Environmental barriers to HIV prevention among incarcerated adolescents: a qualitative assessment

Adolescence, Summer, 2005 by Darcy Freedman, Laura F. Salazar, Richard A. Crosby, Ralph J. DiClemente

Adolescents are at increasing risk for HIV infection. Half of all new HIV infections in the U.S. occur among people aged 25 or younger and the majority of these infections are sexually transmitted (Office of National AIDS Policy, 1996). Nationally, the number of new HIV infections is declining; however, there is no comparable decline among adolescents (Centers for Disease Control and Prevention [CDC], 2001).

Among adolescents, those in juvenile detention facilities are at disproportionate risk for HIV infection (Teplin, Mericle, McClelland, & Abram, 2003). Compared to nondetained adolescents, incarcerated adolescents report earlier sexual debut (Robertson & Levin, 1999; Pack, DiClemente, Hook III, & Oh, 2000), greater prevalence of sexual intercourse (U.S. Department of Health and Human Services [DHHS], 1994; Morris, Harrison, Knox, Tromanhauser, Marquis, & Watts, 1995; Robertson & Levin, 1999; Pack et al., 2000), greater number of sexual partners (Canterbury, McGarvey, Sheldon-Keller, Waite, Reams, & Koopman, 1995; DHHS, 1994; Morris et al., 1995; Pack et al., 2000), and a lower prevalence of consistent condom use (Morris, Baker, Valentine, & Pennisi, 1998; Morris et al., 1995; Pack et al., 2000).

Although studies have investigated determinants of HIV risk behaviors among adolescents, these studies have mostly focused on individual-level factors (e.g., knowledge, attitudes, skills, beliefs, and cognitions) (Cohen, Scribner, & Farley, 2000). Emerging evidence, however, suggests that environmental factors may also have an equal if not greater effect on adolescents' sexual risk behaviors and ultimately on the prevention of HIV transmission (Rotheram-Borus, 2000). Environmental factors represent elements of incarcerated adolescents' environments which facilitate or impede their risk for HIV and other sexually transmitted diseases (STDs). Although a few studies with incarcerated adolescents have assessed the influence of environmental factors on health-risk behaviors such as drug use and aggression (e.g., McGarvey, Canterbury, & Waite, 1996; Shahinfar, Kupersmidt, & Matza, 2001; Sigda & Martin, 1996), studies are lacking that specifically focus on environmental factors and incarcerated adolescents' risk for HIV.

Before environmental or structural interventions for incarcerated adolescents can be conceptualized and implemented, investigators first need to identify relevant environments for this population (e.g., where do incarcerated adolescents find themselves?) (Sumartojo, 2000). Second, we must determine influential factors within these environments that impact incarcerated adolescent's sexual decision-making and risk behavior (e.g., what messages, resources, opportunities within these environments directly or indirectly impact their risk for HIV/STDs?). Accordingly, the purpose of this research was to identify, qualitatively salient environments for incarcerated adolescents and factors within these environments that facilitate or impede the HIV risk behaviors of this high-risk group. The study was guided by the ecological systems theory which posits that adolescents' behavior is a function of environmental and individual characteristics (Bronfenbrenner, 1979).

METHOD

Setting

The setting for this qualitative study was three Regional Youth Detention Centers (RYDCs) in Georgia. Participants were from both urban and rural communities (Government Information Sharing Project, 1998). RYDCs represent secure, short-term centers for adolescents awaiting trial in Juvenile or Superior Court, or placement elsewhere within the Department of Juvenile Justice (Georgia Department of Juvenile Justice, 2002).

Participants

This study recruited a convenience sample from the RYDCs in February 2002. Participants were eligible for the study if they were 14-19 years of age and English speaking. This study was approved by the Emory University and the Georgia Juvenile Justice Department Internal Review Boards. Informed parental consent and assent were obtained from all adolescents prior to study enrollment. A total of 18 males and 10 females participated (Table 1).

Procedure

Six focus groups, stratified by gender, were conducted. Each group consisted of 3 to 7 adolescents. The first author facilitated all group sessions, which were tape recorded for transcription. She began each session by reading a description of the session purpose, format, and ground rules. Specifically, adolescents were told "the purpose of this study was to identify things that may help teens protect themselves from HIV infection or that may cause teens to be more at risk for infection."

Focus groups lasted approximately one hour. A semi-structured interview guide that assessed adolescents' beliefs regarding environmental factors related to their HIV risk behaviors was used. Adolescents were asked to think about their school, family, church, neighborhood, and the media and how these environments may affect their HIV risk behavior. Adolescents were not asked about the detention center environment because RYDSs are short-term facilities. Participants also completed an anonymous demograpics questionnaire.