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Contextual Factors Affecting HIV Sexual Risk Behaviors

Presented at the Midwest Psychological Association Convention
May 10, 1997, Chicago, IL

   While contextual factors impacting HIV risk behavior are important in understanding the disproportionate rate of HIV infection in any marginalized group, this presentation will focus on homeless youth as a vehicle for illustrating key concepts surrounding the need to attend to the context in our research.  Homeless adolescents are growing in number.  It is difficult to estimate how many homeless youth there are in the US, but current estimates put their numbers at between a million and a million and a half.  They are a vulnerable population -- physically, socially and psychologically.  However, they have  traditionally been underserved and understudied.  Part of the reason HY haven't received enough research attention is that they exist at the periphery of a number of active research areas.  They represent less than 2% of adolescents and less than 10% of the entire homeless population.  As such, their status has tended to be marginalized on the larger prevention agendas of both the adolescent and the homeless HIV prevention research communities.   But since the late 1980's, HY has been the focus of a quite a bit of public health epidemiology research and have emerged as THE segment of the adolescent population most at risk for HIV infection.  4-8% of homeless youth are HIV infected.  Their rate of infection is 2-10 times that of other adolescents.  We can expect that rate to continue to climb as the virus spreads through the social networks of homeless youth.  There is clearly an urgent, growing need for HIV prevention with these adolescents.

   Developing effective HIV interventions for homeless youth presents essentially the same challenges as it would for any other marginalized subpopulation.  A key concern that has recently emerged in the prevention of HIV with this group as well as other marginalized groups is the importance of understanding the context of risk behavior.  Simply mobilizing more interventions will not effectively stem the spread of HIV among homeless adolescents or other under served groups.  Existing interventions, even when they have been grounded in models of risk behavior, tend to target adolescents as if they were a homogenous group.  Indeed they have shown some promise in altering the HIV sexual risk behavior of "mainstream" adolescents.  But it's become unrealistic to assume that models of HIV risk are generalizable and uniformly effective across subgroups of adolescents, since the interventions they've produced have at best reached only modest effectiveness levels, with wide variation, even across even large non-marginalized subgroups.

   In order to prevent HIV among the groups that are most vulnerable to it, prevention research must begin to move beyond the demographic correlates of risk behavior, broad generalization of theory, and broad application of standard health psychology constructs.  It must move toward developing subgroup-specific models of sexual risk behavior that take into account the unique context in which sexual behavior occurs for each particular subgroup.  I'm not referring to tailoring program content to subpopulation characteristics.  I'm referring, rather, to tailoring the underlying models themselves to the unique context of sexual risk behavior for that subpopulation -- building new models from the ground up, rather than applying old models from the top down.  This represents a substantial shift in paradigm for researchers steeped in the positivist traditions of health psychology and public health through which so many health threats, past and present, have been effectively addressed.  However, if one accepts the premise that critical features of HIV are unique among health threats, and that unique features of the lives of marginalized groups are critically related to health risk behavior, the conclusion that it's time for a shift in paradigm follows.  

   The challenges of understanding the context of HIV risk behavior are manifold.  Any adolescent subgroups brings a unique constellation of social and psychological factors to the process of HIV decision making.  Consequently, one challenge is to understand how a particular constellation of factors that characterizes a subgroup interacts with decision-making constructions, such as attitude toward HIV prevention, peer norms and protection motivation.  Or, at a more fundamental level, whether those traditional constructs even play a role at all.  Currently, very little is understood about this interaction, if it exists, among homeless youth.  Instead, research has tended to focus on standardized, isolated measures of HY's attitudes toward HIV prevention.  Although such data has been useful in beginning to distinguish one facet of homeless youth's HIV decision making process from that of other subgroups, it provides very little insight into the psychosocial context in which attitudes are formed and behaviors are formulated, so it's been only marginally useful in developing interventions.

   A second challenge is to move beyond description of the social and psychological characteristics of subgroups and begin to explore how, specifically, such factors come into play during sexual encounters.  For example, drug use is thought to contribute to HIV risk behavior generally, and research indicates that HY use substances at a much nigher rate that other adolescents.  However, the nature of the relationship, if any, between HY's substance use and their decision to use a condom is unknown.  A myriad of contextual variables could potentially affect the relationship, including the type of drug used, the reason for using it and even the reason for having sex.  While it's useful to identify behaviors that may be related to HIV risk, again, specific contextual links must be defined between risk factors and the process of decision making in order to tailor an intervention to the context in which risk behavior occurs.

   A third challenge is to understand the priority that a subgroup assigns to HIV in the context of other life concerns.  HIV is only one of the many threats to the health and safety of homeless youth.  They experience enormous day-to-day stressors and are forced to focus on providing for their own immediate needs.  The emotional toll of street life is evident in the high rates of depression and suicide among these youth.  In such an uncompromising context, the future consequences of unprotected sex may not be very salient.  Investing in the future at all may be perceived as naive.  But simply linking risky behavior to depression or hopelessness won't provide enough relevant information to develop effective interventions.  However, expliacting a more fundamental contextual link between future orientation and the risk or protective decision process is more likely to provide innovative direction in intervention development.  One of our current projects on Dr. Harper's research team is examining such factors as optimism, hope, and existentialism and how they may be related to coping and HIV protective behaviors.  These contextual variables may alter the importance that youth assign to HIV concerns and affect their motivation to protect themselves.  

   As prevention research begins to meet these challenges of understanding, appreciating, and accomodating context, the use of qualitative methods will be crucial to model building.  Ultimately, only through qualitative approaches can we be genuinely receptive to comprehending the richness of the meanings attached to the HIV sexual risk behavior of homeless youth and other marginalized groups.  There is simply no objective empirical substitute for attending to the subjective world in which vulnerable groups make decisions about HIV risk and protection.