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.
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...