Increasing access to preventive health care through cultural adaptation of effective HIV prevention interventions: a brief report from the HIV prevention in Haitian youths study

ABNF Journal, The, Nov-Dec, 2004 by Robert M. Malow, Michele M. Jean-Gilles, Jessy G. Devieux, Rhonda Rosenberg, Angela Russell

Abstract: This article describes an HIV prevention study among Haitian youths, based on the cultural adaptation of a cognitive behavioral HIV risk reduction intervention entitled "Becoming a Responsible Teen." The aim of the parent study is to evaluate whether the BART intervention is more effective than a control condition in reducing HIV risk behavior in the target population. The project explores how self-efficacy, behavioral intentions, social factors and acculturation influence the risk behavior of Haitian American adolescents. This community based translation of a risk reduction intervention, previously found to be effective in other populations, can serve as a model for reducing health disparities in a vulnerable adolescent population that lacks access to preventive health care. The purpose of this paper is to present preliminary data from the pre-assessment phase of the intervention, which enabled the project to incorporate health disparity issues with this population and address barriers to health care access.

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Key Words: Haitian American Adolescents, HIV Prevention, BART, Underserved Populations, Health Disparities.

The National Institutes of Health (NIH) define health disparities as "Differences in the incidence, prevalence, mortality, and burden of diseases and other adverse health conditions that exist among specific population groups in the United States" (Fauci, 2000). The Health Resources and Services Administration (HRSA, 2000) operationalizes the definition by attributing disparities to possible "differences in risk factors, lack of access to health care, inadequately targeted prevention messages, and cultural differences between the health care system and the populations it serves." Each of these was addressed by Auerbach and Coates (2000) in a seminal commentary on specific problems facing HIV prevention researchers in the third decade of the epidemic. Interestingly, they approached the topic of cultural competency and sensitivity under the heading of "Ethical Challenges," stating that "HIV prevention research must be culturally sensitive and appropriate for the populations in which it is being carried out and to which its findings will be applied. This underscores the need to enhance the participation and the voice of people affected by HIV/AIDS in the determination of research questions and methods to be undertaken in their communities."

However, culturally competent and sensitive HIV/AIDS prevention intervention research has become the bedrock of NIH-funded trials under the priority of translational design and cultural adaptation of effective interventions for new, underserved populations (Devieux, Malow, Rosenberg, & Dyer, 2004). Such adaptations represent a scientific and strategic approach to countering the structural character of the epidemic, in which populations are so disproportionately burdened that social epidemiologists like Poundstone, Stratdhee, and Celentano (2004) can speak with increasing confidence of pathways between HIV/AIDS risk and structural violence. Their schematic of the social epidemiology of HIV/AIDS delineates a complexity of cultural, neighborhood, and network factors that must be matched by research that can establish causality and lead to the design of effective interventions. Cultural adaptation is an integral part of such a research agenda, serving to interrupt a socio-ocular syndrome of whole communities whose burdens are visible to almost no one except themselves. Valdiserri (2004) has examined an even worse scenario, though, of complacency or burn-out, in which the unprocessed individual and communal losses of the epidemic turn to absence from thought and sight. Cultural adaptation is a proven design procedure that can intervene before this limit is reached.

Our paper is a brief report of an adapted intervention that is ongoing with Haitian American adolescents in Miami, Florida, funded by the National Institute of Child Health and Human Development (1RO1 HD38458; "HIV Prevention in Haitian Youths;" Robert M. Malow, P.I.). Most particularly, we locus on preliminary data from a sub-study that sought to link the larger study with issues of health disparities in the Haitian American population. We utilized an assessment protocol modified from the AD-HEALTH adolescent and parent questionnaires of the National Longitudinal Study of Adolescent Health (Udry, 1997), which allowed us to examine contextual risk factors and access to health care. The larger study was a randomized controlled trial of a cultural adaptation of the cognitive behavioral HIV risk reduction intervention known as "Becoming a Responsible Teen" or BART (St. Lawrence, Brasfield, Jefferson, Alleyne, O'Bannon, & Shirley, 1995).

BACKGROUND AND SIGNIFICANCE

Haitian American adolescents were chosen as the focus of our project because they face many negative circumstances such as inadequate housing, education, and employment, delinquency, and marginalization that contribute to HIV risk behavior (Nachman, 1993). There is growing concern for Haitian American adolescents' involvement in HIV risk and other associated problematic behaviors. According to several reports, there continues to be a rise in violence, gangs, drug and sex risk behaviors among Haitian American youths in Miami-Dade County (Miami Herald, August 10, 18, 1997). Moreover, identifiable Haitian communities are evidencing signs of social and economic disorganization (Miami Herald, December, 1997). These situations translate into very strong effects on the local society and its institutions, such as the correctional system, hospitals, school, and the family. In Miami's metropolitan area, the neighborhood of "Little Haiti," which contains the major immigrant population, has become known in the media as one the most dangerous in South Florida, distinguished for its high rate of crime, violence, drug abuse and sex risk behaviors, and delinquent acts committed by Haitian American youths under 18 years of age.