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A Profile of U.S.-Based Culturally Sensitive HIV/AIDS Prevention Interventions, 1996-2007.

Introduction

Attention to culture is an important aspect of social development theory. Many well- known social problems such as poverty and poor physical and mental health are influenced by attitudes and behaviors that are culture specific. When social issues are addressed using interventions that keep cultural rights in focus, cultural groups become empowered so that all affected can enjoy the best of possible outcomes. The United States has a rich history of culturally sensitive interventions in the arena of prevention and treatment of HIV/AIDS. The goal of this study is to provide a systematic review of culturally sensitive HIV/AIDS interventions in the United States, offering models that can be adopted in developing country contexts.

Globally, thirty-five million people were living with HIV by the end of 2013. To date, the incidence of AIDS is higher in sub-Saharan Africa than elsewhere in the world, accounting for nearly 71 percent of the people living with HIV worldwide (World Health Organization [WHO], 2016). Furthermore, it has been found that a majority of HIV/AIDS cases are globally concentrated in the population of adults aged fifteen to forty-nine years, who are also breadwinners of families and comprise the major work force of nations. It is estimated that 0.8 percent of adults aged fifteen to forty-nine years worldwide are living with HIV. In sub-Saharan Africa, nearly one in every twenty adults is living with HIV (WHO, 2016). The prevalence of HIV/AIDS has had a severely negative social impact upon productivity in economic sectors and has increased demand for supplies and services of health sectors. Moreover, it has posed unprecedented challenges for social support systems and traditional coping mechanisms, especially in developing countries (Danziger, 1994).

The international AIDS pandemic has drawn attention to the importance of cultural sensitivity in HIV prevention programming in addressing different cultural norms of subpopulations or populations in various countries. Cultural sensitivity has been widely used in HIV/AIDS prevention interventions in the United States, targeting subpopulations with their own subcultures, such as racial/ethnic minorities and drug users. An understanding and evaluation of how culture has informed HIV/AIDS prevention interventions in the United States may help identify the gap in culturally sensitive HIV/AIDS prevention interventions and provide suggestions for future HIV/AIDS prevention research and intervention programming in the United States. The lessons learned from the U.S. experience may also inform international HIV/AIDS prevention initiatives that may serve people in various regions and with different cultures.

When the term culture is used in HIV/AIDS prevention research, it usually refers to some group that is distinct from the mainstream culture. Among culturally sensitive HIV/AIDS prevention interventions (CSHAPIs) in the United States, culture remains an umbrella term that covers all high-risk subcultural groups. In contrast, research that does not incorporate cultural features implicitly refers to Caucasian culture. This ambiguous definition of cultural sensitivity can be problematic, for example, when cultural sensitivity is used to deflect attention away from the structural causes of AIDS. It may provide a basis for blaming subcultural groups for their insensitivity to the intervention treatments specifically tailored to their subcultures.

In order to demonstrate effectiveness in enhancing interventions, empirical evidence must prove that cultural sensitivity is helpful. However, a comparison of CSHAPIs with non-CSHAPIs may be confounded by the ambiguous definition of cultural sensitivity and inconsistent operationalizations for different subcultural groups. Thus, an investigation of the culturally sensitive components in the CSHAPIs is the first step leading to a critical examination of their effectiveness. These findings may be used to aid in further categorizing and planning of CSHAPIs.

This study used CSHAPIs in the United States that were published between 1996 and 2007 (see the appendix for a complete list of these studies). It investigated general characteristics of the CSHAPIs in terms of their participants, study designs, and program objectives. It also examined operationalization of cultural sensitivity among different subcultural groups and identified gaps that exist within and across CSHAPIs.

Methods

Criteria of Eligibility

Because culture is contextually embedded, only studies conducted in the United States, reported in English, and published between 1996 and 2007 were eligible. Eligible interventions were required to include components of HIV sexual risk intervention and have either HIV sexual risk behavior (unprotected sex) or HIV sexual preventive behavior (condom use) as a behavioral measure. They were required to be designed as randomized controlled trials or quasi-experiments with pretests and posttests.

In addition, at least 70 percent of the subjects in each eligible study were required to fall into one of the following social categories: men having sex with men (MSM), drug users, or members of a single racial/ethnic subpopulation (Vinh-Thomas, Bunch, & Card, 2003). Because sex norms or networks of MSM and drug users may have more influence on HIV sexual risk behavior than their racial/ethnic cultures, ethnicity was not a criterion for the studies with 70 percent or more MSM or drug users in the samples. However, other eligible studies were required to include a single racial/ethnic group for at least 70 percent of their samples.

A pilot study of twenty CSHAPIs gathered through keyword searches on major academic databases was conducted to develop culturally sensitive themes. Studies were eligible if they explicitly claimed or implicated cultural sensitivity in intervention contents or strategies. Eligible studies included one or a combination of the following culturally sensitive indicators:

* Programs that involve community participation: Bernal, Bonilla, and Bellido (1995) indicated the importance of context in culturally sensitive interventions with Hispanics. Community participation may make interventions culturally sensitive because local variations of behavioral norms and local resources may inhibit or facilitate HIV/AIDS prevention. Community participation may include activities to highlight a program theme, including pilot testing interventions in the targeted population and/or using focus groups before or in the middle of the intervention.

* Program themes that address self-pride in relation to social identities of the participants: People's racial/ethnic status, gender status, and sexual preferences are often sources of social oppression. Self-pride is considered a resource that may buffer stress due to social discrimination (Williams, Spencer, & Jackson, 1999). Stress has been linked to risky sexual behavior among MSM (Martin, Pryce, & Leeper, 2005).

* Program themes that address gender roles in a specific culture: Behavioral norms in a culture are often contingent on gender roles. Wilson and Miller (2003) identified gender roles as influential in HIV prevention initiatives. Gender roles may influence people's sexual behavior. This study includes interventions addressing gender roles in a specific culture.

* Program themes that address social responsibilities: Responsibilities include family and community obligations that are important for individual integration with the community. Marin (1993) indicated that a culturally appropriate intervention is based on cultural values of the subpopulation. Racial/ethnic minority cultures (such as African American, Hispanic, and Asian cultures) place more emphasis on individual obligations to families and/or communities than Caucasian culture.

* Programs that address life experience of participants: A subculture may emerge out of people's collective attempts to solve their shared problems that are often associated with their social positions and geographical locations (Sebald, 1984). Life experience covers the social environment and significant experiences associated with social categories of participants, for example, experiences with urban settings, poverty, or drug use.

* Programs that use at least one facilitator matching participants' social categories or having cultural competency: Jezewski's culture-brokering model (Jezewski & Sotnik, 2001) suggests that an effective culture broker needs knowledge, skills, sensitivity, and awareness of cross-cultural variables to solve conflicts and problems due to cultural differences. Program facilitators may function as cultural brokers between intervention researchers and participants. In addition, facilitators matching participants' social categories may be considered a more credible source of information. Therefore, this study includes interventions that used facilitators or film presenters matching participants' significant social categories, such as drug users, ethnic minorities, or gender.

* Programs that use ethnic language or music: Bernal and colleagues (1995) suggested that the use of culturally ethnic language that was emotional appealed to Hispanics. Similarly, Marin (1993) indicated that strategies of culturally appropriate interventions must fit within the preferred behavioral repertoire of the targeted group. This study includes interventions using African American English, Spanish, and/or ethnic music.

Criteria of Exclusion

Multiple criteria of exclusion were applied in order to eliminate studies with heterogeneous topics. This study focused on risky sex behavior; therefore, drug treatment/prevention interventions without the inclusion of a sexual risk component in the intervention logic were excluded. Similarly, it excluded HIV/AIDS sexual risk interventions that did not include either unprotected sex or condom use as a behavioral measure. Interventions focusing on preventing other sexually transmitted diseases or pregnancy were also excluded because other diseases or pregnancy may be related to different sets of cultural beliefs and behavioral expectancy. Structural HIV/AIDS interventions targeting the economic or social structure of a community were excluded.

This study excluded interventions in which peer outreach recruiters had not functioned as facilitators or possibly role models in the CSHAPIs. In addition, interventions targeting HIV-positive patients, patients with severe mental illness, or inmates were excluded, as were interventions reporting behavioral indexes combining measures of sexual communication, sexual behavior, and/or drug user behavior, which are not direct measures of sexual behavior that may transmit HIV. Finally, studies without comparison groups in the design were not eligible, nor were other meta-analyses or studies reporting an intervention profile, cost, or process without providing empirical data of sexual behavior.

Data Collection

Data collection began by reviewing titles and abstracts of intervention studies. Databases and research registers were searched via a combination of the following keywords: HIV or AIDS; prevention or intervention or program; training, education, clinical trial, or randomized controlled trial; and behavior or condom. A total of 5,889 studies were identified through a database search (which included Medline, Proquest Dissertations & Theses, Social Sciences Citation Index, and Social Services), a manual search of thirty-two journals and the reference sections of eligible studies, and the Cochrane Collaboration Register. Further screening based on the inclusion and exclusion criteria yielded a list of 291 potentially eligible studies.

The second stage involved looking through these studies for culturally sensitive indicators, behavioral outcomes, study designs, and intervention subjects. This search resulted in a list of 50 eligible studies with different CSHAPIs. Figure 1 illustrates this process.

The entire set of eligible studies was coded by the author. Due to the heterogeneity of eligible studies, semi-open coding was conducted to ensure inclusiveness of the characteristics of eligible studies.

Results

Demographic Characteristics

The 50 CSHAPI studies consisted of 26,500 participants (19,088 in cohort studies and 7,412 in cross-sectional studies). These studies were conducted in more than ten states (k = 44), with slightly more than a quarter (27.2%) taking place in California. Other states included Georgia (9%), Wisconsin (9%), and New York (6.8%). As shown in table 1, African Americans were the most highly represented subpopulation (36%), followed by drug users (28%), whereas Caucasians (8%) were the least represented. More studies targeted females (consisting of more than 70% in each sample) than males (39.6% vs. 27.1%). Seventy-five percent of the studies focused on adults over the age of twenty with a median age of 32.4. Based on the aggregate of reports on marital and socioeconomic status (table 2), the CSHAPI participants represented those who were single (never married [55.7%] or separated/divorced/widowed [21.1%]), poorly educated (mean of 10.9 years of education), and unemployed or employed part-time (80.8 %).

Study Designs

More than 90 percent of the CSHAPI studies used money as an intervention incentive for participants (mean = $54.1, SD = $32.3). About half of the studies recruited the participants from their own communities. The remainder of the studies recruited participants from specific locations frequented by the targeted subpopulations, such as health or STD clinics (20.4%), drug treatment centers (8.2%), or gay bars (4.1%).

There were 120 intervention conditions across the studies, including 83 CSHAPIs, 18 non-CSHAPIs, 8 no-treatment groups, and 11 wait-listed groups. Typically, these studies involved a comparison of one or two CSHAPI conditions with a control/comparison condition. Sampling bias was largely prevented by randomly assigning participants to interventions (68% at the individual level, 24% at the community/site/time block level, and 8% without any randomization of assignment) instead of randomly selecting the participants from the targeted population (k = 50).

The studies were conducted at a variety of levels--individual, group, community, or some combination--although 74 percent were conducted at the small group level. In addition, all except one study included local samples, involving a comparison of the participants within one community or a comparison of several communities. An overwhelming majority, 92 percent, used cohort data rather than cross-sectional data. Therefore, generalization of these CSHAPI studies is largely limited to individuals in similar locales at an aggregate level.

Slightly more than half of the CSHAPI studies (56%) focused on different types of sex although some excluded certain types (such as oral sex or vaginal sex) due to small sample sizes. In addition, only 32 percent of the studies examined sexual behavior among different types of partners. Therefore, generalization of these studies may be limited, especially with regard to specific types of sex partners.

Furthermore, generalization of the CSHAPI studies is restricted in terms of the long-term effect of intervention. One-quarter of the studies had three-month follow-ups as the last tests (k = 48). The mean number of months of the last follow-up tests was 8.6 (median = 6, SD = 6.1). Few studies (12.5%) had their last follow-up tests conducted more than a year after the interventions were completed.

General Features of Culturally Sensitive HIV/AIDS Prevention Interventions

A majority (86%) of the CSHAPI studies were based on theories, with 38 percent using more than one theory. Although twenty-five different theories were adopted in the CSHAPI studies, no single theory is dominant. Social cognitive theory was found to be the most widely used (28% of the studies), followed by the Theory of Reasoned Action (22%) and the information-motivation-behavioral skills model (20%).

Table 3 shows that the major intervention objectives in the CSHAPI studies focused on individuals, although 74 percent of the studies were conducted at a group level. The most common intervention objective of the CSHAPI studies was improving individual behavioral skills (74%) through demonstration of condom use and/or sexual communication. Enhancement of intrapersonal competence (such as behavioral self-management, coping enhancement, individual empowerment, and self-esteem) was the next widely used intervention objective (50%).

The most common culturally sensitive feature of the CSHAPI studies (76%) was the use of facilitators or film actors matched with the participants' ethnic status or with their significant social experience, such as drug use, student status, or sexual orientation. An important function of this matching was role modeling of the intended intervention behavioral outcomes. Community participation was the second most common feature (62%). It involved local subpopulations in designing the interventions through conducting formation studies or pilot testing interventions. Culturally specific language or music was used in 30 percent of the studies. Among the culturally sensitive indicators, participants' social identity as related to their self-pride in their ethnic, gender, and/or sexual orientation status received the least attention in general (16%).

Drug User Studies

Table 2 showed that the participants in the drug user studies had an average of 11.9 years of education and were mostly single (45.5% never married, 27.9% separated/divorced/widowed). More drug user studies focused on females than males (38.5% vs. 15.4%).

Table 3 showed that intervention objectives of the African American drug user studies were similar to those of the CSHAPI studies in general, focusing on intrapersonal competence (80%) and behavioral skill training (80%). Table 4 shows that 90 percent of the African American drug user studies explicitly claimed cultural sensitivity to African American culture, although 20 percent did not report the detail of the culturally sensitive content. The single study that did not explicitly claim cultural sensitivity focused on the life experience of drug users. The African American drug user studies placed more emphasis on the salient social experiences of the targeted subpopulation, such as experiences in urban settings and experiences of poverty, drug use, and/or selling sex, than the average of CSHAPI studies (60% vs. 28%). Inclusion of peer facilitators/actors was also common (60%).

On the other hand, intervention objectives in the four mixed-group drug user studies were different from those in the CSHAPI studies in general. Enhancing social support and changing behavioral norms (or perceived norms) was the most common intervention objective (in three studies). Intrapersonal competence was less a focus in the mixed-group studies than in African American drug user studies (25% vs. 80%).

Table 4 showed that cultural sensitivity in the mixed-group drug user studies focused more on life experience pertaining to drug users (75%) and matching peer facilitators or actors (75%). These studies, compared with the African American drug user studies, were less likely to include ethnic culture, such as gender norms (25% vs. 40%) and social roles (0% vs. 40%).

Studies of Men Having Sex with Men (MSM)

Three of the five MSM studies targeted Caucasian MSM whereas one involved African American MSM and another targeted Asian and Pacific Islander MSM. Most of the Caucasian and Asian and Pacific Islander participants (over 66%) had at least attended college.

The CSHAPI studies targeting MSM were distinct from other CSHAPI studies in terms of intervention objectives and culturally sensitive features, but were heterogeneous among themselves. All of these studies had an emphasis on improving social support and/or changing behavioral or perceived norms. In addition, the MSM studies were more likely to match peer facilitators (100% vs. 62% of the CSHAPI studies) and had a focus on social identity (60% vs. 16%). Furthermore, the MSM studies had a lack of focus on gender norms, social roles, and social experience, such as poverty, drug use, and experience in urban settings.

The Caucasian MSM studies had more focus on the participants' involvement in their gay communities unlike other MSM studies that emphasized individuals' self-identity with regard to their racial/ethnic and sexual orientation status. For example, both the Asian and African American MSM studies aimed at changing HIV/AIDS risk behavior through improving the participants' interpersonal skills and intrapersonal competence. Individual empowerment of racial/ethnic minority MSM was achieved through promoting self-pride in belonging to both racial/ethnic and sexual orientation minorities. Only 33.3 percent of the Caucasian MSM studies had an emphasis on social identity.

None of the MSM studies for racial/ethnic minorities included interpersonal growth, such as gay community empowerment, whereas 66.7 percent of the Caucasian MSM studies had such a focus. Community empowerment was largely achieved through involvement of the community members in the process of intervention (33.3%) or through identifying the formation of pride in homosexuality in a group setting (33.3%).

African American Studies

Nine of the eighteen African American studies predominantly involved women, whereas four targeted males. Nearly 69 percent of these studies focused on adults. The participants tended to have low socioeconomic status (11.3 years of education, k = 8). More than 14 percent of the participants in eight studies (k = 8) had or were having substance abuse problems; among those who had substance abuse problems, about three-quarters engaged in selling sex for money or drugs (k = 4).

The prevailing intervention objectives and culturally sensitive indicators in these studies were similar to those of CSHAPI studies in general. The most common intervention objectives included behavioral skills training (83.3%) and enhancement of behavioral motivation and/or interpersonal skills (61.1%). In addition, a variety of culturally sensitive features were included in the African American studies. Use of matching facilitators/actors was the most popular culturally sensitive feature (88.9%), followed by community participation (66.7%). Other culturally sensitive features were incorporated in less than 40 percent of the studies.

Hispanic Studies

More than 50 percent of the nine Hispanic studies primarily targeted females, with about 55 percent targeting adults. However, the participants in the Hispanic studies were young (median age of 24.3) and were more likely to be married or have steady partners (40.1%, k = 6). On average, they had 9.4 years of education (k = 6) and a family income of less than $10,000 (66.2%, k = 4). In the four studies reporting national origins of the study participants, about 75 percent of the participants were born in foreign countries.

In general, the Hispanic studies were similar to the African American studies and used a variety of culturally sensitive features. Nearly 80 percent of the studies involved community participation. However, these studies were somewhat different from the African American studies in their emphasis on culturally specific language (88.9%) rather than on matching the facilitators with the participants' ethnic status (44.4%). Furthermore, in comparison with the African American studies, the Hispanic studies had more focus on social roles (33.3% vs. 16.7%) and social experience (33.3% vs. 11.1%), but had a lack of focus on social identity (0% vs. 33.3%).

Caucasian Studies

Among all CSHAPI studies, the participants of these four Caucasian studies were youngest (median age = 19.6). Three studies were conducted with mixed-gender heterosexual college samples, whereas one study targeted runaway homeless youth.

These studies were the least theoretically grounded (50% vs. 86%). The most common intervention objectives were behavioral skills training (75%), improving social support/behavioral norms (50%), and enhancing perceived susceptibility of the participants (50%). Interpersonal growth and intrapersonal competence were not included as intervention objectives.

In addition, these studies incorporated the fewest culturally sensitive features of all CSHAPI studies. All studies included matching peer facilitators/actors. Other features included community participation (25%) and culturally specific language/music (25%). These studies were more likely (50% vs. 5.6% of the African American studies and 11.1% of the Hispanic studies) to be conducted at an individual level.

Conclusion and Discussion

The use of cultural sensitivity among CSHAPIs was an attempt at the organizational level to enhance the intervention effectiveness of HIV/AIDS prevention. It was found that these studies tended to target African Americans, females, the poorly educated, or those who were not employed full time. On the other hand, the author found heterogeneity within the socioeconomic status of CSHAPI participants. The Caucasian or MSM studies (60% were Caucasian MSM studies) were more likely to involve participants with higher levels of education. This suggests a lack of CSHAPIs targeting Caucasians with low socioeconomic status.

Another research gap is studies targeting adolescents. Except for the Caucasian studies, all studies had a median age over twenty. However, adolescents are at a high risk for HIV infection because they are at a stage of sexual exploration and are less skillful in sexual communication or condom use. The author speculates that the lack of adolescent participants in the CSHAPIs may be due to this subpopulation's lack of attention to health matters. Another possible explanation is that intervention studies targeting adolescents were not included because they did not meet the criteria of eligibility. In revisiting the data, the author found that adolescent intervention studies had been conducted with mixed racial/ethnic samples (e.g., Coyle et al., 2006), but without a comparison group study design (e.g., Ebreo, Feist-Price, Siewe, & Zimmerman, 2002) or a behavioral measure (Lazebnik, Grey, & Ferguson, 2001), or they were conducted in school settings (e.g., Basen-Engquist et al., 2001) instead of in communities.

In addition, this study found that the existing CSHAPIs were limited in terms of an intervention objective. Similar to non-CSHAPI studies (e.g., Baker et al., 2003), these studies tended to focus on individuals' skills with condom use and intrapersonal competency as intervention objectives. Only 38 percent of these studies were aimed at improving social support or changing community norms. Although 74 percent of the studies were conducted at a group level, group learning may function to change individual perceptions of group norms with regard to HIV/AIDS preventive behavior. However, the author argues that these CSHAPIs may not induce behavior changes due to the conflict between small group norms and larger community norms. Interventions may present special social situations in which new group norms attenuate over time if their support structures disappear. Therefore, future CSHAPI studies should include community-level intervention components in their designs to examine the impact of community norm changes on HIV risk behavior.

In terms of a culturally sensitive indicator, this study found that these interventions were tailored to fit the specific cultural experiences of their participants. More than half involved participants in formative research or matched facilitators with the participants' status. The culturally sensitive indicators were, however, diverse between studies, targeting different subcultures. For example, matching facilitators was not as important as matching messages and conducting formative research in Hispanic American studies, largely because 74 percent of the Hispanic participants were born in foreign countries, not fluent in English, and still maintained their original cultural traits.

In addition, the two racial/ethnic minority MSM studies and 33.3 percent of the African American studies included ethnic pride as a culturally sensitive indicator, whereas this focus was lacking in the drug user, Hispanic, and Caucasian studies. Ethnic pride may be more of an issue for a racial/ethnic minority that has developed various social relationships with other racial/ethnic groups. This group is more likely to collectively accumulate experiences related to its racial/ethnic disadvantages in history and to internalize the experiences at an individual level. In a mixed-racial/ethnic context, social comparisons may function to strengthen the importance of ethnic pride. This pride may be less important for the Hispanic participants, who were less integrated with U.S. society, and the Caucasian participants, who were the racial/ethnic majority.

Furthermore, the author found that the drug user interventions tended to include social experiences (64.3%) rather than ethnic pride. It was assumed that drug use experience was more important than experiences related to racial/ethnic status. This corresponds to Watters's work (1996) that found racial/ethnic minority drug users to be discriminated against in their own racial/ethnic communities. The drug use networks these racial/ethnic minorities frequented may represent a close community in which subcultural norms and economic activities are both sustainable, making ethnic pride less important than their social and economic relationships with other drug users.

It was also found that, in general, the Caucasian studies and Caucasian MSM studies incorporated relatively fewer culturally sensitive indicators, largely because the intervention studies were based on mainstream culture. The lack of CSHAPI studies targeting Caucasians with low socioeconomic status, as indicated earlier, also reflects the assumption of the studies that cultural sensitivity refers to non-Caucasian culture. The author criticizes the insufficient representation of other Caucasians who are also socially oppressed, such as Caucasian drug users or adolescents, who are at a high risk of HIV infection. The experiences of socially repressed Caucasians are usually invisible in mainstream culture, which primarily belongs to middle-class adult men. Therefore, the author argues that HIV/AIDS prevention framed with the mainstream culture may not be effective for Caucasians who are socially oppressed. Exploration of salient culturally sensitive indicators for these groups may be the first step in developing interventions for this subpopulation. Further research on socially oppressed groups--other than MSM--may aid in understanding the relative importance of racial/ethnic status and social oppression in shaping safe sex behavior.

Finally, the study designs of the existing CSHAPI studies were found to have limited collective generalization. It was found that only 32 percent of the studies examined sexual behavior with different types of partners. This may limit the generalization to intervention effectiveness on changing HIV risk behavior with different sex partners. Prior studies (e.g., Civic, 1999; Fritz, 1998) have found that sex behavior changes may depend on types of sex partners. For example, people are more likely to use condoms with casual sex partners (Catania, Stone, Binson, & Dolcini, 1995). The author argues that this limitation in study designs may either inflate or deflate intervention effectiveness depending on the types of sex partners and the frequencies of their sexual behavior with different types of sex partners. In addition, the CSHAPI studies can be generalized only in terms of short-term intervention effectiveness because only 12.5 percent of the studies measured long-term intervention effectiveness one year after the interventions had been completed. This limitation hinders justification of the cost of CSHAPI studies. In order to examine long-term effectiveness of interventions, more studies are needed involving follow-up tests at least a year after interventions are completed.

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Basen-Engquist, K., Coyle, K., Parcel, G. S., Kirby, D., Banspach, S. W., Carvajal, S. C., & Baumler, E. (2001). Schoolwise effects of a multicomponent HIV, STD, and pregnancy prevention program for high school students. Health Education and Behavior, 28, 166-185.

Bernal, G., Bonilla, J., & Bellido, C. (1995). Ecological validity and cultural sensitivity for outcome research: Issues for the cultural adaptation and development of psychosocial treatments with Hispanics. Journal of Abnormal Child Psychology, 23, 67-82.

Catania, J. A., Stone, V., Binson, D., & Dolcini, M. M. (1995). Changes in condom use among heterosexuals in wave 3 of the AMEN survey. Journal of Sex Research, 32, 193-200.

Civic, D. (1999). The association between characteristics of dating relationships and condom use among heterosexual adults. AIDS Education and Prevention, 11, 343-352.

Coyle, K. K., Kirby, D. B., Robin, L. E., Banspach, S. W., Baumler, E., & Glassman, J. R. (2006). All4You! A randomized trial of an HIV, other STDs, and pregnancy prevention intervention for alternative school students. AIDS Education and Prevention, 18, 187-203.

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Appendix: Culturally Sensitive HIV/AIDS Prevention Interventions

The following culturally sensitive HIV/AIDS prevention interventions were included in this review:

Avants, S. K., Margolin, A., Usubiaga, M. H., & Doebrick, C. (2004). Targeting HIV-related outcomes with intravenous drug users maintained on methadone: A randomized clinical trial of a harm reduction group therapy. Journal of Substance Abuse Treatment, 26, 67-78.

Branson, B. M., Peterman, T. A., Cannon, R. O., Ransom, R., & Zaidi, A. A. (1998). Group counseling to prevent STD and HIV: A randomized controlled trial. Sexual Transmitted Diseases, 25, 553-560.

Carey, M. P., Braaten, L. S., Maisto, S. A., Gleason, J. R., Forsyth, A. D., Durant, L. E., & Jaworski, B. C. (2000). Using information, motivational enhancement, and skills training to reduce the risk of HIV infection for low-income urban women: A second randomized clinical trial. Health Psychology, 19, 3-11.

Carey, M. P., Maisto, S. A., Kalichman, S. C., Forsyth, A. D., Wright, E. M., & Johnson, B. T. (1997). Enhancing motivation to reduce the risk of HIV infection for economically disadvantaged urban women. Journal of Consulting and Clinical Psychology, 65, 531-541.

Choi, K. H., Lew, S., Vittinghoff, E., Catania, J. A., Barrett, D. C., & Coates, T. J. (1996). The efficacy of brief group counseling in HIV risk reduction among homosexual Asian and Pacific Islander men. AIDS, 10, 81-87.

Collins, C., Kohler, C., DiClemente, R., & Wang, M. Q. (1999). Evaluation of the exposure effects of a theory-based street outreach HIV intervention on African-American drug users. Evaluation and Program Planning, 22, 279-293.

Cottler, L. B., Compton, W. M., Ben Abdallah, A., Cunningham-Williams, R., Abram, F., Fichtenbaum, C., & Dotson, W. (1998). Peer-delivered interventions reduce HIV risk behaviors among out-of-treatment drug abusers. Public Health Reports, 113(Suppl. 1), s31-s41.

DeLamater, J., Wagstaff, D. A., & Havens, K. K. (2000). The impact of a culturally appropriate STD/AIDS education intervention on black male adolescents' sexual and condom use behavior. Health Education and Behavior, 27, 454-470.

DiClemente, R. J., Wingood, G. M., Harrington, K. F., Lang, D. I., Davies, S. L., Hook, E. W.,... Robillard, A. (2004). Efficacy of an HIV prevention intervention for African American adolescent girls: A randomized controlled trial. Journal of the American Medical Association, 292, 171-179.

Fisher, J., Fisher, W., Misovich, S., Kimble, D., & Malloy, T. (1996). Changing AIDS risk behavior: Effects of an intervention emphasizing AIDS risk reduction information, motivation, and behavioral skills in a college student population. Health Psychology, 15, 114-123.

Flaskerud, J. H., Nyamathi, A. M., & Uman, G. C. (1997). Longitudinal effects of an HIV testing and counseling programme for low-income Latina women. Ethnicity and Health, 2(1/2), 89-103.

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Ya-Chien Wang, PhD, is assistant professor, Department of Medical Sociology and Social Work, Chung Shan Medical University, and consultant in the Social Services Section of the Chung Shan Medical University Hospital, Taichung City, Taiwan, Republic of China.

This research was supported by the Michigan State University Research Enhancement Reward. The author would like to extend her gratitude to Toby Ten Eyck for his valuable contributions to the conceptualization of the ideas in this article.
Table 1 Demographic characteristics of the CSHAPI participants

                    No. of                        African
                    studies   Drug user    MSM    American   Hispanic
Characteristic      (k = 50)  (k = 14)   (k = 5)  (k = 28)   (k = 9)
                     k   %     k   %      k   %    k   %      k   %

Racial/ethnic
majority
  Caucasian          7  14     0   0      3   60   0    0     0    0
  African American  29  58    10  71.4    1   20  18  100     0    0
  Hispanic           9  18     0   0      1   20   0    0     9  100
  Asian              1   2     0   0      0    0   0    0     0    0
  Mixed groups       4   8     4  28.6    0    0   0    0     0    0
Gender majority
  Male              13  27.1   2  15.4    5  100   4   22.2   2   22.2
  Female            19  39.6   5  38.5    0    0   9   50.0   5   55.6
Mixed groups        16  33.3   6  46.2    0    0   5   27.8   2   22.2
Age (median)            32.4      38.5        31       32.1       24.3

                    Caucasian
Characteristic      (k = 4)
                     k   %

Racial/ethnic
majority
  Caucasian          4  100
  African American   0    0
  Hispanic           0    0
  Asian              0    0
  Mixed groups       0    0
Gender majority
  Male               0    0
  Female             0    0
Mixed groups         3  100
Age (median)             19.6

Table 2 Aggregate estimation of the socioeconomic and marital status of
the participants in CSHAPIs

                 No. of                            African
                 studies    Drug users    MSM      American   Hispanic
                k     %     k    %      k    %     k    %     k    %
                     (SD)       (SD)        (SD)       (SD)       (SD)

                                            Employment
Unemployed      17   80.8   9   85.2    1   56.2   5   78.9   2   78
 /employed          (12.2)     (10).2      (13.2)      (8.5)
 part-time
Family income   11   63.9   1   55.9    1   16.2   5   73.2   4   66.2
 < $10,000/yr       (22.1)                            (11)       (23)
                                            Education
Mean years      19   10.9   4   11.9    1   13.2   8   11.3   6    9.4
                     (1.9)      (0.9)                  (1.6)      (2.0)
High school     15   60.6   8   68.6    3   25.2   3   67.8   1   81.5
 or less            (24.4)     (14.9)       (0.1)     (27.7)
                                          Marital status
Single, never   13   55.7   6   45.5    1   88.0   3   76.7   3   44.3
 married            (22.4)      (6.3)                 (20.4)     (28.5)

Married/steady  17   25.5   8   21.1         -     3    8.1   6   40.1
 relationships      (19.2)     (10).2                  (6.3)     (23.7)
Separated        8   21.1   4   27.9         -     3   15.2   1   12.3
 /divorced          (11.7)      (5.9)                 (15.4)
 /widowed

                Caucasian
                k    %
                    (SD)

                Employment
Unemployed           - (a)
 /employed
 part-time
Family income        -
 < $10,000/yr
                Education
Mean years           -
High school     3    0
 or less
                Marital status
Single, never        -
 married
Married/steady       -
 relationships
Separated            -
 /divorced
 /widowed

(a) Data were not obtained or are not reported.
Note: The aggregate is estimated based on the number of available
studies reporting raw information. Studies may report more than one
measure of employment, education, and/or marital status.

Table 3 Description of CSHAPIs

                       No. of
                       studies      Drug users              MSM
                       (k = 50)     (k = 14)              (k = 5)
                                 African
                                 American  Mixed     Caucasian  Minority
                                 (k = 10)  (k = 4)   (k = 3)    (k = 2)
                        k   %     k   %    k   %     k   %      k   %

                                  Intervention objective
Perceived               9  18     2  20    1  25     2  20      1  25
 susceptibility
Behavioral motivation  21  42     2  20    2  50     2  20      2  50
Interpersonal skills   23  46     3  30    2  50     3  30      2  50
Intrapersonal          25  50     8  80    1  25     8  80      1  25
 competence
Interpersonal growth    3   6     0   0    0   0     0   0      0   0
Social support         19  38     5  50    3  75     5  50      3  75
 /community norms
Behavioral skill       37  74     8  80    2  50     8  80      2  50
 training
                                  Intervention level
Individual              5  10     1  10    0   0     1  10      0   0
Group                  37  74     7  70    2  50     7  70      2  50
Individual & group      3   6     1  10    1  25     1  10      1  25
 levels
Community               5  10     1  10    1  25     1  10      1  25

                       African
                       American  Hispanic  Caucasian
                       (k = 18)  (k = 9)   (k = 4)
                        k   %     k   %     k   %

                        Intervention objective
Perceived               3  16.7   1  11.1   2  50
 susceptibility
Behavioral motivation  11  61.1   5  55.6   0   0
Interpersonal skills   11  61.1   3  33.3   0   0
Intrapersonal          10  55.6   3  33.3   0   0
 competence
Interpersonal growth    1   5.6   0   0     0   0
Social support          3  16.7   1  11.1   2  50
 /community norms
Behavioral skill       15  83.3   7  77.8   3  75
 training
                          Intervention level
Individual              1   5.6   1  11.1   2  50
Group                  17  94.4   8  88.9   0   0
Individual & group      0   0     0   0     1  25
 levels
Community               0   0     0   0     1  25

Table 4 Culturally sensitive indicators by subcultural groups

                      No. of
                      studies      Drug users              MSM
                      (k = 50)     (k = 14)              (k = 5)
                                African
                                American  Mixed     Caucasian  Minority
                                (k = 10)  (k = 4)   (k = 3)    (k = 2)
                       k   %     k   %    k   %     k   %      k   %

Community             31  62     4  40    2  50     1  33.3    2  100
 participation
  Formative research  26  52     4  40    2  50     1  33.3    0    0
  Pilot test          15  30     2  20    0   0     0   0      2  100
Social identity        8  16     0   0    0   0     1  33.3    2  100
 (pride)
  Ethnicity            8  16     0   0    0   0     0   0      2  100
  Women                2   4     0   0    0   0     0   0      0    0
  Sexual orientation   3   6     0   0    0   0     1  33.3    2  100
Gender norms          12  24     4  40    1  25     0   0      0    0
Social roles          10  20     4  40    0   0     0   0      0    0
 (responsibility)
  Family               8  16     3  30    0   0     0   0      0    0
  Community            5  10     2  20    0   0     0   0      0    0
  Other                2   4     2  20    0   0     0   0      0    0
Social experience     14  28     6  60    3  75     0   0      0    0
  Urban settings       6  12     2  20    0   0     0   0      0    0
  Poverty              2   4     1  10    0   0     0   0      0    0
  Drug use            11  22     6  60    3  75     0   0      0    0
  Selling sex          1   2     1  10    0   0     0   0      0    0
Matching              38  76     6  60    3  75     3  33.3    2  100
 facilitator/actor
  Facilitator         31  62     5  50    2  50     3  33.3    2  100
  Film/actor          16  32     2  20    3  75     0   0      0    0
Culturally specific   15  30     1  10    0   0     0   0      1   50
 language/music
  Language            12  24     1  10    0   0     0   0      1   50
  Music                5  10     0   0    0   0     0   0      0    0

                      African
                      American  Hispanic  Caucasian
                      (k = 18)  (k = 9)   (k = 4)
                       k   %     k   %     k    %

Community             12  66.7   7  77.8   1   25
 participation
  Formative research  12  66.7   6  66.7   1   25
  Pilot test           7  38.9   4  44.4   0    0
Social identity        6  33.3   0   0     0    0
 (pride)
  Ethnicity            6  33.3   0   0     0    0
  Women                6  33.3   0   0     0    0
  Sexual orientation   0   0     0   0     0    0
Gender norms           5  27.8   2  22.3   0    0
Social roles           3  16.7   3  33.3   0    0
 (responsibility)
  Family               2  11.1   3  33.3   0    0
  Community            2  11.1   1  11.1   0    0
  Other                0   0     0   0     0    0
Social experience      2  11.1   3  33.3   0    0
  Urban settings       2  11.2   2  22.2   0    0
  Poverty              0   0     1  11.1   0    0
  Drug use             0   0     2  22.2   0    0
  Selling sex          0   0     0   0     0    0
Matching              16  88.9   4  44.4   4  100
 facilitator/actor
  Facilitator         13  72.2   4  44.4   2   50
  Film/actor           8  44.4   0   0     3   75
Culturally specific    4  22.2   8  88.9   1   25
 language/music
  Language             2  11.1   8  88.8   0    0
  Music                3  16.7   0   0     1   25
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Publication:Social Development Issues: Alternative Approaches to Global Human Needs
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