach, we conducted a cross-sectional survey in early
2007 with 175 African-American adults (≥ 18 years). Confirmatory
factor analysis and structural equation modeling were performed
and the findings support the potential of the model in understanding
behavioral intentions toward HIV vaccine research.
____________________
1Emory University School of Medicine, Department of Medicine, Division of
Infectious Diseases
2Emory Center for AIDS Research
3The Hope Clinic of the Emory Vaccine Center
4The University of Georgia, College of Public Health, Department of Health
Promotion and Behavior
5Emory University, Department of Sociology
6Emory University, Rollins School of Public Health
*Please address all correspondence Paula M. Frew, The Hope Clinic of the Emory
Vaccine Center 603 Church Street Decatur, GA 30030 or e-mail: pfrew@emory.edu
Frew, ET AL. 61
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Introduction
In the fifty states and the District of Columbia, the number and
proportion of HIV/AIDS cases1 among African Americans continue
to highlight the need for new and effective prevention strategies.
Since the inception of the US epidemic through 2005, African
Americans encompassed approximately 42% of all AIDS cases. In
2005 alone, African Americans comprised 50% of the AIDS burden
(CDC 2007) while making up only 12.8% of the general population
(U.S. Census Bureau 2005). The AIDS rate among African American
men (95.1/100,000) is eight times higher than that of white men
(12.1/100,000) (Kaiser Family Foundation 2007). Among women
this difference is even greater. AIDS rates are approximately 23 times
higher for African American women (45.5/100,000) than for white
women (2.0/100,000) (CDC 2007). An estimated 66% of new AIDS
cases in women during 2005 were among Black/African Americans
(CDC 2007). Regional HIV/AIDS data shows that the South has
the highest proportion of newly reported AIDS cases among African
Americans in the country, constituting 56% of all AIDS cases in 2005;
as well as over half (51%) of all African Americans living with AIDS
in the US (Kaiser Family Foundation 2007). Furthermore, Black
females accounted for 72% of HIV/AIDS diagnoses among women
in the South (CDC 2006).
With respect to the population of the Southern US, it has been
suggested that factors such as poverty, unemployment, inadequate
access to healthcare, and sociocultural environmental factors may
explain the higher AIDS burden (Reif, Geonnotti, and Whetten 2006;
Whetten and Reif 2006). Sociocultural factors that can impact risk
behaviors include racial disparities, a lack of access to prevention
and education, high levels of poverty and homelessness, suboptimal
healthcare, and the inability to obtain adequate health insurance due
to low income levels (Southern States AIDS Directors Work Group,
National Alliance of State and Territorial AIDS Directors, and CDC
Division of HIV/AIDS Prevention in the National Center for HIV/
STD/TB Prevention 2003). Issues such as mistrust in the medical
system also prevail (Gamble 1997; Whetten et al. 2006), resulting in
greater health disparities among minorities. Black/African Americans
1HIV/AIDS: This term is used to refer to (1) a diagnosis of HIV infection without the
presence of AIDS, (2) a diagnosis of HIV infection with a later diagnosis of AIDS, and
(3) concurrent diagnoses of HIV infection and AIDS. (CDC definition)
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comprise 19% of the population in the South (19 million persons),
making this racial/ethnic group much larger in this geographic
setting compared to other regions such as the Midwest (6.5 million)
(Southern States AIDS Directors Work Group et al. 2003). Black/
African Americans who engage in high risk behaviors in the South
may experience greater stigmatization with HIV prevention or care
service utilization (Southern States AIDS Directors Work Group et
al. 2003; Whetten et al. 2006).
HIV counseling and testing, as well as other evidence-based
behavioral interventions, are available in many communities, but
these measures alone have been unsuccessful in preventing the
spread of HIV (Janssen, Holtgrave, and Valdiserri 2001). Inequitable
decision-making and compromised power have been identified
as primary obstacles to women’s ability to negotiate condom use
(Aral and Wasserheit 1995; Jemmott, Catan, and Nyamathi 1995;
O’Leary and Wingood 2000; Wingood and DiClemente 2002). With
respect to condom use as a preventive measure, domestic violence
and economic dependency on men have been recognized as key
components driving this phenomenon (Aral et al. 1995).
The advent of the female condom provided new barrier
options, yet adoption of the new prevention technology has not
been widespread in the United States. Since its introduction on the
market in 1993, it has not been consistently used as the method of
choice by heterosexual women (Choi, Roberts, Gomez et al. 1999;
El-Bassel, Krishnan, Schilling et al. 1998; Macaluso, Demand,
Artz et al. 2000) and men (Seal and Ehrhardt 1999) given a lack
of awareness about the product, inexperience with the device,
and other psychosexual factors. As women are vulnerable to HIV
infection through heterosexual transmission, and may lack control
in condom negotiation, other biomedical prevention options such as
a preventive HIV vaccine would be of great benefit.
While most agree that an HIV vaccine may not be available
for some years (Solomon 2005; Tonks 2007; Tramont and Johnston
2003), the pipeline of preventive vaccines in clinical trials remains
robust with more than 39 candidate vaccines in the testing process
worldwide (IAVI 2007). These ongoing clinical trials necessitate
the involvement of various groups to ensure social justice aims
of the effort are fulfilled, to maintain scientific integrity, and for
generalizability of study findings. Therefore, cultivating relationships
with the community is critical to the success of HIV vaccine research
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and to future vaccine dissemination efforts. This is particularly
important among minority populations who are underrepresented
in HIV vaccine clinical trials (Djomand, Katzman, di Tommaso
et al. 2005) and where research suspicion has been a significant
barrier (Corbie-Smith, Thomas, and St. George 2002; Corbie-Smith,
Thomas, Williams et al. 1999).
The role of community engagement in HIV vaccine research
therefore figures prominently in addressing salient concerns
among diverse groups. Previous findings related to clinical trial
recruitment of African Americans suggest motivation differences
exist among men and women from diverse communities (BeLue,
Taylor-Richardson, Lin et al. 2006; Smith, Johnson, Newman et al.
2007). The results suggest the value of a strong researcher-study
participant relationship for women in which study volunteers are
made to feel comfortable, are treated well, and share rapport and good
communication with the study team (BeLue et al. 2006). Moreover,
women appreciate notification of research conducted in their
locales, and of its importance and relevance to their communities.
Researcher involvement in the local community also is a significant
motivator in consideration of clinical trial participation (Smith et al.
2007). Men, however, express concern with the “business and profit
elements of research” (BeLue, Taylor-Richardson, Lin, et al., 2006, p.
501). This includes issues such as compensation for participation,
informed consent, and reputation of the research facility and the
researcher. These issues highlight an array of attitudes and beliefs
among men and women from African American communities on
health research.
Given the ill-fated history of the Tuskegee syphilis study
involving African American men, it is not surprising that minorities
report lower levels of trust than their Caucasian counterparts in
the assessment of health care providers and healthcare systems
(Boulware, Cooper, Ratner et al. 2003; Gamble 1997). Moreover,
negative experiences and perceived bias in minorities’ healthcare
encounters influence trust perception of those in the medical
establishment (McAlpine 2002; Saha, Arbalaez, and Cooper 2003).
Direct experiences with providers and “social cues” from referent
others and the environment (e.g., media), are incorporated in the
formation of trust in providers and medical entities (Boulware,
Cooper, Ratner et al., 2003, p. 363). Although there are similarities
observed across studies, perceptions vary greatly among African
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American communities. McAlpine (2002) notes that the variations
may be due to socioeconomic status, access to care, health service
utilization patterns, insurance provision, and interpersonal
dynamics of patients and physicians. With this assemblage of
factors, interpersonal and perceived socioenvironmental normative
pressures have an influential effect on health decision-making.
With the 1994 NIH mandate specifying inclusion of women
and minorities in research, greater emphasis has been placed on
recruiting and retaining these populations. Enrollment trends of
racial/ethnic minorities in HIV vaccine studies from 1988 to 2002
indicate ≤ 26% enrollment of these groups in all Phase I and II studies
(Djomand et al. 2005). Although minorities are not participating
in health research at a level equal to Whites (Caucasians) (Corbie-
Smith et al. 2002; Corbie-Smith et al. 1999; Moutsiakis and Chin
2007; Smith et al. 2007), it is important to recognize that knowledge
of and access to health research activities may have a favorable
impact on willingness to participate in health research (Wendler,
Kington, Madans et al. 2006). In a large scale review study of 70,000
persons, minorities were found to be more willing to participate in
clinical and surgical studies than Whites (Wendler et al. 2006). These
findings indicate that little difference is seen in enrollment patterns
when minorities are invited to participate in health research studies
(Wendler et al. 2006). With these differences taken into account,
the authors conclude that underrepresentation in health research is
likely due to other factors.
Recent evidence on minority participation in health research
indicate a desire for information of the research activity in the
community, greater demand to understand the relevance of the
research efforts in addressing medical problems, and occasions to
learn about clinical research entities and study volunteer participants
(Smith et al. 2007; Wendler et al. 2006). Thus, the creation of
opportunities to serve these needs is a necessary precursor for effective
community engagement with African American communities.
Involving Community: Issues affecting Participation
Community engagement involves multidirectional
communication for the overarching purpose of enhancing the public’s
trust in the effort. Evidence-based methods include consultation,
dialogue, and collaboration with communities (MacQueen, McLellan,
Metzger et al. 2001) to develop shared understanding and meanings
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associated with the research programs (Swartz and Kagee 2006).
This process also fosters voice in the research endeavor and a sense
of empowerment (Dickert and Sugarman 2005; Strauss, Sengupta,
Quinn et al. 2001). These methods are vital in reaching minority
communities and women to sustain their involvement in medical
research studies (Boulware, Ratner, Cooper et al. 2002; Brown-
Peterside, Chiasson, Ren et al. 2000; Brown-Peterside, Rivera, Lucy
et al. 2001; Crawley 2001; Djomand et al. 2005), and to promote
favorable health outcomes in the population (Miller and Shinn
2005; Sengupta, Strauss, DeVellis et al. 2000). Through the NIH-
sponsored Local Partnership Program (LPP) initiative, funding has
been provided for the development of local community engagement
programs in cities where HIV vaccine research studies are taking
place.
The overarching objectives of these efforts include building
awareness through effective information dissemination, increasing
understanding through facilitation of learning opportunities, and
cultivating public support for HIV vaccines (Allen, Liang, Salvia et
al. 2005; Frew, del Rio, Clifton et al. 2008). This can be accomplished
through synergistic program efforts and the support and involvement
of collaborating partner organizations (Frew 2005). In cities across
the United States, efforts are underway to reach, educate, and
influence the American public on the importance of HIV vaccine
research. These foundational efforts may potentially contribute to the
realization of any number of outcomes including building sustained
dialogue on issues affecting involvement and support for the cause,
cultivating community mobilization, building social support, and
generating interest in study volunteerism, although the existing
evidence is ambiguous as to which of these will be achieved (Koblin,
Holte, Lenderking et al. 2000; Swartz et al. 2006).
Previous research on AIDS volunteerism suggests a
combination of factors (e.g., gaining knowledge and helping others)
fuels participatory motivation (Reeder, Davison, Gipson et al. 2001;
Simon, Sturmer, and Steffans 2000). Moreover, identification with
an AIDS service organization significantly increases the likelihood
of volunteerism (Simon et al. 2000), a finding similar to our own
in the role of study site organizational identity in promoting HIV
vaccine community involvement (Frew et al. 2008). Additionally, a
high degree of individualism among heterosexuals, contrasting with
greater collective identity among homosexuals, has been identified
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as an important intrapersonal motivation for AIDS volunteerism
(Simon et al. 2000).
Earlier survey research with a population comprised primarily
of African American women suggests that motivation related to HIV
prevention volunteerism stems from concern for the community
and a desire for HIV/AIDS knowledge (Reeder et al. 2001). These
independent predictors rank above others of personal development,
esteem enhancement, and knowing those with HIV/AIDS (Reeder
et al. 2001).
It is useful to frame these socioecological issues within a
historical perspective. Social networks arising from race and ethnicity
powerfully structure the context in which knowledge, information,
social experiences, attitude formation and sociopolitical action
take place (McPherson, Smith-Lovin, and Cook 2001; Putnam
2000). Solidaristic networks generate a sense of trust and promote
civic engagement based on concern for community (Knack 2003).
African American communities experience an enhanced sense
of social cohesion, at least as measured by participation in local
groups aiding in the mobilization of members in lieu of difficult-to-
obtain socioeconomic resources (Verba and Nie 1972). Verba and
Nie (1972) argue that community membership exerts normative
pressures promoting collective action. The salutary effects of African
American cohesion on sociopolitical participation may be limited to
a specific periods, however, since deeply rooted inequality precludes
full community engagement (Chong and Rogers 2005; Putnam 2000;
Skocpol, Liazos, and Ganz 2006).
Within the current context of HIV vaccine research, several
studies have been conducted that specifically examine “willingness-
to-participate” in HIV vaccine trials (Buchbinder, Metch, Holte et al.
2004; Colfax, Buchbinder, Vamshidar et al. 2005; Halpern, Metzger,
Berlin et al. 2001; Newman, Duan, Roberts et al. 2006; Priddy,
Cheng, Salazar et al. 2006) and HIV “vaccine acceptability” issues
(Crosby, Holtgrave, Bryant et al. 2004a; Crosby, Holtgrave, Bryant et
al. 2004b; Esparza, Chang, Widdus et al. 2003; Tello, Soong, Hunter
et al. 1998). Overall, the HIV vaccine willingness-to-participate and
acceptability literature indicate trust, confidentiality, side effects
and safety concerns, social stigma, and other factors as barriers to
involvement in the effort (Halpern et al. 2001; Hays and Kegeles
1999; Koblin, Heagerty, Sheon et al. 1998; Koblin et al. 2000; Priddy
et al. 2006). However, altruistic participatory motives, a desire to
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represent the community, the ability to “bring an end to AIDS,”
and other health benefits (i.e., free HIV testing, medical care, etc.)
counter such impediments (Colfax et al. 2005; Newman et al. 2006).
Additional work on social influences related to trial participation
decision-making suggests a need for interventions targeting family
and friends (Allen et al. 2005; Brown-Peterside et al. 2000; Newman
et al. 2006).
Conceptual Framework: The Theory of Reasoned Action
The theory of reasoned action was selected as a useful model
of inquiry for analysis of participant behavior. The TRA has been
applied to HIV vaccine acceptability (Gagnon and Godin 2000) and
other HIV/AIDS prevention studies (Koniak-Griffin 2006; Koniak-
Griffin, Lesser, Nyamathi et al. 2003) including condom use (Mclaws
1996; Sneed 1998). More recently it has been applied to pneumococcal
vaccination in urban settings (Zimmerman 2005). The TRA model
is motivational in nature, with integration of individual (behavioral
attitudes) and social (subjective norms) components in the formation
of intentions which are predictive of behavioral outcomes of which
persons have full volitional control (Ajzen and Fishbein 1980; Ajzen
and Madden 1986; Fishbein and Ajzen 1975). This predictive model
focuses on antecedent factors that conjoin in operation to explain
behavior.
In the current study we utilize an established behavioral theory
(TRA) to develop a predictive model of community engagement
focusing specifically on the intentions of African Americans, with an
emphasis on women. According to the TRA, formation of individual
attitude is affected by behavioral beliefs and evaluation of behavioral
outcome (Montano and Kasprzyk 2002). The salience of these
beliefs (attitude), combine with the social factors - normative beliefs
and motivation to comply (subjective norm formation) – and are
weighted in relation to each other (Ajzen et al. 1986). The addition
of the social component is useful for prediction of health behavior
outcomes, particularly as the approval or disapproval of referent
others (family, friends, colleagues), and importance afforded to these
opinions can be important (counter) persuasive factors. In total, all
of these form the basis for intention. As intention increases, the
likelihood of realizing the behavioral outcome improves.
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Methods
Study sample
From April 2007 through June 2007, project staff members
approached members of populations attending multiple Atlanta-
based events: a Morehouse College health symposium, a Georgia
Perimeter College health fair, two “AIDS 101” educational
presentations, Atlanta Harm Reduction Center (AHRC) “house
parties,” an HIV vaccine awareness day symposium entitled “There’s
Hope in Our Soul” at Hopewell Baptist Church, The Atlanta Voice’s
health outreach at a local mall, Atlanta Pride Festival, and a small
group educational session on HIV vaccines with Americorps
volunteers. These activities were organized and sponsored by the
research study site (The Hope Clinic of the Emory Vaccine Center)
and its community organizational partners with a focus on building
HIV vaccine awareness and providing community education on
HIV vaccine research.
Recruitment occurred at arbitrary times and days of each
week, and throughout the duration of the activities. The recruitment
area was limited to Atlanta, Georgia. Persons were eligible for study
participation if they were at least 18 years of age and could read
and speak English. Study staff made an effort to ensure that surveys
were completed only once among attendees. Approximately two
hundred people were invited to participate in the study. Of these,
175 were eligible and provided written informed consent (yielding
a response rate of nearly 87.5%). A t-shirt or health promotion
incentive for participation was provided. The Emory University
Institutional Review Board approved the study protocol prior to
study implementation.
Data Collection
Participants completed a 93-item self-administered
questionnaire. The study staff and research assistants ensured that
participants were provided with a semi-private area, or directed
to nearby quiet spots (such as picnic tables) in outdoor locations,
to complete the questionnaire. In addition, the staff and research
assistants made themselves available to participants in the event that
any of the instrument language required clarification.
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Results
Participant Characteristics
The study population (Table 1) was comprised of 175 African
Americans of which 70% were female, including one transgender
person (male-to-female). Their median age was 37 years. Most were
between 18 and 55 years of age (86.8%), single (55.4%), employed
(62.3%), and many achieved postsecondary educational status
(66.3%). The majority of the respondents indicated heterosexual
orientation (84%, n = 147), and 12% reporting Gay/Lesbian, Bisexual,
Transsexual/Queer/Questioning (GLBTQQ) orientation, with 4%
unknown. The annual household income range of participants
varied, with most earning ≤ $40,000 per year (58.3%). Primary
motivation for attendance included a desire for more scientific/
medical information (34.3%, n = 58), an obligation to represent the
community (23.1%, n = 39), to inquire about volunteer opportunities
(10.1%, n = 17), to meet others with similar concerns about HIV/AIDS
and medical research (12.4%, n = 21), and other reasons (21.1%, n
= 34). Most participants (57.9%, n = 99) rated the sponsoring study
site as “excellent/outstanding” and “good/very good” (39.8%, n = 68)
and favorably assessed the community engagement event or activity
as exceeding expectations (35.8%, n = 59) or meeting expectations
(59.4%, n = 98).
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Table 1: Selected Participant Characteristics
Characteristic (n=175) Frequency Percent
Gender
Male 53 30.3
Female 121 69.1
Transgender (Male to Female) 1 0.6
Age (missing =1)
18 to 25 37 21.3
26 to 35 45 25.9
36 to 45 31 17.8
46 to 55 38 21.8
≥56 years 23 13.2
Education (highest level completed)
K-8 or high school 59 33.7
Post-secondary education 116 66.3
Sexual Orientation (missing=3)
Heterosexual 147 85.5
LGBTQ 25 14.5
Motivation for attendance
(missing=6)
Scientific/Medical Information 58 34.3
Volunteer Opportunities 17 10.1
Obligation to Community 39 23.1
Meet Others With Same Concerns 21 12.4
Other reasons, not specified 22 13.0
Multiple reasons, specified
12 7.1
Rating of Study Site (missing=4)
Excellent/Outstanding 99 57.9
Good/Very Good 68 39.8
Fair/Poor 3 1.8
No opinion 1 0.6
Rating of Event (missing=10)
Exceeds expectations 59 35.8
Meets expectations 98 59.4
Does not meet expectations 8 4.8
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Scale Construction
Theory of reasoned action variables were constructed based
on a review of the literature, from existing instruments (Frew et al.
2008; Priddy et al. 2006), and scaling options presented by the TRA
progenitors (Ajzen et al. 1980). TRA variables cover volunteers’
intentions or willingness to participate in HIV related events, and
their subjective norms, attitudes, motivations and beliefs about
engaging in HIV-related events.
Intentions. Three outcome variables were used to measure
volunteers’ willingness to participate in future activities and events,
to mobilize others in the cause of HIV vaccine research, and to
contact organizers about participating in the vaccine trials. The first
outcome option was measured on a 3-point scale. Participants were
asked to rate the probability that they would return to HIV vaccine
community engagement activities as “very likely,” “somewhat likely,”
or “not likely.”
Of the initial 175 surveyed, most responses were captured
(98%) with nearly 80% (n=137) who indicated that they were “very
likely” to attend a similar event or activity in the future. To account
for missing cases (n = 3) and “don’t know” responses (n =2), along
with other non-response items essential to theoretical assessment,
the resulting dataset was reduced to N=126 for structural equation
modeling of this outcome. Notably, only one person indicated “not
likely” and this response was combined with “somewhat likely” to
manage a potentially spurious outlier effect.
The second outcome represents the probability of involving
others in the cause (i.e., “community mobilization”). Measured on the
same 3-point scale, participants indicated that they would be “very
likely” (35.4%, n=62), “somewhat likely” (34.9%, n=61),” or “not
likely” (14.9%, n = 26). Although the response rate was 100% for this
outcome, some selected “don’t know” (14.9%, n = 26) and missing
responses to essential items for theoretical analysis were identified.
The dataset was subsequently reduced to N = 110 for modeling this
outcome of interest.
Finally, the potential for study volunteerism (i.e., contact
the study site about clinical trial participation) was investigated as
the third outcome of interest. Results indicated that 25.4% (n=44)
would be “very likely,” 27.2% (n=47) “somewhat likely,” and 31.8%
“not likely” to contact the study site about clinical trial participation.
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Two cases were missing responses, and 15.4% (n = 27) indicated that
they were unsure if they would contact the site about participation
in a clinical trial. This again resulted in data reduction yielding N =
106 for final modeling analysis with complete responses to all items
for those cases. (See Table 2, next page)
Attitudes. The influence of attitudes on the three outcome
intentions was explored. Communication, particularly persuasive
forms (Petty and Cacioppo 1983; Petty, Strathman, Cacioppio et al.
1994), plays a powerful role in attitude formation and alteration. It
was therefore hypothesized that favorable responses to attitudinal
items would increase intentions. Respondents indicated positive
attitudes toward HIV research with statement agreement on 5 items
within a scale including “I like to do good for others,” “I like getting
involved with HIV vaccine research,” “HIV is a serious concern
in my immediate community,” “HIV testing is a benefit of an HIV
vaccine study,” and “I would benefit from the medical care associated
with an HIV vaccine study.”
Subjective Norms. Perceived “social pressure” (Ajzen &
Fishbein, 1980, p. 246) to perform a behavior or forego it, is reflected
in the “subjective norm” construct. In this study, participants were
also asked if they thought people, including family and friends,
might respond negatively to ones’ participation. We hypothesized
that negative social opinion of research involvement would reduce
participatory intention. Influential normative concerns were directly
measured through items including “people negatively judge those
who participate in HIV vaccine research,” “I think some of my family
members would be upset if I participated in an HIV vaccine research
study,” and “I think my friends would negatively judge me if I joined
in an HIV vaccine study.”
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Table 2: Potential Community Engagement Outcomes
Characteristic Frequency Percent
Likelihood of Attending Future Activity/Event
Very Likely 98 77.8
Somewhat and Not Likely (1 case) 28 22.2
N= 126
Likelihood of Involving Others in the Cause
Very Likely 45 40.9
Somewhat Likely 44 40.0
Not Likely 21 19.1
N=
110
Likelihood of Contacting Site About Study
Participation
Very Likely 29 27.4
Somewhat Likely 30 28.3
Not Likely 47 44.3
N= 106
Behavioral Beliefs. Several questions measured volunteers’
salient beliefs about their role in HIV vaccine research. We
hypothesized that beliefs about HIV vaccines and medical
research favoring participatory behavior would increase intentions
to participate in future activities, generate greater community
mobilization, and study volunteerism. Beliefs pertaining to self-
interest constituted modal scale 1 and those concerning the benefit
to others arising from involvement were included in scale 2. Scale 1
items included “my community would really benefit from an HIV
vaccine,” “My actions can inspire others to act,” and “I benefit from
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health science research.” Scale 2 items included “My participation
in an HIV vaccine study would be very good,” “My involvement in
this cause will result in more ethical research,” “My involvement in
this cause will improve my community’s trust in medical research,”
and “I would participate in an HIV vaccine research study because it
would help to prevent AIDS.”
Outcome Evaluations. Consideration of outcomes related
to study participation was uniquely assessed to understand negative
salient beliefs related to volunteerism. Previous studies indicated
logistical, physical, and psychological as barriers with respect to
involvement in HIV vaccine research among ethnic minorities
(Newman et al. 2006; Priddy et al. 2006). We hypothesized that
reduced personal concerns, and decreased concern of negative
health and social consequences specifically related to HIV vaccine
study participation, would more likely result in greater participatory
intention. Items therefore included in the scale were “My participation
in an HIV vaccine research study would be more trouble than it’s
worth,” “Even if I wanted to participate in an HIV vaccine research
study, I just don’t have the time,” “Participating in an HIV vaccine
research study seems risky,” “I would participate in an HIV vaccine
research study, but I don’t like needles.”
Normative Beliefs. Two aspects of normative beliefs were
considered. Those connected to beliefs about the effects of research on
a community and beliefs about the effects of ones’ own participation
in research for the greater good. We hypothesized that these motives
would influence subjective norms and participatory intentions.
Normative beliefs consisted of six questions based on these two
dimensions. They include reference to specific individuals within
the social realm who may affect individual decision-making. Items
on the 5-point scale therefore included “I think my doctor would
approve of my involvement in HIV vaccine research,” “I think my
work colleagues would approve of my involvement in this cause,” “My
immediate family is supportive of my involvement in HIV vaccine
research,” “Most people important to me think my involvement
in HIV vaccine research is good,” “Most people important to me
usually support my interests,” and “If my pastor supported HIV
vaccine research, I would be inclined to get involved.”
Motivation to Comply. Lastly, individuals might declare a
willingness to participate or reluctance to get involved due to general
compliance with referent opinion. The theorized influence of family,
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friends, and others on behavioral performance will exert social
pressure to act or engage in avoidance. We hypothesized that greater
self agency would lead to greater participatory intention. The items
measuring this domain therefore include “I tend to be concerned
about what people think of me, even if I don’t know them,” “I
generally do what my family expects of me,” “I would not want to
do something my friends disapproved of,” “If my superiors told
me to do something I disagreed with, I would obey their wishes,”
“Sometimes I do what my friends say to do, even though I know they
are wrong.”
Analytic Strategy
A covariance structure model was used to test the causal
relationships between factors implied by the theory of reasoned
action. We tested the effects of normative beliefs, outcome evaluations
and motivation to comply on attitudes and subjective norms. At
the same time, attitudes and subjective norms were used to explain
respondents’ intentions with respect to future involvement in HIV
research, whether through attending future events, mobilizing
others or participating in vaccine trials. A structural equation model
is well-suited for this type of analysis because (1) it examines both
direct and indirect paths to willingness to participate in an efficient
(simultaneous) manner, (2) random measurement error can be
taken into account, reducing its effect on parameter estimates, (3)
non-random error can be explicitly accounted for, and (4) we can
explicitly investigate the fit of these measures to TRA constructs
thereby promoting their more general definition.
The basic structural equation model follows Jöreskog and
Sörbom (1993):
ή = βή + γξ + ζ
where ή and ξ are latent constructs based on vectors of observed
variables (y and x); β is a matrix of coefficients expressing the mutual
effects of endogenous variables; γ represents the effects of latent
exogenous on endogenous variables, and ζ is a vector of random
error. One underlying assumption of the model is that the errors
are uncorrelated with latent constructs and uncorrelated among
themselves.
Assessing the measurement of constructs is possible within
this framework. It is done by incorporating factor analysis into the
model. Although there is considerable prior knowledge about the
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dimensions of the theory of reasoned action, its application to this
health issue may be beneficial to the field. We therefore include a
provisional confirmatory factor analysis of measurement fit to
establish the components of the factors by estimating the strength
of the relationships between indicators and constructs. SPSS’ Amos
7 was the software package used to generate maximum likelihood
estimates of the parameters (Arbuckle 2006).
Factor Analysis
A preliminary confirmatory factor analysis using maximum
likelihood estimation was undertaken to test the adequacy of the
model measuring the underlying factors (Table 3). Each latent
construct (intentions, attitudes, subjective norms, behavioral beliefs,
outcome evaluations and normative beliefs) was identified by its
corresponding measured variables. One indicator per construct was
fixed to define the scales of the indicators. Results of the factor analysis
generally support the validity of the constructs. Three exceptionally
low factor loadings were: an outcome evaluation measure of the
wish to participate but not liking needles; the attitude measure of
HIV being a serious community concern, and, the subjective norm
where respondents thought people judge HIV vaccine participants
negatively. The GLS χ2 was 454.24, df=407, p>.05 indicating the
model fit reasonably well (the residual mean square error was
.087).2
2 A generalized least squares χ2 was run because Amos does not provide a
maximum likelihood chi. Note also that while this model fits the data reasonably
well, other measures of fit such as goodness of fit index were disappointingly low
and associated with problems with the fit matrix. Increasing the sample size is
one possible solution.
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Table 3: Descriptive Item Statistics. Measuring HIV Vaccine
Community Engagement
Variable n (%) Mean SD Min Max Factor
Loadings1
Dependent Measures2
1. Future Attendance:
Likelihood of returning to
activity or event
172
(98) 1.24 0.53 1.00 4.00 .725
2. Community Mobilization:
Likelihood of involving others
in the cause
175
(100) 2.09 1.05 1.00 4.00 .817
3. Study Volunteerism:
Likelihood of contacting the
site about study participation
173
(99) 2.38 1.03 1.00 4.00 .810
Independent Measures3
Behavioral Beliefs scale 1 (α =0.74)
BB1. My community would
really benefit from an HIV
vaccine.
168
(96) 1.44 0.74 1.00 5.00 .779
BB2. My actions can inspire
other to act.
166
(95) 1.77 0.79 1.00 5.00 .668
BB4. I benefit from health
science research
167
(95) 1.66 0.77 1.00 5.00 .735
Behavioral Beliefs scale 2 (α=0.88)
BB3. My participation in an
HIV vaccine study would be
very good
164
(94) 2.07 0.91 1.00 5.00 .782
BB5. My involvement in this
cause will result in more ethical
research.
167
(95) 2.01 0.92 1.00 5.00 .845
BB6. My involvement in
this cause will improve my
community’s trust in medical
research.
167
(95) 2.03 0.93 1.00 5.00 .862
BB7. I would participate in
an HIV vaccine research
study because it would help to
prevent AIDS.
169
(97) 2.20 1.06 1.00 5.00 .725
Outcome Evaluations (α = 0.76)
OE1. My participation an HIV
vaccine research study would
be more trouble than it’s worth.
170
(97) 3.31 1.21 1.00 5.00 .856
OE2. Even if I wanted to
participate in an HIV vaccine
research study, I just don’t have
the time.
165
(94) 3.05 1.18 1.00 5.00 .823
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Table 3 (con’t):
Variable n
(%) Mean SD Min Max Factor
Loadings1
OE3. Participating in an HIV
vaccine research study seems
risky.
165
(94) 2.74 1.22 1.00 5.00 .653
OE4. I would participate in an
HIV vaccine research study, but
I don’t like needles.
163
(93) 3.12 1.26 1.00 5.00 .386
Normative Beliefs (α = 0.82)
NB1. I think my doctor would
approve of my involvement in
HIV vaccine research.
165
(94) 2.38 0.93 1.00 5.00 .635
NB2. I think my work
colleagues would approve of my
involvement in this cause.
161
(92) 2.39 0.96 1.00 5.00 .634
NB3. My immediate family is
supportive of my involvement in
HIV vaccine research.
163
(93) 2.61 1.01 1.00 5.00 .738
NB4. Most people important
to me think my involvement in
HIV vaccine research is good.
161
(92) 2.45 0.92 1.00 5.00 .854
NB5. Most people important to
me usually support my interests.
166
(95) 1.90 0.73 1.00 5.00 .612
NB6. If my pastor supported
HIV vaccine research, I would
be inclined to get involved.
163
(93) 2.50 1.08 1.00 5.00 .595
Motivation to Comply (α=0.85)
MC1. I tend to be concerned
about what people think of me,
even if I don’t know them.
166
(95) 3.26 1.33 1.00 5.00 .605
MC2. I generally do what my
family expects of me.
167
(95) 2.92 1.21 1.00 5.00 .558
MC3. I would not want to
do something my friends
disapproved of.
161
(92) 3.41 1.15 1.00 5.00 .691
MC4. If my superiors told me to
do something I disagreed with, I
would obey their wishes.
167
(95) 3.40 1.19 1.00 5.00 .621
MC5. Sometimes I do what my
friends say to do, even though I
know they are wrong.
164
(94) 3.74 1.19 1.00 5.00 .735
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Table 3 (con’t):
Variable n
(%) Mean SD Min Max Factor
Loadings1
Attitudes (α=0.76)
A1. I like to do good for others. 169
(97) 1.36 0.61 1.00 4.00 .507
A3. I like getting involved with
HIV vaccine research.
167
(95) 2.15 0.89 1.00 .792
A4. HIV is a serious concern in
my immediate community.
170
(97) 1.52 0.80 1.00 4.00 .427
A5. HIV testing is a benefit of an
HIV vaccine study.
171
(98) 1.78 0.83 1.00 4.00 .633
A6. I would benefit from the
medical care associated with an
HIV vaccine study.
171
(98) 2.04 1.03 1.00 5.00 .742
Subjective Norms (α=0.60)
SN1. People negatively judge
those who participate in HIV
vaccine research.
165
(94) 2.58 1.11 1.00 5.00 .482
SN2. I think some of my family
members would be upset if I
participated in an HIV vaccine
research study.
164
(94) 2.80 1.27 1.00 5.00 .548
SN3. I think my friends would
negatively judge me if I joined
an HIV vaccine research study.
164
(94) 3.37 1.12 1.00 5.00 .895
The next set of findings refers to the causal model implied
by the theory of reasoned action. Table 4 provides estimates of
standardized regression coefficients measuring relationships
among the theoretical constructs. Standardized coefficients can
be interpreted as standard deviation unit changes in the outcome
of interest for a unit change in its precursor. They also permit
comparisons of the degree to which one variable influences
another.
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D
ependent Variables
Independent Variables
Future Attendance
C
om
m
unity M
obilization
Study Volunteerism
Attitudes
.311 *
.698 ***
.687 ***
Subjective N
orm
s
-.036
.092
-.087
Independent Variables
Attitudes
Subjective N
orm
s
Attitudes
Subjective N
orm
s
Attitudes
Subjective N
orm
s
Behavioral beliefs-other
.346 **
--
.347 **
--
.288 *
--
Behavioral beliefs-self
.667 ***
--
.676 ***
--
.723 ***
--
O
utcom
e evaluations
.020
--
.005
--
< .001
--
N
orm
ative beliefs
--
-.186 †
--
-.185 †
--
-.188 *
M
otivation to C
om
ply
--
.814 ***
--
.811 ***
--
.818 ***
RM
SEA
.077
.829
.077
.831
.079
.831
CFI
Chi-square
729.91
731.6
753.23
N
126
110
106
N
ote: † <.10 * p< .05 ** p<.01 *** p<.001: tw
o-tailed tests.
Frew, ET AL. 81
Table 4: SEM
M
axim
um
Likelihood Standardized Regression C
oeffi
cients
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The pattern of significant and nonsignificant coefficients is
similar across the three different measures of intention to engage in
action around HIV research. Attitudes but not subjective norms had
a positive affect on the likelihood of community mobilization (.698),
study volunteerism (.687), and to a lesser extent, future attendance
at HIV-related events (.311). Respondents’ favorable attitudes about
the importance of HIV vaccine trials were in turn shaped by their
positive beliefs about their role in HIV research. The strength of the
relationship was greater for beliefs linked to how respondents’ viewed
their own actions (e.g., .667 for the model with future attendance
as the intention variable) in contrast to beliefs emphasizing how
respondents’ viewed the effects of their actions (e.g., .346). Negative
beliefs (defined as outcome evaluations) were not related to either
attitudes or subjective norms. Normative beliefs and motivations
to comply, however, were related to both attitudes and subjective
norms.
The effect of respondents’ compliance to others wishes
in general (e.g., “I would not want to do something my friends
disapproved of ”) was linked to their subjective norms regarding
participation in HIV research (e.g., “…my family members would
be upset if I participated…”).The low degree of compliance with
others’ expectations was robust across models (i.e., .814, .811, .818,
respectively). Not surprisingly, normative beliefs about doctors’
and colleagues’ encouragement to participate were less likely to be
associated with negative judgments of others (i.e., -.186, -.185, -.188,
respectively). Although these construct coefficients contrast, the
pathways suggest that independent cognitive appraisal of the HIV
vaccine effort has an effect on the formation of subjective norms.
However, these are less likely to be influenced by normative beliefs
and they are unlikely to shape intentions to participate in HIV
research when other beliefs and attitudes are taken into account.
Discussion
This current study is significant because it utilizes an
established behavioral theory (TRA) in predictive modeling of HIV
vaccine community engagement. This study specifically focused
on intentions of African Americans within the continuum of the
decision-making processes about the role of the individual in the
endeavor. In this study, special emphasis has been placed on African
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American women who are greatly affected by HIV/AIDS, and whose
participation is needed in ongoing trials (Djomand et al. 2005;
Moutsiakis et al. 2007).
This study also adds to the literature with information gathered
among those attending HIV vaccine-related events and activities.
As favorable attitudes, perceptions, and beliefs are theorized to be
critical predisposing factors influencing future behavioral outcomes
(Ajzen 1991; Fishbein et al. 1975; Maiman and Becker 1974), these
attendees have the potential, at a minimum, to serve as allies in
expanding needed social support for HIV vaccine research (Allen
et al. 2005). Our results from this study offer evidence to reinforce
this notion. Specifically, this study extends our earlier findings on
factors influencing community engagement formation (Frew et al.
2008) with the addition of theory-driven assessment of outcomes
anticipated with targeted community approaches.
The goal of the current study was to examine the theory of
reasoned action covariates impacting respondents’ willingness to
participate in events surrounding HIV vaccine research. Overall,
the hypotheses were mostly supported, with the exception of
subjective norms and outcome evaluations, and the findings suggest
the importance of theoretical guidance in predicting community
engagement outcomes.
Important relationships materialized among constructs
especially those related to self-empowerment beliefs on attitude, and
counter-resistance (motivation to comply) to negative normative
pressure (subjective norms). In particular, belief in one’s participation
resulting in positive, tangible outcomes for the community, research,
and HIV/AIDS mediated through the attitude construct had a
profound impact on the potential to mobilize the community for
action (.698) and participate in HIV vaccine trials (.687). Attitude
formation clearly is evidenced by the lower coefficient (.311) on future
attendance, indicating the critical role of effective communication
and community engagement programming in fostering positive
attitudes towards the cause. Moreover, the set of self-empowering
perceptions (.667) on attitude outweighed more generic beliefs
related to involvement (.346) such as “I benefit from health science
research.”
Our findings support the need to clearly articulate as many
concrete outcomes that can be expected from involvement in HIV
vaccine research. A key assumption of the value-expectancy theories
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(i.e., TRA) is that some end will be achieved through the performance
of a behavior. Yet, in the context of HIV vaccine development, it is
unclear exactly what end will be met – will the vaccine partially or
fully prevent infection? Or, among those living with HIV, will the
vaccine reduce viral loads to prevent AIDS-related illness? Although
it is likely that one of these outcomes will be achieved, participatory
behaviors do not yet have clear consequences. In other words, people
do not know what to expect of their involvement. Thus, the findings
point to a need for effective communication citing specific examples
of the role of African Americans in the realization of ethical oversight
(i.e., participation on CABs, IRBs, etc.), improving community trust
(e.g., increases in study participation rates), and preventing AIDS
(e.g., risk reduction through greater condom use among study
enrollees). Communication emphasis should be on individual self-
empowerment to affect collective change.
In contrast to previous studies examining willingness-to-
participate among predominantly minority populations (Corbie-
Smith et al. 1999; Newman et al. 2006; Priddy et al. 2006) and among
women (Mills, Nixon, Singh et al. 2006), logistical concerns relating
to the formation of community engagement outcomes did not
materialize. With respect to inconvenience, time constraints, risk
perception, and use of needles in studies, these items as related to
the “outcome evaluation” construct, did not impact attitudes. The
findings related to outcome evaluation may be indicative of other
issues. A lack of thorough consideration may have been afforded to
these issues of practical concern given the high first time attendance
rate of the majority of respondents (85.4%, n=146). Furthermore,
the HIV vaccine messages promoted in these situations may have
strengthened individuals’ resolve to manage any concerns or logistical
issues likely to be encountered in the future.
Obviously, the relationship of subjective norms to intention
was not significant in this study population. This finding is consistent
with a previous HIV vaccine study that tested TRA effects (Gagnon et
al. 2000). The result could be due to a manifestation of measurement
issues associated the items designed to measure subjective norms (α
= .64, n = 3 items) in combination with a small sample size. With
consideration given to these shortcomings, the nonsignificant
pathways between subjective norms to intention could represent a
theoretical deviation. That is, negative normative influences may not
causally impact community engagement outcomes. In contrast with
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other studies citing social harms (Francis, Heyward, Popovic et al.
2003) and negative social judgments (Koblin et al. 1998) as barriers
to participation, our nonsignificant finding suggests the possibility
that our participants rejected the negative views of others related to
behavioral intention.
Alternatively, the findings suggest the possibility that those
who become engaged in HIV vaccine research exhibit a degree
of independent thinking to resist counterattitudinal messages.
Surprisingly, the strength of the relationship of the (lack of) motivation
to comply with subjective norms resulted in powerful pathway effects
(.814-future attendance, .811-community mobilization, .818-study
volunteerism). Moreover, approval of doctors, family, pastors,
work colleagues, and others in HIV vaccine research weakly, but
significantly, offset negative opinion on involvement. Thus, it is likely
that a degree of social support is valuable in promoting involvement,
but not required for the formation of participant initiative.
It merits consideration that the emphasis on issue-relevant
thinking (e.g., ending HIV/AIDS) in community engagement
activity may result in greater psychological resiliency to withstand
counterpersuasive normative thinking. Within this culture-centered
context, albeit a supportive situation, it is likely that the conditions
favorably predispose individuals to resist negative normative pressure
encountered in “real world” conversations with others.
Research pertaining to HIV/AIDS volunteerism, clinical
trials participation, and other forms of elective health behavior (i.e.,
bone marrow donation) suggest the decisional pathways are complex
and have a strong affective component (Bagozzi, Lee, and Van Loo
2001; Curbow, Fogarty, McDonnell et al. 2006; Davis and Randhawa
2006; Reeder et al. 2001). In short, the emotional commitment
accompanying a health behavior may sufficiently explain the decision
to become a health research volunteer or support a cause (Eagly and
Chaiken 1993). Others have argued that TRA is compromised in its
ability to predict intention and behavior in the face of alternative
options (Sheppard, Hartwick, and Warshaw 1988). Thus, the TRA
model may have limited explanatory power to understand the
complexity of the relationships in the broader socioenvironmental
milieu of African American communities. Additionally, our findings
would imply that a decision to forego involvement may be highly
“rational” based on reasons pertaining to historical violations of
trust.
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Limitations
Findings are limited by several factors, including the inherent
limitations of a cross-sectional study design, the venues where the
participants were recruited, and the use of a small purposive sample
consisting of primarily African American females. The views of this
group may not be representative of others in the diverse African
American population.
With the exclusion of cases missing data and uncertainty
signals given to outcome responses (e.g., “don’t know”), the resultant
datasets may have been limited in their ability to detect pathway
effects within this complex model. Additionally, the study design does
not allow for causal conclusions to be drawn. The study was solely
concerned with relational modeling of various theoretical constructs
thereby facilitating covariate evaluation. Although the data were
collected at several activities, the study cannot be characterized as
longitudinal in design.
An important limitation is that intent may not be strongly
associated with future participatory behavior. It should also be
noted that participation bias in a study of HIV vaccines and health
behaviors is particularly likely (i.e., it is conceivable that people
having strong beliefs and attitudes on HIV vaccine research may be
the least inclined to complete the study questionnaire). Thus, even
though the study achieved a response rate of approximately 88%,
participation bias may have affected the results. However, we do not
anticipate that these limitations resulted in large or systematic errors
in data collection.
Summary
The results from our study indicate the importance of
developing favorable attitudes toward HIV vaccine research among
African Americans living in Atlanta, Georgia. This construct yielded
strong intentions related to community mobilization and study
volunteerism intent.
Surprisingly, negative normative pressure had no effect on
intentions. Normative concerns related to medical mistreatment
are deeply embedded within the culture and therefore may be more
resistant to change. Thus, a collective norm of mistrust and suspicion
within these communities may be precluding the simultaneous
realization of normative shifts within the TRA model. Despite this
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finding, there is powerful evidence of self-deterministic thinking
(motivation to comply) in relation to these influences. The present
research points to the valuable benefit of theory-driven inquiry, yet
also highlights its limitations in understanding a complex array of
relationships between the individual and the sociocultural context.
Sources of Support:
This research was supported by the Emory Center for AIDS Research
(P30 AI050409) with additional support for programmatic activities
from NIAID Local Partnerships Project (LPP) and Academy for
Educational Development (AED).
Acknowledgements:
The authors wish to thank our partner organizations and their staff
for support of the programmatic activities associated with this work:
Action Cycling Atlanta, AIDS Alliance for Faith and Health, AID
Atlanta, AID Gwinnett, AIDS Research Consortium of Atlanta,
AIDS Survival Project, Atlanta Harm Reduction Center, the Centers
for Disease Control and Prevention, Concerned Black Clergy, Emory
Center for AIDS Research, Georgia Perimeter College, Hopewell
Baptist Church, Humanitarian Endeavors, the Institute for Health
Protection, the Interdenominational Theological Center, the Legacy
Project, Morehouse College, National AIDS Education and Services
for Minorities, and SisterLove, Inc. Special thanks to Bethany Wexler
for editorial assistance.
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Ida Rousseau Mukenge
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