    |
||
 |
||
 |
||
 |
|
|
|
|
|
|
  |
 |
|||||||||||||||||||
|
ReCAPP
Forum on Disparities On December 1, 2004, Dr. Barbara Sugland, Executive Director and Co-Founder of the Center for Applied Research and Technical Assistance (CARTA) in Baltimore, MD and Dr. Claire Brindis, Director of the Center for Reproductive Health Research and Policy, and Executive Director of the National Adolescent Health Information Center at the University of California at San Francisco, joined ReCAPP Project Director Lori Rolleri to moderate a discussion forum on health disparities. More than 170 people throughout the United States (including Puerto Rico), Canada, the UK and Romania participated. They represented a wide variety of organizations including: state health departments, state adolescent pregnancy prevention coalitions, Planned Parenthood, national non-profit organizations, the Department of Health and Human Services, CDC, and several universities. After introductions, the moderators and participants fielded questions and offered advice on the following topics:
An Hispanic outreach coordinator wanted to know the best way to link the community with county service providers. Co-moderator Lori Rolleri offered the following outreach strategies that she found effective when working with the Latino population on Long Island:
Co-moderator Claire Brindis liked these practical suggestions, which could be used by other groups as well. Speaking specifically about Latino populations, she said that community health outreach workers called "Promotoras" have been integrated into a number of public health initiatives, from TB treatment to reproductive health. As widely respected members of their communities, Promotoras are highly effective ambassadors. They could be "cross-trained" so they could bring a variety of educational messages to their neighborhoods. Young people are also an important resource to tap, Brindis added, both as outreach educators and as individuals who can help shape programs, messages, and media campaigns that better resonate with their peers, If your agency does not have resources for a full fledged peer educator model, a youth advisory council might be useful, even if for short-term projects such as reviewing videos and other program materials.
A participant from Brooklyn, NY wanted to know what forum participants thought the policy priorities were right now in adolescent health. "Where should our advocacy efforts be focused and where should funding be targeted?" she asked. Co-moderator Claire Brindis responded by offering a resource on the topic. In conjunction with CDC, Division of Adolescent and School Health (CDC/DASH) and HRSA, Maternal and Child Health Bureau, Office of Adolescent Health, her organization has recently completed a guide entitled Improving the Health of Adolescents and Young Adults: A Guide for States and Communities which is downloadable at nahic.ucsf.edu/2010guide. The purpose is to help concerned individuals focus on 21 critical health objectives that address mortality, unintentional injury, violence, mental health and substance abuse, reproductive health (including HIV/AIDS), and prevention of chronic diseases. The guide provides a data profile and help in priority setting, coalition building, program planning and evaluation. Another participant felt it was important to put funding in areas that have shown to be scientifically sound, while another felt that education is a huge priority. Providing comprehensive sex education was especially important given the current emphasis by the federal government on abstinence-only funding. Abstinence-only Funding The comment about abstinence-only funding triggered a wider discussion of that topic. One participant felt that abstinence-only curricula did not give youth enough information to make informed decisions about their health. Others felt that a sexual abstinence program could work if it was presented within a cultural context and included developing good parent-teen communication and goal setting skills. One participant said that while abstinence was definitely a viable option, it should be taught within the context of a complete comprehensive program. A participant who teaches comprehensive sex education in Northwest Indiana is not allowed in most of the schools because of the emphasis on abstinence-only education. Co-moderator Barbara Sugland suggested that she look into accessing other community networks and educational opportunities in the area. "Can you use your connections to leverage broader support?" she asked. "Do you know what the community support is for abstinence vs. comprehensive sexuality? If there is support, perhaps this needs to be surfaced more publicly. If there is less support, perhaps education by surfacing the issues of sexual behavior among local youth might be useful." Another participant added, "I always contact the counselors and school nurses. They know what it going on in the schools." Co-moderator Claire Brindis brought the discussion back on topic by saying, "While the focus of the forum is on disparities, clearly the lack of access to information that young people need is a type of disparity that results in even more negative outcomes." She then suggested attempting to work with the parents in the school because having parents advocate for having comprehensive messages is an important stepping stone towards getting school boards involved. "While you may have a small number of parents initially," she said, "it is important that they can help take the lead in demonstrating that the majority of parents want their children to receive comprehensive messages." Youth serving organizations, such as girls and boys' clubs and Parks and Recreation can also be places to present more comprehensive messages outside of the school setting, Brindis said. Finally, young people can express their concerns about lack of information to the school board. Brindis concluded by saying that groups such as the National Campaign to Prevent Teenage Pregnancy, Advocates for Youth, ETR Associates (i.e., ReCAPP), and Child Trends have summarized the research on programs that have been shown to work and have made that information readily available to parent groups, teachers, etc. A participant acknowledged the enormous amount of federal funds that abstinence-only programs are currently receiving and asked if these programs are being targeted at minority youth. "Can these misleading programs, in part, help explain why minority youth experience disparities in STD/HIV rates, teen pregnancy etc.?" Co-moderator Barbara Sugland did not think that abstinence programs were contributing to disparities for minority youth. "First, even if abstinence programs were being focused on minority communities," she said, "we also know that clinics are generally located in communities where rates are high, so minority youth would also have community access to reproductive health services. In addition, while minorities generally have higher birth, pregnancy and STD rates, the contraceptive use picture is mixed. African-Americans report higher condom use than others; and Hispanics lower contraceptive use." Sugland felt that what's contributing to disparities is much broader and more complex. "While I think there are many programs doing a good job in communities of color, I think we should take a closer look at whether strategies being used in prevention programs and services are culturally relevant and sensitive to the styles, preferences and values of youth given their cultural heritage." "Second, we don't think enough about partner issues when we look at our strategies or when we assess our effectiveness. Partner issues have an important cultural context. Relationship dynamics, (male/female, same sex) are culturally driven. Concerns about trust, respect, comfort with communication, are all shaped by culture. We haven't teased those things apart particularly well. Nor have we designed programs or services that can address these issues as well as we could." "Third, we tend to think about the solutions for disparities as only coming from programmatic action, rather than broader social and community forces, " Sugland said. She feels that access to education "has a lot to do with disparities, since educational attainment, connections to school not only differ by race/ethnicity, but the quality of schools are different (generally) in communities of color than White communities. So we continue to have racial inequities in what young people of color are able to receive in terms of access to education, educational opportunities and preparation for future opportunities." Finally, Sugland said our trend data come from different populations, so it can be misleading. "For instance, sex and contraceptive data from the YRBS is for a high school population. The STD data is from the general youth population. Thus, youth who are connected to school are generally a less risky group than those not connected to school." What we really need is contraceptive use data for all youth, or STD data for the high school population only.
Co-moderator Lori Rolleri encouraged discussion on the following information: "The good news is that teen pregnancy and birth rates have been on a steady decline since 1991," she said. "Adolescent health professionals like us have a lot to celebrate. Much of the work we are doing is successful at supporting youth to make more informed and safer decisions about sex. The bad news is that there still remains a remarkable disparity in adolescent reproductive outcomes between white adolescents and African American adolescents and white and Hispanic adolescents." To support this statement, Rolleri offered the following statistics:
In response, co-moderator Claire Brindis pointed out that there have been substantial improvements among adolescents. For example, African-American adolescents have had a 41% reduction in teenage birth rates, and there has been a 29% reduction overall between 1990-2002. These improvements indicate that when youth are given a variety of comprehensive programs that are tailored to their group, culture and stage of development, they are extremely capable of making responsible decisions. "Still," Brindis cautioned, "we need to recognize that Latina/Hispanic birth rates are 3.3 times, and African-American birth rates are 2.4 higher than Whites (Native American are 1.9 higher)." Birth Weights vs. STD Rates A participant wondered why the African American teen birth rate is less than the Latina/Hispanic rate, but the 15-19 female chlamydia rates (and in Colorado also the gonorrhea rates) are so much higher for African Americans. "Could this be related to differences in use of condoms vs. other contraceptives, and/or are there other factors?" Co-moderator Barbara Sugland thinks the lower birth rates for Blacks vs. Latinos does have something to do with overall contraceptive use although just how much of this difference is the result of higher contraceptive use among Blacks vs. Latinos is not clear. It is clear that Latinos have the lowest levels of contraceptive use. Also greater use of Depo Provera among Black teens could be providing some additional benefit. Sugland added that while the Latino population is increasing, we are still struggling with how to address the cultural context and language barriers, not to mention issues of immigration and access to services and programs. She suspects that Latinos are probably not able to access contraceptive and other prevention programs at the same level as Blacks, even in the same community. Less access means less success in reducing birth rates. The reasons why Blacks are showing drops in birth rates but still have high STD rates is a bit more complex, Sugland said. It is partly a data issue because the populations studied are not exactly the same, so it's like comparing apples and oranges. Second, multiple partners and method use are factors. "African Americans have a higher number of lifetime sexual partners than Latinos and Whites," Sugland said, "which can increase the risk for STDs ... A large part of this has to do with an earlier age at first sex among AAs, particularly young males. Also, we're not capturing whether methods are being used with each partner. Generally, we ask about condom use at last sex." Finally, Sugland suggested that high STD rates could lead to lower birth rates because of the greater likelihood of infertility. "I have facilitated focus groups among 16- to 19-year-olds where Black women have repeatedly said, 'I have friends who don't use contraception because they've had sex and not gotten pregnant,'" she said. Co-moderator Lori Rolleri wondered if another factor might be the fact that abortion is more accepted in the Black community than in the Latino community. Sugland thought that a greater acceptance of abortion may be part of it since AA girls have higher abortion rates than Latinos and Whites. "However," she cautioned, "there is a cultural context of children in the AA culture that is still pretty strong. Children are still seen as the 'future' and a new chance for the next generation." So although the abortion rate may play a role, Sugland feels it's important to acknowledge the fact that we still have a lot of research to do. Rolleri suggested another possible factor — the role that religion plays and the fact that Catholicism may be much less tolerant of birth control than other Christian churches. A participant disagreed with this supposition. Advocates for Youth's European Study Tour indicated that the separation of church and state in public health issues was a big part of the acceptance of safer sex practices and in their decreased numbers, she said. Another participant added that she thought "a strong majority of Catholics use birth control." A participant wondered how to address the Catholic Church's stance on birth control without insulting anyone's faith. Rolleri replied, "Sometimes getting the message out about family planning is easier if you go through the 'back door' of the Church — that is with the Church youth coordinator or community outreach worker." "We're not in the business of changing people's religious beliefs,' Rolleri said, "but we can still report the facts about adolescent pregnancy, STDs and HIV and the strategies that have been proven effective, including abstinence." Reporting on statistics closer to home (i.e., on the county level rather than the national level) makes the picture more real, Rolleri added. "We may be able to learn some common ground lessons from the ABC work in Africa, Rolleri said. "(A) Abstinence is the best choice, (B) if you do have sex, Be faithful to your partner, (C) use Condoms when you have sex." An educator from Sacramento CA said that in addition to Catholics, many other fundamental Christian groups in her community do not want to talk "birth control." "They will listen to natural ways to 'prevent pregnancy,'" she said. As clarification, she added that she was referring to the use of the verbiage "ways to prevent pregnancy," not to the rhythm method. Rolleri followed up on the issue of finding common ground by forwarding a copy of "Common Ground on HIV Prevention," which was written by leaders in HIV prevention from different perspectives, and has been endorsed by key public health and government leaders from around the world. It can be found at: www.thelancet.com. A participant mentioned problems with young teens getting pregnant by older Black men (19-25) who come into the community selling crack and meth. Increased sexual activity among Latina, SE Asian and AA teens as a gang initiation was another problem. "What is the relationship between older adult male partners and higher birth rates for Latinas and higher STD rates for Blacks?" she asked. And did anyone have any ideas about the gang problem? Another participant admitted that these are tough issues. We need to tackle "some of the 'why' behind youth getting involved with gangs to begin with," she said. "And the same goes for substance use, or affiliation with the drug scene and the sellers. Why are youth going this route, and how can we help to provide other opportunities?" "This is why stepping outside the silos of 'STDs and teen pregnancy" is so important — collaborating more with youth development programs, boys and girls clubs, substance use prevention and treatment programs," the participant added. "Another approach is working with the key stake holders (not just providers and teachers, but the gatekeepers of the community — the drug sellers themselves)." Co-moderator Claire Brindis also admitted that there were no easy answers to these problems. We probably need to begin a good deal earlier than high school to help young people understand what they might lose if they engage in this type of risk taking behavior, she thought. Statistics Related to Minority Groups A participant asked if there are statistical data sheets on minority groups, teenage sexual activity and decision making. In response, co-moderator Lori Rolleri contributed the following resources:
Co-moderator Lori Rolleri asked participants to comment and share what they have learned from working with Latino and African American youth and/or their parents. A health educator who works in California's San Joaquin Valley said that issues of poverty, unemployment, access to health care and health insurance (or lack thereof) are doubly impacting the Latinos she works with as compared to the rest of the state. One reason is the nature of the predominantly agricultural industry there, which is dependent on seasonal and migrant farm labor. A participant working on a teen pregnancy prevention program in Southern California said it takes time to truly engage the community in your programs or services. In fact, it took her about two years to identify "key leaders," the "spokespeople" who helped her legitimize herself in the community. Another participant pointed out that it's important to put behavior within an environmental and cultural context. For example, "if an individual lives in an environment where premarital sex, teen pregnancy, etc. are accepted, then they are not going to see their behavior as being negative or problematic to society as a whole." We need to assess the environment's readiness to change and how the issue is rated on a scale of importance, she said. "If the individuals living within a particular community do not view this topic as a priority of change, then no matter what program a health educator ... tries to implement, there will be limited success." A participant from Indianola, Iowa explained her program. To address Latino teen pregnancy, the high school ESL teacher, school nurse, university extension Latino outreach coordinator, high school guidance counselor, and herself worked together with two Latinas who had recently graduated from college to put on a Mother/Daughter Night. The Latinas wrote a three-act play about values, peer pressure and self-respect from a cultural perspective. High school students performed in the play and provided background music. After the performance, mothers and daughters did several "get to know each other" quizzes together. The entire program was done in Spanish, including the introduction by the school district superintendent, and a light Mexican meal and child care were provided. As a result, both mothers and daughters have requested more workshops on communication, pregnancy prevention, and substance abuse. Cultural Factors A health educator with the California Dept. of Health Services mentioned that when she presents data on the disparities among African-American and Latino youth STD morbidity, she brings up factors like access to health care and poverty as some of the reasons behind large STD disparities. She asked for information about other cultural factors that affect sexual decision-making — such as attitudes about sex, beliefs around pregnancy, potential fatalism, social norms around sexual behavior. Co-moderator Barbara Sugland agreed that there are many other factors affecting sexual decision-making. Her organization, CARTA, is finishing up a guide for providers on culturally-based parent/family engagement. It is part of a broader project they have been working on to learn more about how providers are connecting with parents/families, without compromising access to and confidentiality of contraceptive services for teens. Although the focus of the guide is parents and families, its cultural context is still relevant. It focuses on values for family, interpersonal relationships, gender dynamics, the historical context of slavery and racism and how these have influenced relationship dynamics and parent-child relationships. The guide also has a section that highlights suggestions for program strategies. It should be ready for electronic release by late 2004 or early 2005, Sugland said. "I'm sure we can make it available through ReCAPP, so be on the look out for it. If you have specific questions about it, please email me directly (bsugland@cartainc.org)." Co-moderator Claire Brindis later mentioned that she has had the opportunity to preview the guide and found it very practical. Sugland mentioned other useful resources on the subject, including:
The participant then asked for suggestions of concrete steps that smaller community programs could take to address these cultural factors. In response, Sugland provided the following suggestions:
"None of the above has to take a lot of time or additional resources," Sugland said, "but it is something you have to be intentional about doing and making a priority." Brindis responded by saying that linking youth development with reproductive health services is becoming increasingly important. Often agencies work together to make both types of services available to young people. For example, one of California's Department of Health Services, Office of Family Planning Male Involvement programs has incorporated cultural beliefs, strengths, values — a celebration of the positive nature of culture and its protective features — into their teenage pregnancy prevention message. One of the programs works closely with a local employment agency to assist youth in developing skills in filling out work applications for work, interviewing, and searching for jobs. They also help young people to find potential employment opportunities and debrief afterward. "This calls for strongly dedicated and caring staff," Brindis said. "While not wanting to sound overly simplistic, ways that programs can help diminish some of the pain of racism is to create strong connections with the young people they serve — as a protective measure in their environment." Another strategy, Brindis said, is for young people to engage in a community needs and assets assessment and to map out the strengths and gifts of their community. At the policy level, it is important to recognize where "hot spots" of underserved populations exist and to consider ways to develop culturally specific, developmentally appropriate and strategic programs, such as California's approach to preventing teenage pregnancy by using a system of local collaboratives that bring different resources together on behalf of youth. After thanking the moderators for their suggestions, the participant asked if anyone knew of policy suggestions (related to education, housing, etc.) that have come out of the race and poverty research. In response, Sugland said some of the Move to Opportunity (MTO) work may be relevant to the question. MTO was created by Congress in the early 1990s as a demonstration program to determine the effect on housing, employment and educational outcomes when families are moved from high poverty to low poverty neighborhoods. Several cities were involved in this program. www.huduser.org/periodicals/rrr/rrr10_99/1099_2.html The idea behind this initiative is that moving low-income families from high to low poverty neighborhoods would reduce the negative impact of a difficult environment, Sugland said. See www.wws.princeton.edu/~kling/mto/baltimore.htm#Balt2 (MTO in Baltimore) and www.jcpr.org/newsletters/vol5_no1/articles.html in other areas. The findings are generally promising, but mixed. In Baltimore, there was a reduction in juvenile crime behavior and some improvements in academic outcomes for younger children. For older children, there appears to be retention in grades but also increases in behavior problems. "My general knowledge of this program and the results is that the program did not take into consideration the potential social isolation of poor families in non-poor neighborhoods," Sugland said. "Even though poor communities have challenges, people did have some type of network, a network that might be difficult to establish in a new neighborhood where individuals and community norms may be different. For young people, developmentally, there may be additional challenges with making friends and gaining support. If many of these neighborhoods are also racially mixed or primarily White, there may also be another dynamic on a cultural level to think about." Parent-Teen Communication A graduate student in Southern CA shared information about a dissertation she thought was interesting: "Health Beliefs as Predictors of Parent-Teen Communication About Pregnancy, Sexually Transmitted Diseases, Sexual Respect, and Sexual Morality" by Naima Brown Smith. She said it was a great study to try to understand whether parental perceptions and demographic variables have an influence on communication of sexual issues. Participant Shelly Masur said that her organization in Northern California is about to release a toolkit for communities that includes a social marketing campaign for improving parent-child communication about sexuality. It contains ads in Spanish, English and Taglish that represent seven different ethnicities and are ready to use. The toolkit also contains a family communication curriculum. It should be available in early January 2005, and thanks to a grant from the Packard Foundation, it is free to organizations located in San Mateo, Santa Clara, Santa Cruz and Monterey Counties who are interested in implementing it. For more information, contact her at: smasur@californiateenhealth.org.
A sexuality educator in Atlanta, GA recommend a newly published resource on racism: www.kaisernetwork.org/daily_reports/rep_index.cfm?DR_ID=26993. Although this study looks at adult women rather than adolescents, she thought it would be relevant to the discussion. She included the following excerpt:
The article triggered a discussion of racism as a factor related to disparity. Co-moderator Lori Rolleri conveyed an example based on her own experience. On several occasions, she saw for herself how poorly one of the African American teens she was working with was treated by the clerk in a local store. "My student went on to tell me about so many other similar experiences and I felt myself — only a bystander — getting angry, agitated and stressed," Rolleri said. "This type of subtle, daily kind of prejudice and racism has to affect the mental and physical health of African American teenagers." A participant added that sometimes an attack on self worth comes from within the African American community. For example, when she objected to the fact that 10- and 11-year-old young people were treated with harshness, physical violence and emotional abuse by the teacher and school counselor in an elementary school, she was told that "they must be spoken to this way because they are project kids." "If we write off the youth in impoverished areas, then how are they to learn to respect themselves and their partners?" she wondered. Rolleri asked if anyone knew of a study that looks at the stress caused by racism on teens, specifically on their sexual decision making. Co-moderator Claire Brindis did not think that — as far as she knew — the impact of racism on adolescents has received a lot of attention in studies. "Clearly, researchers in the field are cognitive of the fact that poverty is probably one of the most (if not the most) important antecedent factors to adolescent pregnancy, yet not all poor adolescents get pregnant, nor are they the only ones that have a monopoly on sexual activity or unintended pregnancy," she said. "Although recognizing that poverty is an important factor, it is often the 800-pound gorilla in the room that we are not quite sure how to approach. While we can measure factors such as income level, school lunch program participation, unemployment, family structure, etc., it is far more challenging to measure the impact of how poverty changes people's hopes, dashes young people's dreams, how it limits a sense of viable alternatives. Furthermore, beyond 'simple' poverty, are the additional factors of racism and prejudice that young people face growing up in communities." Brindis mentioned a study conducted with Jill Denner, Doug Kirby, and Karin Coyle and herself which looked at the role of social capital on Latino adolescents (The Protective Role of Social Capital and Cultural Norms in Latino Communities: A Study of Adolescent Births, Hispanic Journal of Behavioral Sciences, Vol. 23, No. 1, February 2001). The zip codes with lower teen births (reflecting very poor communities) had a higher percentage of residents of Latino descent, stronger social networks, and more ties to their countries of origin. First generation Latinos were less likely to have sex, but they were also less likely to use contraceptives and had greater ambivalence about using them. In contrast, second and third generation Latinos tended to have a greater likelihood of sexual activity but tended to use more contraceptive protection. Brindis went on to discuss poverty as a major contributor to disparities in more detail. "National estimates show that about a third of Latino and African-American youth live in poverty about $14,000 for a family of three, with an additional 15-19% living in near poverty conditions (150% of poverty)," she said. "Strong research exists demonstrating the strong link between poverty and poor/fair health, largely stemming from lack of access to health care, poorer housing conditions, environmental conditions and limited employment. Thus, it is important to consider the relationship between poverty, lack of hope and access to positive educational opportunities and experiences as antecedents to early childbearing." Following up on Brindis' comments, Rolleri asked, "Why are African Americans and Latino living in the US so disproportionately affected by poverty? It's my understanding that when poverty and education are controlled for, the disparity in adolescent reproductive health outcomes between Whites, Blacks and Latinos almost disappears, but not totally. What accounts for the remaining disparities? Cultural beliefs/norms? Racism?" Co-moderator Barbara Sugland provided a lengthy response to this question. "While controlling for poverty reduces the racial/ethnic gap in reproductive health outcomes," she said, "it's important to understand the 'poverty' measure (a national measure) doesn't really capture the dynamics of poverty across race/ethnicity. First, there are many reasons why folks of color are more likely to be poor (and there is probably a circular argument here) — less education, family generation of poverty, etc. — but there is also income inequality. Blacks and Latinos with the same education don't earn the same income. So getting out of poverty (from a strict financial sense) is harder." "In addition, poor Blacks and Latinos, because of residential segregation, are more likely to live in neighborhoods that are racially segregated. Racially segregated neighborhoods tend to have fewer human and fiscal resources and fewer basic needs services (e.g., grocery stores, etc.) Thus, the 'environmental' context of poverty for minorities looks and feels different than the environmental context for Whites. So being poor doesn't necessarily imply a homogenous group across race/ethnicity. This is not to diminish what poverty means for Whites, but rather that issues of racial inequality across income, housing, employment, etc. create a community context that is different for whites than for Blacks and Latinos. This means the neighborhood context for youth of color (which studies show can play a role in shaping sexual behavior and outcomes) is different than for White youth." Sugland went on to agree with an earlier comment by Brindis — that there is an "800-pound gorilla in the room" which the research and policy and provider community has not taken on. "It isn't easy," Sugland said, "but it is fundamental to the issue of disparities. Racism is fundamental part of American history, and it's silly to think that it hasn't created a context that still remains. Also, it's easy to presume that legal precedents have somehow eliminated racism, but we know there is evidence that it still exists." Sugland said her organization, CARTA, recently started doing some work on structural racism and disparities in adolescent sexual and reproductive health. They currently have a draft working paper which will turned into an issue brief/research-to-action brief coming 2005. They also hope to create a training institute to share what they've learned and begin capacity building within the field. "Through this work, we're finding that the issue of inequality is quite central to many of the links that are important for teen sexuality," Sugland said. "Not only are there institutional barriers, not just within the health field, but within schools. There are also interpersonal exchanges that are biased. We believe there is evidence that racism not only leads to negative and unhealthy exchanges between Whites and non-Whites, but between individuals of color with each other, as a form of internalized racism, and minority groups with each other." Sugland offered the following suggestions:
Sugland concluded by saying, "Providers have to begin to acknowledge that we need to partner on this 'prevention' work...We have to get better at thinking outside of the box, not just in terms of the program strategies, (but also) in terms of our larger policy and advocacy strategies." Brindis agreed with her co-moderator's comments. She added, "One strategy that you have raised in the past is the vital importance of also working with young people — helping to educate and provide them with the tools to recognize issues of racism and poverty in their lives and what 'tools' they have to deal with these issues in as positive a manner possible ... In this regard, it may be important to consider inter-generation programs and ways that parents as well as their children can be involved." At a later point, Sugland provided a resource which she said gives a good overview of the issue of structural racism and how it shapes youth development and identity formation: www.aspeninstitute.org/Programt1.asp?i=83. See pdf on "Structural Racism and Youth Development: Issues, Challenges and Implications" and pdf on "Structural Racism and Community Building." Co-moderator Lori added that there was an interesting article on structural racism in the July/August 2004 issues of the Youth Today. The article was taken from the Forum for Youth Investment. www.forumforyouthinvestment.org/whatsnew.htm#jul04focus. Gender Roles A participant believes that some of this disparity comes from the Freud's origins of sexuality theory. After reading Janice Irvine's work on Sexuality and Culture and James Sears' work with Filipino and Cherokee peoples, she has been interested in how so much of our sexuality education is from a White male dominant paradigm. "While many communities have done an excellent job of creating meaningful opportunities for young people, working with parents and building community support for relevant sexual health education, we still struggle as a society with the unequal power dynamics associated with gender roles," she said.
Co-moderator Lori Rolleri asked fellow moderator Claire Brindis about the protective aspects of Latino culture. "Could you tell us a little bit about the cultural norms of less acculturated Latinos and how they might be protective against adolescent pregnancy?" Brindis responded by saying, "In terms of risk behaviors, first generation pregnant Latinas are far less likely to smoke, use drugs, or drink, especially during their pregnancies. Over generations, many of these behaviors that have impact both during and subsequent to pregnancy become more acceptable. In terms of pregnancy prevention, first generation Latinas who have migrated to this country tend to be more connected to their families and have a strong sense of 'Familismo' — dedication to the family of origin and concern about that family's standing in the community — with a desire not to bring any shame to that family, for example, through an unintended pregnancy. Young girls, in particular, tend to be more 'chaperoned' and protected, and there are stronger ties to their religious community as well." "All of these social institutions contribute to strong protective messages that young people are cared about and that they matter to the community, as they represent the future," Brindis said. "As young people become a greater part of the mainstream over generations, many of these same ties are diluted and diminished in importance. There are also other pressures, for example, from the media regarding what is acceptable behavior." A participant asked if there were programs that did a good job of incorporating issues of "familismo" and "respeto" into their interventions. She mentioned "Circulo de Hombres" (Circle of Men). Brindis responded by saying that the "Circulo de Hombres" curriculum has been used by a number of programs both in California and in the U.S. One of her colleagues, Hector Sanchez-Flores, is knowledgeable about programs throughout the country; his email is hectors@itsa.ucsf.edu. A participant has been working with schools on the Hoopa Reservation creating a "Respectful Living" character education approach which focuses on respect, responsibility, cultural pride, family, integrity etc. It's not a program but a philosophy and a process for creating culture. "The thing I have liked about integrating value laden language into my work with pregnancy prevention is that it fits into all cultures and faiths," she said. "I think that laying the foundation with core values in working with any group is essential. It cuts to the chase with the concept that we all want young people to make healthy decisions based on their personal value system. By creating common definitions within a cultural group (Native Americans in this case), we were able to increase adult conversations about youth issues and how the community/school was serving their youth. When the adults started talking about respect and family, they began to interact with each other with increased respect and treated the young people with increased compassion. This translated into better programs in which the students wanted to be connected."
The discussion of protective factors led to comments about culturally related risk factors. A participant who serves a mostly Latino population in the San Gabriel and Pomona Valleys of Southern California said that when Latina teens come in to the clinic with their pregnant friends and find out that they are pregnant too, "they jump with joy that they will be parenting at the same time." Some Latino parents are still encouraging child bearing in adolescent years, she said. While admitting that it's difficult to place Latinos (or any other cultural, ethnic, or racial group) in a particular "box" or stereotype of expectations, co-moderator Claire Brindis said, "Motherhood is highly respected among the culture, and it appears that these young women may not have a sense of alternatives. We know that school academic failure is often a strong predictor of early childbearing. It used to be that we thought that young women would drop out of school after they got pregnant; however, in a study in the late 1980s, we noted that about a third of the girls have already dropped out of school before they get pregnant and thus early childbearing appears to be a viable alternative, especially if peers appear to support these actions." Brindis added, "Economics clearly contributes to young people of color wearing 'blinders' to alternatives, and we need to recognize the role of adults in limiting young people's choices." Another participant in a more rural area of California has had similar experiences. An program evaluator who visited recently was surprised that there are actual benefits to becoming pregnant as teenager. In response to several questions, the participant elaborated: "Some teens talk about feeling like they finally got respect from their families after having a baby. Some report a feeling of purpose for the future. The baby can be motivating to teens to finish their educations and get jobs so that they can provide for their babies. For substance abusing teens, becoming pregnancy might serve as motivation to stop using drugs. Having a baby may provide an opportunity for some teens to leave their houses where they may feel unsafe or abused. Loving their babies may boost their self-esteem in some way." When asked about economic and education levels in the county, the participant explained that it is a primarily agricultural area and overall, is one of the poorest areas in California. Throughout the county, approximately 25% live in poverty and in some areas over 50%. Countywide, only 68.8% of residents have a high school diploma. In one community, the graduation rate is 18%. The per capita income is $15,732, lowest of all other counties in the state. As an example, the participant told the story of a 14-year-old who is stuck in an abusive marriage to the 21-year-old father of her child. She wants out, but for various economic reasons and pressure from both sides of the family, is unable to leave. Co-moderator Barbara Sugland felt the story made an important point - the importance of adult-related strategies as well as youth strategies and the need to address the broader issues of self-respect, intimate partner violence, and the ever looming issues of poverty and lack of opportunities. "When there is little else to see in terms of options, there's a lot that folks will settle for and allow to happen," she said. Sugland suggested the following resource on the topic of intimate partner violence: www.cdc.gov/ncipc/factsheets/ipvlinks.htm. While she couldn't speak to its quality, she felt that it was worth looking at.
Co-moderator Claire Brindis mentioned another possible factor related to education and early childbearing, which is the fact that many Latino parents, especially those with little education themselves, are reluctant to let their children go away to college. They are afraid for their safety or fear their children will reject their families of origin. She mentioned a project in Monterey, CA where high school graduates who have gone on to college mentor high school girls. A small group of 3-4 parents who allowed their daughters to participate later served as spokespeople for the program and were extremely helpful in alleviating the concerns of the other parents. Two participants were interested in getting more information about the Monterey mentoring program because they faced similar situations in their communities. In fact, one participant said that several students had turned down four-year scholarships because they would have to leave the area. The Monterey program is the Women's Community Health Leadership Program, Brindis said, by the Charitable Council of Monterey County, Inc. and ECHO (Education, Careers, Health, Opportunities). For more information, contact: Patty Fernandez-Torres, ECHO Coordinator, 369 Main Street, Suite 207, Salinas, CA 93901 email: patty-echo@ultimanet.com, phone: 831-783-1244 A participant provided a personal comment on the issue. "I am a Latina, and I've been raised with the idea that children have to care for their parents when they are of age," she said. "I too was accepted to UCSD, UC Davis, and UC Riverside. I was not able to attend because my father felt that the only education I would be receiving is one of an immoral nature (drinking binges, sex parties, etc). I found a way to make it work by being close to home to be near my family without compromising a higher education. Also, I understand the culture in the sense that families begin at a young age. My cousins were pretty much married with children by the age of 18. I was considered old when I got married (21). It was 'selfish' of me to want to educate myself when my husband is home having to make dinner for himself because I'm in class. Latinos have a different perspective on life. In my line of work, I have developed a heightened sense of respect and found different approaches to educate without offending." After thanking the participant for sharing her experiences, co-moderator Lori Rolleri pointed out that not all Latino parents will insist that their teen daughters stay close to home. "Country of origin, parent education, family income, level of acculturation, and religion are all factors that might affect this," she said. "The US has a rich mix of Latino immigrants from all over Latin America representing different races, religions, reasons for moving to the US, and education levels." Brindis also thanked the participant and commended her for maintaining the qualities of the culture while also pursuing an education. She then added her own personal note." As a Latina woman and the first to graduate from college in my family," she said, "I put myself through college and lived at home for the first years... But, I did have the total support (e.g. pride) of my family and did not have the uphill battle that many young people have to face."
A participant asked if there was any research on the effectiveness of peer education in reducing health disparities among African American & Latinos. A participant from Humboldt County in Northern California said her organization has had excellent success with a peer education program conducted through one of their collaborative partners, Six Rivers Planned Parenthood, in addressing the issues of healthy relationship norms, interpersonal/dating violence, pregnancy prevention and STDs. "While our community is predominantly white," she said, "the teens have done a good job trying to create a level of cultural competency within their work. They are also now incorporating LACAAW's "In Touch With Teens" curriculum into their theater and classroom work to add to their violence prevention work." Co-moderator Lori Rolleri mentioned other programs that have been implemented with Latino youth and involve teen led components, all of which have been evaluated for effectiveness:
A registered nurse from Southern California wondered if there was any correlation between the health outcomes and substance abuse prevalence by race. Co-moderator Claire Brindis said that the issues of substance abuse and sexual behavior are clearly intertwined both in terms of increasing the level of risk that young people engage in and the likely lack of contraceptive use to assure "safe sex." She recommended going to the CDC web site and looking under the Division of Adolescent and School Health for the trend data on the subject. But, as was mentioned earlier in the forum, this data set only reflects students who are enrolled in school so that there may be an underestimate of actual drug and alcohol use before sexual behavior.
Co-moderator Lori Rolleri asked participants about their experiences with cultural competency trainings, specifically for working with Latinos and African Americans. One participant has been involved in a couple of cultural competency trainings — one specifically created for working with Latinos. She thinks one of the most important elements is "not to have the laundry list of 'Asians are like this...' and 'African Americans are like this...'" Although she admitted it was important to be aware of differences, she thinks competency is not about learning what could be seen as stereotypes but about building skills that will allow you to approach people with an open mind and an eagerness to learn from them. Another participant said, "We have stopped calling them cultural competency (trainings) and started using the term 'cultural proficiency training' — can anyone ever really be competent in cultural when it is so dynamic?" Co-moderator Claire Brindis appreciated the type of cultural competency and sensitivity advocated by the first participant. As we work to avoid stereotyping, we also have to acknowledge the challenges of providing family life education in multi-ethnic settings, she said. "This represents a great opportunity for different groups to begin to understand both the 'universals' of what it means to be a young person and, in particular, a young person of color, as well as the unique aspects that vary across class and ethnic/racial lines." Immigration status and setting are also important cultural factors, "Many years ago, we conducted a knowledge, attitudes, and practice study of Southeast Asians and found more similarities among Hmong, Laotian, Vietnamese, Cambodian, and Mien who were from rural vs. urban centers, rather than differences among individual groups," Brindis said. A participant who teaches at a community college starts every class with a cultural diversity exercise. Each student interviews someone from a different culture or ethnic background and then the class has a discussion about differences and similarities.
Health and Funding Priorities
Finding Common Ground/HIV Prevention
Statistics Related to Minority Groups
Cultural Factors
Parent-Teen Communication
Racism and Poverty
Protective Factors
Partner Violence
Parental Attitudes/Mentoring
Peer Education
Home | Index | Topic in Brief | Evidence-Based Programs Skills for Educators | Skills for Youth | Current Research Library | Statistics | Theories & Approaches | Links Professional Credits | Learning Activity | Forums | Archives
|
|
||||||||||||||||||||
