Small Islands, Big Problem: HIV/AIDS and Youth in Trinidad and Tobago
Baird, Donna S
PROBLEM: In the Caribbean region, women and young girls are becoming infected with HIV at a 6:1 rate more than men. Our study investigated effective methods for reducing HIV/AIDS risks among adolescent girls in the Caribbean.
METHODS: One hundred females, aged 15-21, were randomly assigned into a control or intervention group. Subjects were assessed at baseline and postintervention.
FINDINGS: Analysis of variance revealed that items measuring feelings about self, perceived risk, and sexual attitudes had statistically significant postintervention increase.
CONCLUSION: Sustainable HIV/AIDS prevention programs that address stigma, promote HIV testing, and reinforce safer sex practices are needed.
Search terms: Adolescents, Caribbean, HIV/ AIDS, prevention, sexual risk
Introduction
The Caribbean is the most affected area in the Americas and the second most affected region globally, after sub-Saharan Africa, to be impacted by HIV/AIDS. Consequently, by 2005, roughly 4,970 newly contracted HIV cases were projected for the Caribbean region (CAREC/PAHO/WHO, 2001). Moreover, the highest rates of HIV/AIDS have been reported among Caribbean countries with tourist-dependent economies. Interestingly, however, even though Trinidad and Tobago are not considered a tourist-dependent economy, Tobago’s recent entry into the tourism industry has propelled that island into the mainstream of the HIV/AIDS crisis in the region.
Over the last two decades, Trinidad and Tobago witnessed an unprecedented 500% increase in HIV/ AIDS cases (CAREC, 2000). In addition, at the end of 2001, the country experienced an additional 14% increase in AIDS cases. Specifically, incidence rates in the region reflect a continually growing epidemic in the general female population, particularly among those aged 15-24. Indeed, heterosexual transmission is the primary mode for the 64% of new HIV infections among women of all ages in the Caribbean (DeYoung, 2001; St. Lawrence et al., 1998). Women and young girls have become the most vulnerable and most exposed group to the current HIV/AIDS epidemic (UNAIDS/ WHO, 2002; Stuart, 2000). Moreover, it is estimated that women comprise 35% of the 440,000 adults and children living with HIV /AIDS in the Caribbean (UNAIDS/WHO). While youth aged 15-24 make up 18% of the total population in Trinidad and Tobago, they account for 48% of all reported HIV infections (Voisin, Baptiste, Da Costa Martinez, & Henderson, 2006).
Having little control over their partner’s sexual behavior (Weeks, Schensul, Williams, Singer, & Grier, 1995), having older partners, the high costs of condoms (d’Cruz-Grote, 1996), and feeling incapable and powerless to discuss safe sex even when they recognize the risk of unprotected sex (Amaro, 1995; International Organization for Migration, 2004; Neely-Smith, 2003) are barriers that especially place young girls and women of color at risk for HIV (Ickovics & Rodin, 1992).
In its 2000 study, the Pan American Health Organization (PAHO) found that adolescents in the Caribbean reported their first sexual encounter by age 10 or younger (Ohene, Ireland, & Blum, 2005). In addition, almost two thirds of the adolescents had engaged in sexual intercourse before the age of 13. Moreover, in the same study, adolescent males indicated that they had five or more sexual partners, and most reported that they did not worry about contracting HIV or developing AIDS.
Crosby et al. (2001) identified that adolescent complacency about acquiring a sexually transmitted infection (STI) or HIV appeared to be related to repeated risky sexual behavior and negligence with seeking effective treatment. Furthermore, adolescents who had acquired an STI were more worried about STI reinfection and less so about HIV. Other studies (Blum et al., 2003; DiClemente, 1992; Main et al., 1994) have also found that sexually active adolescents continue to engage in unprotected sexual intercourse even after they become knowledgeable about HIV transmission (Halcon et al., 2003), suggesting that adolescents might need more direct and continuous prevention programs than older groups.
Developmentally, adolescence is a time of rapid physical, emotional, social, and psychological changes. The major task of adolescence is discovering one’s own identity separate from that of family and peers. Beginning and progressive refinement of abstract thinking, ability to problem solve, autonomy, initiation of intimate relationships, and the push-pull of loyalty to family versus peer group are all components of normal adolescence (Breinbauer & Maddaleno, 2004). In addition, Bandura’s self-efficacy theory (1977, 1990) asserts that adolescents are guided by perceptions of their competence. This suggests that the more confident the adolescent feels about his or her ability to enact a given behavior successfully, the more likely the adolescent will implement that behavior (Sandburg, Rotheram-Borus, Bradley, & Martin, 1988). Self-efficacy theory posits that adolescents can be taught to solve their own problems (McDermott, 1998). The theory further suggests that information alone is often not enough to bring about behavioral change; adolescents must have the resources and support available to make the changes necessary to protect themselves.
The purpose of this study was to investigate effective methods for promoting safer sex behaviors and reducing HIV/AIDS risks among adolescent girls in the Caribbean. To accomplish this, we used the “Be Proud! Be Responsible!” (BPBR) HIV prevention program. This model is included in the Centers for Disease Control and Prevention (CDC) compendium of effective HIV prevention programs for reducing risk behaviors among African American youth.
Methods
Sample
Flyers were used to advertise the study. Females (N = 100) between the ages of 15 and 21 years were recruited from high schools and local communities in Trinidad and Tobago. Respondents were randomly assigned to either an experimental (n = 50) or control group (n = 50) as they consented. The mean age of participants in the control group was 16.22 (SD = 1.48); the experimental group was older, with a mean age of 17.56 (SD = 1.95). The majority of the sample attended high school (70%, mean = 16.07, SD = 1.25). Less than 10% reported that they had dropped out (mean = 18.80, SD = 1.58) of high school. The majority of the respondents (96%) were Afro-Caribbean and single. As is common in the Caribbean, the overwhelming majority of respondents (99%) lived with parents even if they had completed school and had a job.
Measures
An adapted version of the BPBR (Jemmott, Jemmott, & Fong, 1998) instrument was used to assess sexual risk behavior. Items on the self-report questionnaire were reworded because of cultural sensitivities and to facilitate better understanding of the items. Pilot testing of the adapted instrument occurred with a representative sample of Afro-Caribbean girls (N = 30) prior to the study. The instrument consisting of 36 paperand-pencil items was administered. The instrument covered six domains: sexual attitudes, feelings about self, sexual behavior, relationships, self-efficacy, and perceived risk. Appendix 1 contains a sample of the questions included in the adapted instrument. The number of items for each domain varied. Overall, domain items had internal consistency estimates of alpha 0.05 and test-retest reliability. The experimental group received the BPBR intervention, and the control group viewed drug abuse education videos. Questionnaires were administered pre- and postintervention for both groups. Completion time for each administration was approximately 30-45 min, and facilitators were available to assist with any questions or concerns.
Procedures
Following institutional review board approval, and prior to administering the survey, all recruited respondents were given a thorough description of the study, and consent and assent were obtained. Parental consent was obtained for respondents younger than 18 years. Respondents were also informed that they were free to cease participation at any time without penalty or repercussion. Those wishing to withdraw were advised to notify a study staff. All respondents remained in the study through completion.
Facilitators
Two female adult facilitators who had teaching backgrounds were recruited from the community. They were assisted by two peer facilitators. All facilitators completed a 2-day training session conducted by the principal investigator (PI) that included the purpose of the program, how to respond to questions, and how to handle potentially difficult situations (e.g., if a respondent decided to terminate participation).
Intervention
The experimental group attended one 5-hr session where the BPBR intervention was used. This session provided basic anatomy information and HIV/AIDS education by using learning games such as AIDS basketball, and videos that featured rap artists Salt-NPepa, and a skit by Robert Townsend. Respondents seemed particularly excited about opportunities to role-play where they learned negotiation and refusal skills using SWAT techniques (Jemmott, Jemmott, & Fong, 1998): say no to unsafe behavior, be prepared to explain why you want to be safe, provide alternatives, and talk it out. Role-plays were critiqued by other group participants. The control group attended one 5-hr session led by study staff where they viewed substance abuse messages and engaged in a group discussion on the information provided.
Analysis
We used descriptive statistics to report means, and repeated measures anova (analysis of variance) to test for variance (time 1 [pretest] versus time 2 [posttest]). Meaningful changes and p-values were used to report the effect of the intervention.
Results
Statistical findings of pre- and postintervention mean scores are presented in Table 1. Data are provided for those dependent variables that reflected significance at a p-value of 0.05: feelings about self (Figure 1), sexual attitudes (Figure 2), and perceived risk (Figure 3). Analysis of the sexual behavior, relationship, and self-efficacy variables yielded no significant effects. Additionally, there was no significance between in-school versus out-of-school means for both groups.
Using a 2 × 2 × 2 mixed anova, significance was only found on items that measured feelings about self, perceived risk, and sexual attitudes. Following completion of the posttest questionnaire, respondents engaged in a brief focus group discussion, led by the PI, where they critiqued the intervention. According to the feedback given, respondents indicated that they wanted to hear real-life stories, and to see images of people afflicted by HIV and AIDS instead of using music videos or constructed vignettes to convey HIV information. This truly resonated when respondents engaged in the role-play exercises. Respondents seemed to “come alive” once they were allowed to create HIV dramatizations around their personal experiences. Overall, however, respondents felt that engaging in the BPBR exercise was beneficial, and provided them with new information and skills that they did not have previously.
Other postintervention results showed that 99% of the experimental group indicated that “it was likely that they would use a condom if they had sex in the next 3 months.” Moreover, 98% indicated that they never had an HIV test. Additionally, respondents expressed that testing would result in “people knowing their business,” which could lead to stigmatization, and possible alienation by their families and/or communities.
Discussion
In our study, female adolescents who received the experimental treatment reflected significant changes postintervention. The findings demonstrated that the BPBR program of cognitive-behavioral intervention may be effective for changing perception of risk, sexual attitudes, and feelings about self. Findings suggested a possible readiness and/or intent of respondents to change their sexual behaviors (e.g., delaying sex, condom use) and to adopt sexually responsible behaviors. These findings have limited generalizability to sexually active adolescent females in Trinidad and Tobago and other Caribbean countries, but it likely provides a snapshot of what may be occurring in the wider Caribbean region. Knowledge about the long-term effects of the intervention to reduce sexual risk among female adolescents in the Caribbean will require further evaluation (e.g., follow-up at 3 and 6 months). It is important to note, however, that studies have shown that it is not clear that people always do as they intend (Kami, 1997).
Nonetheless, there is still a need to gain a better understanding of the prevailing sociocultural and traditional practices in the Caribbean that may put young girls at risk (d’Cruz-Grote, 1996). It is imperative that adolescents have a clear understanding of the threat they face; otherwise complacency may lead to a leveling-off of their safer sex practices (Wright et al., 2002).
Stigma has been associated with HIV/AIDS from the very beginning of the disease. Moreover, adolescents are not immune to the fear of being stigmatized by their peers, family, or community for being tested or for positive test results. Adolescents in this sample believed that “people knowing their business” placed them at risk for rejection, isolation, blame, and negative valuing, all factors associated with not being “normal.” Avoiding testing translates into “not knowing” one’s status, which further allows that person to remain “normal” and avoid rejection by others (Cunningham, Tschann, Gurvey, Fortenberry, & Ellen, 2002; Herek, 2002).
In order to achieve effectiveness, healthcare providers should intervene on multiple levels. More importantly, the collaborative efforts of key stakeholders are necessary to achieving a targeted and comprehensive approach to address the HIV/ AIDS problem in the adolescent population. Services and interventions should be grounded in sound behavioral principles, and conducted with innovation, cultural sensitivity, and timeliness (Kelly & Murphy, 1992; Olukoga, 2004). Due to persistent HIV/AIDS risk behaviors among adolescents, there is urgent need for research and interventions that promote widespread change in sexual attitudes and behaviors. Research endeavors may prove more beneficial if they are long-term and include some level of social supports and mechanisms for sustainability. It is imperative that this remains a priority for researchers and health professionals in the region.
Limitations
Several factors may be contributing to fluctuation in means observed with the controls. First, this was the first time our sample had ever participated in a research study. Second, we think that there may be some social desirability influences occurring within the sample’s self-reporting behavior.
Implications
Further investigation is needed to elucidate the myriad issues facing youth and their sexual practices in the Caribbean. However, these data suggest that large segments of the Caribbean population have never tested for HIV/AIDS and, therefore, do not know their HIV/AIDS status. As a result, adolescents and young adults may be at risk for contracting and transmitting HIV/AIDS. In addition, investigating barriers to HTV/AIDS testing as well as understanding the role of confidentiality and stigma as potential barriers to testing are areas for future study. Furthermore, this study provides information that may be useful for prevention efforts with Caribbean immigrant youth in the United States. In addition, adolescents flxrth females and males) may be more engaged in learning and derive more benefit if they are involved from conception to implementation in programs that purport to address issues that affect them. Also, it is imperative that such programs be structured and sustainable.
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Donna S. Baird, PhD, LCPC, NCC, Edilma L. Yearwood, PhD, APRN, BC, and Carrol S. Perrino, PhD
Donna Baird, PhD, LCPC, NCC, is a Postdoctoral Research Fellow, Department of International Health, Georgetown University, Washington, DC; Edilma Yearwood, PhD, APRN, BC, is an Assistant Professor, School of Nursing, Georgetown University; and Carrol Perrino, PhD, is an Associate Professor, School of Psychology, Morgan State University, Baltimore, MD.
Author contact: dbaird@ahm.com, with a copy to the Editor: poster@uta.edu
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