Fundamentals of Adolescent Care and Cultural Competence
Authors: Donna Futterman, MD; Sandra Y. Lewis, PsyD; Stephen Stafford, BA; Robert Johnson, MD, FAAP
March 2007
Introduction
Adolescence is a time of dramatic physical, emotional, cognitive, and social change. The transitions that occur during adolescence and young adulthood usher youth into the social and sexual world as independent beings. These changes provide opportunities for positive growth experiences but they also bring new vulnerabilities.
Unfortunately, young people in the United States and other parts of the world are particularly vulnerable to HIV infection. One of the developmental markers of adolescence is the formation of a sexual identity; another marker is the propensity for taking risks. When mixed, these characteristics can be dangerous. Proof of that is reflected in the fact that half of all new HIV infections each year are estimated to occur among youth aged 13 to 24.
HIV-infected youth deserve care that is not only clinically competent but also culturally competent. The goal of this educational series is to provide clinicians with the basic tools needed to deliver culturally competent HIV clinical care and support to adolescent and young adult patients.
The information in this introductory module provides an overview of the HIV epidemic among youth in this country. One of the most significant lessons is that minority youth are especially at risk of HIV infection. Additionally, many Blacks/African Americans, American Indians/Alaska Natives (AI/AN), Asian Americans/Pacific Islanders (AA/PI), and Latino youth often experience significant disparities in health care. One of the greatest disparities these youth face is a health care system that is not sufficiently prepared to address the many ways that medicine and culture interact. This module offers an introduction to cultural competence in the health care arena and offers strategies for providers who are interested in beginning and maintaining the ongoing process of cultural competence training.
Following this introductory module are 4 additional modules that explore key domains of adolescent HIV care:
In Psychosocial Issues, the authors review the known challenges that frequently confront perinatally and behaviorally acquired HIV-infected youth as they negotiate adolescent development. The module also provides training on how to perform a brief psychosocial assessment (the HEADSS interview) that is sensitive to cultural norms particular to racial and ethnic minorities and lesbian, gay, bisexual, and transgender (LGBT) youth, with the aim of improving capacity to identify comorbid conditions and create a more bias-free and supportive clinical environment.
Antiretroviral Therapy and Adherence addresses the challenges of initiating antiretroviral medications for adolescent patients and helps providers to select regimens that are compatible with patients' different lifestyles. The module begins with an overview of general clinical care considerations for treating HIV-infected youth, and highlights important concepts that can facilitate culturally competent care.
In Transitioning Care, the authors offer providers practical strategies for devising transition plans for youth of different ages and races/ethnicities. The module explores the key issues related to transitioning from pediatric to adolescent and adult care settings, and guides participants to begin thinking about how cultural beliefs on growing up and becoming independent can influence a family's process of allowing an adolescent to assume responsibility for his or her own health care.
Prevention with Positives provides guidance to providers on how to work with young racial/ethnic minority HIV-infected patients to reduce their risk behaviors, with a goal of improving their health and reducing the annual number of new infections. The module discusses customized risk-reduction counseling for clinical providers that is culturally and developmentally appropriate for youth, and provides guidance to participants on how to integrate culturally competent prevention counseling into their care for HIV-infected patients.
This is not a textbook approach to teaching, nor should these modules be considered a comprehensive review of all issues relevant to provision of culturally competent HIV clinical care. Instead, the modules in this series focus on presenting the essential elements of several topics of particular concern to clinical providers working with HIV-infected youth. Our hope is that the information presented in these modules and the resources provided for further learning improve the clinical care delivered to HIV-infected racial/ethnic minority youth.
Learning Objectives
Upon completion of this module, providers will be able to:
- Describe the epidemiology of HIV among youth in terms of race, gender, and mode of infection.
- Integrate at least 3 concrete strategies for achieving cultural competence in their clinical practices.
- Appreciate at least 3 factors that put adolescents at increased risk of HIV infection.
- Identify at least 3 issues affected by culture that often challenge the relationship between providers and young HIV-infected patients.
Instructions
The course may be navigated either by selecting the "Next Page" button at the bottom of each screen, or by using the course outline buttons in the left navigation column.
All users will be asked to complete a final evaluation to help the sponsors assess the value of the course.
Authors
Robert L. Johnson, MD, FAAP, is The Sharon and Joseph L. Muscarelle Endowed Dean (Interim), Professor of Pediatrics and Psychiatry, and Director of the Division of Adolescent and Young Adult Medicine at the New Jersey Medical School of the University of Medicine and Dentistry of New Jersey. His research focuses on adolescent physical and mental health, adolescent HIV, adolescent violence, adolescent fatherhood, and risk prevention/reduction programs with specific emphasis on substance and alcohol abuse, sexuality and sexual dysfunction, male sexual abuse, suicide, and AIDS.
Dr. Johnson serves as chair of the U.S. Department of Health and Human Services' Council on Graduate Medical Education, a member of the Board of Law and Justice and the Committee on Improving Research Information and Data on Firearms of the National Academy of Sciences, and a member of the Community Prevention Task Force of the U.S. Centers for Disease Control and Prevention. He chairs the New Jersey Governor's Advisory Council on HIV/AIDS and Related Blood-Borne Pathogens, the Newark Ryan White Planning Council, and the Board of Deacons at Union Baptist Church in Orange, New Jersey. Dr. Johnson is a Fellow of the American Academy of Pediatrics. He has previously been a member of the National Council of the National Institute of Mental Health, a member of the NIH AIDS Research Council, a member of the Institute of Medicine Committee on Unintended Pregnancy, chair of the National Commission on Adolescent Sexuality, president of the New Jersey State Board of Medical Examiners, and chair of the Board of Advocates for Youth.
Dr. Johnson has become a well-recognized spokesperson for adolescents and adolescent issues. He addresses numerous local, state, national, and international audiences each year, and frequently appears on television and radio. He has published widely, and he conducts an active schedule of teaching, research, and clinical practice at the New Jersey Medical School. Dr. Johnson's book The Race Trap (Harper Business) discusses the pitfalls commonly encountered in communications across the racial divide. His latest book, Strength for Their Journey (Doubleday), a guide for parents of African American teens, was published in the fall of 2002.
Epidemiology of HIV among Youth
Unless otherwise noted, references throughout this series to "adolescents" and "youth" refer to young people aged 13 to 24.
The HIV pandemic continues to evolve among adolescents. In the United States, many youth of minority racial and ethnic groups are disproportionately burdened by a number of factors, including higher prevalence of HIV in their communities and a lack of access to care that is culturally sensitive.
Epidemiology of HIV among Youth
Key Statistics on Adolescent HIV/AIDS
- Although youth aged 13-24 account for only 13% of reported cases of HIV/AIDS,1 it is estimated that young people in this age group actually account for between 25% to 50% of new HIV infections each year. Because it is believed that many HIV-infected youth have not been tested, reported cases may underrepresent the true extent of infection among youth.
- Among youth, most HIV transmission occurs via sexual exposure.2
- HIV Transmission among Young HIV-Infected Males
- Sexual contact with other men: 76%
- High-risk heterosexual contact: 11.5%
- Injection drug use: 7.5%
- Sexual contact with other men and injection drug use: 4.5%
- Other (including perinatal infection): 0.5%
- HIV Transmission among Young HIV-Infected Females
- High-risk heterosexual contact: 85%
- Injection drug use: 14%
- Other (including perinatal infection): 1%
- Blacks/African Americans account for 55% of all HIV infections reported among youth.1
- Young men who have sex with men (YMSM), particularly minority YMSM, are at high risk of HIV infection. The CDC's Young Men's Survey found that 14% of Black/African American YMSM and 7% of Latino YMSM aged 15-22 were infected with HIV.3
- The proportion of HIV infections among Blacks/African Americans, Latinos, Asian Americans/Pacific Islanders, and American Indians/Alaska Natives (AI/ANs) resulting from high-risk heterosexual contact is more than twice that of non-Hispanic whites.4
- Injection drug users are at high risk of HIV infection, and the prevalence of transmission resulting from injection drug use is more than twice as high among Blacks/African Americans and Latinos than among non-Hispanic whites.4
Although recent national data provide only limited adolescent-specific transmission information, we do know that transmission among adult populations varies significantly on the basis of race and ethnicity. It is therefore critically important for providers to learn about the HIV epidemic in their local geographic area, and to understand the epidemic in light of variations in age, race/ethnicity, and gender within transmission categories; substance abuse trends; and other locally available information.
Epidemiology of HIV among Youth
AIDS and Youth
HIV transmission in the United States between birth and puberty is now rare; therefore, most AIDS cases among youth result from HIV acquired during adolescence. These AIDS cases represent "rapid progressors" who developed AIDS within 10 years of becoming infected and did not receive HIV treatment, so they account for only a portion of the overall U.S. adolescent HIV-infected population. The major exception is the small but growing number of perinatally infected youth who are now surviving into their teenage years.
- In 2004, an estimated 2,174 young people received a diagnosis of AIDS, bringing the estimated total number of youth living with AIDS to 7,761.5
- Treatment advances have contributed to the growth in the number of youth living with AIDS. Between 2000 and 2004, there was a 42% increase in the number of youth living with AIDS.5
Epidemiology of HIV among Youth
HIV and Minority Youth
Minority youth have been disproportionately affected by HIV since the beginning of the epidemic and they continue to bear the brunt of the epidemic. According to the CDC, in 2004, Black/African American youth aged 13-19 accounted for 73% of all AIDS cases among youth, and Latino youth accounted for 14%. Among the 33 states with confidential name-based HIV infection reporting, Black/African American youth aged 13-24 accounted for 61% of all HIV/AIDS cases.6
Epidemiology of HIV among Youth
HIV and Young Women
Young women, especially minority young women, are increasingly at risk of HIV infection through heterosexual contact:
- In 2003, females accounted for 50% of HIV cases reported among all youth aged 13-19, and 37% of HIV cases among all youth aged 20-24.7
- In 2004, females comprised 43% of incident AIDS cases among 13- to 24-year-olds.
Epidemiology of HIV among Youth
HIV and Young Men
According to the most recent CDC Surveillance report that broke out mode of HIV transmission among HIV-infected young men, "engaging in sex with other men" is the leading cumulative transmission category: 40% of transmission among teens and 64% among males aged 20-24. Injection drug use is the probable route of transmission in 15% of cumulative AIDS cases among young males, and heterosexual contact is the cause of infection in 7% of these cases. Few young men with AIDS are hemophiliacs, as there has been uniform HIV testing of the blood supply since the late 1980s.
Epidemiology of HIV among Youth
STIs Facilitate HIV Infection
Compared with older adults, sexually active adolescents and young adults under age 25 are at higher risk of acquiring STIs, owing to behavioral, biological, and cultural factors.8 Inflammation arising from STIs is known to increase susceptibility to HIV, and adolescents have relatively high rates of these diseases. Each year in the United States, 25% of STIs occur among youth. Another contributing risk factor is the fact that young people have higher numbers of sex partners than other age groups, and they tend to use condoms less often.
During and just after puberty, young women are biologically more susceptible to HIV, chlamydial infection, and gonorrhea. Young women also frequently have older sex partners. In 1996, the Institute of Medicine released a report highlighting the interaction of behavioral, biological, and socioeconomic pathways that increase adolescent susceptibility (particularly young women's risk) to STIs, including HIV infection.9
Epidemiology of HIV among Youth
Other Significant Risk Factors
Behavioral factors:
Many normative behaviors of adolescents intersect with risk-taking behaviors. Sexual activity is usually initiated during adolescence. In 2005, 47% of all high-school students (grades 9-12) reported having had sexual intercourse. Males were slightly more likely than females to report having sex. Black/African American high-school students (68%) were more likely to have had intercourse than Whites (43%) or Latinos (51%).10 About 63% of these teens reported condom use during their most recent sexual intercourse. Though not necessarily behavior related, it should be noted that youth who are gay, bisexual, and transgender; homeless or runaway; injection drug users; incarcerated; in the foster care system; mentally ill; or sexually or physically abused are all at increased risk of HIV infection.
Biological factors:
There are several reasons for the heightened HIV infection rate among young women. These include:
- Before puberty, the exocervix is lined with single-layer columnar cells, which leaves young women vulnerable to infection with HIV and chlamydial and gonorrheal pathogens. During puberty, these cells are progressively replaced by multilayer squamous cells, which are less susceptible to such infections.
- STIs are transmitted with greater efficiency from males to females owing to the mechanics of sexual intercourse and the larger surface area of the female genital tract.
- STIs in women are more likely to remain asymptomatic, and hence go unnoticed and untreated, for a longer period of time.
Socioeconomic factors:
Poverty and lack of access to health care, education, and prevention skills heighten vulnerability to HIV. Youth are the least-insured sector of the population, with 25% of youth aged 15-29 having no health insurance. They also face other barriers to accessing care, including mistrust of the health system, fear of inappropriate disclosure, and lack of understanding of their rights to confidentiality in the provider-client relationship. In addition, many minority youth encounter health care providers with limited understandings of their cultural contexts. For nonnative English speakers, language also can serve as a barrier to care and treatment. Young people often use walk-in facilities and hospital emergency rooms for their acute health care needs. Providers in these settings are often unable to adequately communicate risk-reduction messages or provide culturally competent care.
Youth with HIV-infected parents:
Tens of thousands of children and teenagers in the United States have lost one or both parents to AIDS. In addition to the emotional devastation of this loss, parental illness and death from AIDS may raise youths' vulnerability to HIV and risk behaviors. This arises from the great disruption that occurs among families in which a parent is sick. Children of HIV-infected parents frequently live in the same high-seroprevalence communities as their parents, which increases their risk of acquiring infection. The percentage of these "affected" youth who are also HIV infected is unknown. A review of 81 sexually infected teens followed at the Bronx-based Montefiore Medical Center Adolescent AIDS Program found that 21% reported having at least one HIV-infected parent.11
The Importance of Culture in Care
Culture and Cultural Competence
America is a culturally diverse society and, consequently, people from a wide range of cultural backgrounds seek services in health care settings. The scope of health care paradigms cannot be limited to those that work for the dominant culture. Clinicians must be prepared to address each patient's needs in culturally responsive ways. Accordingly, health care professionals need cultural competence skills and training, regardless of their ethnic heritage.
Cultural competence is a set of congruent behaviors, attitudes, and policies that come together to enable systems, agencies, and professionals to work effectively in cross-cultural situations.12
Culture is an integrated system of beliefs and values that serve to guide thought and behavior.1213 It is shared by a group of people with a common history, place of origin, or social experience. Culture is normally associated with racial, ethnic, and religious groups. However, professions and organizations can also develop a culture that guides behavior, thought, and action. One primary function of culture is to maintain and foster the growth and development of those who share in it. Thus, in this respect, culture is necessary for our very existence. Culture helps to guide choices and decisions about what is appropriate. It provides a sense of what is right or wrong, good or bad. Culture can be viewed as a distinctly consistent worldview. It helps us to interpret our world and the events we encounter in our everyday existence.14 Cultural influences permeate every aspect of our experiences. This influence is particularly strong in areas that are relevant to our welfare, quality of life, and survival, such as our health care.
Cultural competence is a set of congruent behaviors, attitudes, and policies that come together to enable systems, agencies and professionals to work effectively in cross-cultural situations.12 Cultural competence training cannot be limited to learning about specific groups and their commonly held beliefs. Learning about Latino, Asian American/Pacific Islander, American Indian/Alaska Native, or Black/African American cultures can be helpful in the health care setting; however, providers must be cautious not to create a set of stereotypes or generalize patient characteristics within ethnic groups. Rather, knowledge of a culture's shared experiences should be used by clinicians as a foundation on which to build a personal care relationship with each particular patient.
Both providers and patients come to the health care relationship with their unique cultural perspectives. In addition to their personal culture, providers are influenced by their professional culture. For example, within U.S. health care systems, several common values are honored, including the efficient use of time and a strict adherence to schedules and appointments, the assumption that professionalism requires a certain degree of detachment from patients, the reliance on often-complex technology and procedures, and the belief that causes of illness can be practically determined.14 These values often conflict with the values of some ethnic and cultural groups. For example, traditional healers may perceive an illness as emanating from negative spiritual forces. The solution may be a spiritual or natural intervention such as the use of herbs. Additionally, a number of issues that arise in HIV care tend to press our value/belief button. They have the potential to create challenges in the provider-patient relationship, as described below.
Reproductive issues:
Having children is highly valued in most cultures. Within American society, it is so important that there are numerous medical interventions to help people facing infertility (inability to give birth to children). Having HIV infection does not extinguish the desire to have children. However, providers may feel that HIV-infected women should not carry a pregnancy unless they take medication that has been shown to reduce the risk of transmitting HIV to the infant. Still others may feel that HIV-infected women should not consider pregnancy at all and that HIV-infected parents are contributing to the problem of AIDS orphans.
Sexuality:
Patients and providers may not see eye to eye regarding sexual choices, orientation, and practices. Effective HIV care requires open discussion of sexuality. However, providers may experience a range of emotional responses to their patients' sexual behavior that includes everything from acceptance to rejection. Providers may find their comfort level and sense of morality challenged.
Substance use:
Use of mind-altering substances increases the likelihood that someone may engage in behavior that presents a high risk of becoming infected with HIV. This empirically proven fact is of utmost importance to providers. Drug use also may interfere with medication treatment regimens. Although patients may be aware of these risks, they may use such substances anyway. Providers may experience disappointment or even anger when dealing with substance-use issues.
Meaning of illness:
Providers may examine illness from a completely scientific perspective whereas spirituality may influence patients' understandings of illness. For some patients, becoming infected with HIV may represent an opportunity to get their lives together and correct past behavior. They may view their illness as a journey, an opportunity to help others as medical professionals learn from their experience. If providers focus solely on the medical understanding of illness, they may miss this very important point of view.
Communication styles:
Most professionals are taught that making eye contact with patients is essential. However, patients may come from cultures where looking someone directly in the eye is disrespectful. Whereas providers may view lack of eye contact as discomfort, patients may see it as a gesture of respect.
Family:
Involvement of family members in health care is a natural occurrence in some cultures. Although providers may feel that the patient is the sole focus of care, a patient may view family members as an essential source of support. Thus, providers may be required to move out of their comfort zone and engage family members in the treatment process.
Help seeking/Role of helpers:
Certain kinds of helpers such as ministers, teachers, doctors, and nurses may be widely accepted within various cultural groups. Others, such as mental health professionals, may be less accepted. Whereas providers may consider mental health care to be an integral part of health management, patients may not share this perspective.
Religion/Spirituality:
Turning to one's religion or spiritual resources is both a proactive and reactive strategy. Ministry, meditation, ritual, and prayer may be as important to patients as taking their medication is to providers. The spiritual resources that support people in their daily lives often become more pronounced when someone is faced with chronic or life-threatening illness. Providers may easily prescribe an appropriate medication, but they may be less able to suggest a helpful spiritual intervention. For this, they may have to be educated by their patients.
Gender:
Gender roles are very influenced by culture. Providers may come from a perspective of freedom and gender equality whereas patients may believe that women must be subservient to men. Even more challenging for providers may be those instances when they are working within in a culture where gender is not a binary concept but there are more than the usual male and female roles.
Death and dying:
Numerous culture-based rituals involve the phenomenon of death. Some of these rituals may preclude the conduct of an autopsy. Providers may value the scientific contribution of this procedure, but families may see it as a violation. If families have a cultural tradition in which funerals are important, providers who work with them may be expected to participate in the last rites. This may violate the professional cultural value that providers must be impersonal and maintain a proper distance in their relationships with patients.
In summary, providers may be faced with bridging gaps between their cultural worldview and those of their patients. Health care solutions are most likely to be multifaceted. Effective implementation requires negotiation of provider and patient perspectives on the nature of the problem as well as how to resolve it.
The Importance of Culture in Care
Cultural Competence Is a Process
A number of interrelated factors must come together in synchronicity to establish and maintain a standard of cultural competence. Clinicians can attend Cultural Competence training to improve their practices, but agency policy and procedure also must support cultural competence. This skill is not acquired by attending a workshop. It is a dynamic developmental process.
Cultural competence is enhanced and honed as providers interact with diverse patient populations. Regardless of how proficient a professional or agency becomes, there is always room for growth. It is a dynamic rather than a linear process. Progress toward certain developmental tasks can be measured. Behavior in response to cultural difference can be viewed as occurring on a continuum. Cross et al developed the following stages along a cultural competence continuum to illuminate this range of possibilities.12 This continuum provides a useful set of guidelines for providers to assess their professional and organizational level of cultural competence as well as to develop culturally competent policies and practices.
Cultural Destructiveness:
Attitudes, policies, behavior, and practices that are destructive to cultures. This could include purposeful destruction of a culture such as genocide or restrictions on access to services by racial/ethnic minority patients.
Cultural Incapacity:
The bias that one (dominant) group is superior and others are inferior is reflected in service provision. The dominant group (evinced in the values of the medical care system) assumes a paternalistic relationship with racial/ethnic minorities. Empowerment in patients is overlooked. They may be provided with concrete services (eg, food vouchers) but never assisted in applying their ability to meet their own needs.
Cultural Blindness:
This can be characterized as the "we're all human" approach. Culture is seen as irrelevant. All people are the same. Thus, services can be delivered in the same way and result in comparable levels of success. Strengths associated with particular cultures are ignored. Assimilation into the dominant culture is encouraged.
Cultural Precompetence/Awareness:
The agency recognizes the relevance of culture in the health care setting. It may employ racial/ethnic minority staff members, send personnel for cultural sensitivity training, or engage in outreach to local minority communities. One danger at this level is tokenism. An agency may feel that hiring racial/ethnic minority personnel is a sufficient response to the need for addressing cultural differences. However, minority staffers may be familiar with cultural practices of their racial/ethnic groups, but they are trained in the values of the dominant professional culture, which may present challenges in their interactions with clients. All medical professionals need training that helps them address culture-based issues in health care.
Cultural Competence:
The culturally competent agency demonstrates acceptance and respect for difference. There is ongoing assessment of agency responsiveness to culture. Service models are adapted to fit the needs of racial/ethnic minority populations. Clients are involved in the development of services. Communities are consulted for advice on how to better meet their needs.
Cultural Proficiency:
At this level, culture is held in high esteem. Agencies seek to add to the body of knowledge on cultural competence by conducting research, developing new culturally responsive interventions, and disseminating the results of demonstration projects through publications. These agencies hire staff members who are specialists in cultural competence.
Cultural Competence with Youth of Color in HIV Care|
|
Youth must speak English in order to receive services Youth who do not follow treatment regimens will be released from care Alternative / Traditional therapies are not incorporated into the treatment regimen | Provide youth with items they need rather than teach them how to get these for themselves Treat youth as though they are not or cannot be empowered to act in their best interests | HIV prevention programs and strategies are uniformly applied to all youth
| Recognition that cultural differences matter and are important in service delivery Hire multiethnic and multilingual staff | Include youth and caregivers in program development such that their ideas and values are integral to service development Offer services at a range of times during the day Employ multiethnic and multilingual staff at all levels | Develop and share effective models of culturally competent service delivery Conduct research on the effectiveness of culturally competent service delivery |
The Importance of Culture in Care
Models That Support Cultural Competence in Health Care
Based upon the foregoing continuum, it is clear that cultural competence concept is not limited to the level of the individual professional. Whereas providers are charged with getting the appropriate training, agencies must establish policies that support cultural competence. Systems of care must be organized in ways that foster service to a wide range of cultural groups. The professional, the agency, and the system of care come together to provide culturally competent service.
The LEARN Model 15
- Listen to the patient's explanation of the problem.
- Explain your perspective on the problem.
- Acknowledge differences between the provider and the patient perspectives.
- Recommend treatment to the patient.
- Negotiate treatment by collaborating with the patient to find an intervention that addresses his or her concerns and those of the provider.
Multisystems Model
Effective care requires a range of interventions. Providers can be so focused on the individual that they miss opportunities to strengthen care interventions and provide essential support to patients. In many cases, patients may be involved with several social services or care agencies. Effective interventions require coordination of a range of services. Within the Multisystems model, strengths, challenges, and resources can be assessed at each level.16 Interventions to support well-being can be designed at various levels. The individual is viewed as existing at the core of several surrounding systems. Problems and, more importantly, resources can be identified at all levels of this model. The levels include:
- Individual
- Subsystems (parent-child, spousal/partner relationships)
- Family/household
- Extended family
- Community
- Social systems
The Importance of Culture in Care
Strategies for Achieving Adolescent Cultural Competence in Clinical Settings 17
Step 1: Understand the Impact of Prejudice and Discrimination on Young People
- Learn as much as possible about the connections between oppression and the sexual and reproductive health of young people. Prejudice and discrimination have a powerful impact on vulnerable youth. Policy makers and program planners need to recognize that:
- The historical and cultural context of reproductive and sexual rights, especially for women of color and low-income women, is one of persistent inequality.
- Prejudice and discrimination have strongly negative impacts on the health of young people.
- Young people face barriers and obstacles in sexual and reproductive health programs as well as in substance abuse treatment programs.
- Teens who experience prejudice and discrimination may have less self-esteem and fewer resources and skills to meet the challenges that all teens face.
- Media strongly influence adolescents' self-perceptions and self-concept.
Step 2: Assess the Needs and Assets of Youth in the Community
- Understand the connections between various forms of oppression and adolescent sexual and reproductive health as the first step in building effective programs. The next step requires an examination of community programs and services.
- Assess the health status of youth and the accessibility of services.
- Assess the cultural appropriateness of services.
- Learn about the cultural and family background, health beliefs, and religious practices of each young person in the program.
- Assess the experience and knowledge of youth in the community.
Step 3: Empower Youth and Offer Culturally Competent Programs in the Community
- Use information obtained from the needs assessment to facilitate the design, operations, and continuous improvement of programs. This information can help in developing strategies that will empower teens and ensure that programs are culturally appropriate.
- Support peer education and the leadership of youth.
- Create opportunities for youth to talk openly and frankly about racism, sexism, homophobia, and class discrimination.
- Replicate and adapt HIV/STI and pregnancy prevention programs that have been evaluated and shown to achieve positive outcomes for young women, youth of color, low-income youth, and LGBT youth.
- Ensure that prevention efforts are culturally specific.
Strategies for Serving Youth
Creating an Ideal Medical Setting for Youth
The second decade of life is associated with biological, physical, psychosocial, emotional, developmental, and behavioral changes that differentiate pediatric from adolescent health care. Adolescents are among the most challenging patients to engage into care, but with preparation and vigilance, improved success with this population can be achieved. Key questions to ask of your practice include:
- Are you aware of local laws pertaining to the care of minors?
- Do you respect the confidentiality of adolescents and have you thought through what information you will share between your adolescent patients and their parents or guardians?
- Have you established with your adolescent patients and their parents or guardians that you sometimes examine and speak with your young patients privately?
- Does your staff and overall practice environment exude a sensitive, nonbiased attitude toward all youth, irrespective of gender, ethnicity, culture, or sexual identity?
- Are you aware of signs among youth of common mental health, substance abuse, and eating disorders?
- If you do not have personnel on-site who can address all normal adolescent concerns comfortably and comprehensively, have you established a referral network of youth-friendly providers who can fill any service gaps?
- Do you really like young people and not simply tolerate them?
Adolescents, especially minority youth, are among those most vulnerable to health care disparities. Affirmative answers to these key questions provide a foundation for establishing a successful "medical home" or youth-friendly clinic for young people. Specific strategies will be outlined throughout the modules in this series.
Strategies for Serving Youth
Engaging Youth: The Multidisciplinary Approach
The model of care that best engages and retains youth in care is a multidisciplinary approach. This paradigm includes on-site or proximate availability of personnel with expertise in reproductive health, mental health, substance use, case management, and nutrition. As many health care centers will not have the resources to establish this model of care, an alternative approach is to establish relationships with referral sources that are known to be youth-friendly and that are prepared to provide prompt appointments and follow-up.
Once engaged, clinicians should emphasize the importance of maintaining continuity of care by keeping all appointments. Especially if HIV-infected youth are on antiretroviral medications, attendance at all visits is extremely important to emphasize. These visits provide invaluable opportunities to identify unrecognized medical and psychosocial issues, provide anticipatory guidance, disseminate health promotion information (to parents and youth), and establish a habit of routine as opposed to episodic health care.
Strategies for Serving Youth
STI Screening Is an Adolescent Health Priority
The presence of any STI is a marker of unsafe sexual practices. In the primary care setting, the ability to evaluate, diagnose, treat, and provide education about STIs and to offer HIV counseling, testing, and referral services is of critical importance. As previously described, there is an increased risk of both acquiring and transmitting HIV in the presence of another STI, and adolescents are more vulnerable to STIs than any other group.
The prevalence of STIs, including HIV, in youth populations intersects socioeconomic status, gender, and ethnicity. For this reason, counseling about the benefits of abstinence, secondary risks of sexual activity, acquisition of STIs, pregnancy, contraception, and condom use is appropriate for all young people. It should be noted that parents also may need guidance in these areas.
THE CDC RECOMMENDS SCREENING ALL YOUTH FOR HIV
The CDC recommends that all youth between the ages of 13 and 24 receive at least 1 HIV test, and advises annual testing for high-risk patients.
HIV counseling and testing can and should be offered by providers in all clinical settings. Office-based approaches to HIV counseling and testing such as ACTS (see Toolbox) and OraSure rapid tests now make provider-delivered HIV testing feasible. A recent editorial in the Journal of Adolescent Health Care noted that the most common reason given by youth for being tested for HIV was that it had been offered.18 Routine provider-delivered HIV testing with CLIA-waived rapid tests, OraSure, or ELISA/Western blot supports early identification and engagement in care for HIV-infected youth.
References
- U.S. Centers for Disease Control and Prevention. HIV/AIDS among Youth. CDC HIV/AIDS Fact Sheet. Atlanta: US Department of Health and Human Services; June 2006.
- U.S. Centers for Disease Control and Prevention. HIV/AIDS Surveillance in Adolescents and Young Adults (through 2005). Atlanta: US Department of Health and Human Services, CDC. Revised June 28, 2007.
- U.S. Centers for Disease Control and Prevention. HIV incidence among young men who have sex with men--seven U.S. cities, 1994-2000. MMWR Morb Mortal Wkly Rep. 2001 Jun 1;50(21):440-4.
- U.S. Centers for Disease Control and Prevention. Cases of HIV infection and AIDS in the United States and Dependent Areas, 2005. HIV/AIDS Surveillance Report; Vol. 17, Table 9. Atlanta: US Department of Health and Human Services, CDC; 2005.
- U.S. Centers for Disease Control and Prevention. HIV/AIDS Surveillance Report, 2004; Vol. 16. Atlanta: US Department of Health and Human Services, CDC; 2005.
- U.S. Centers for Disease Control and Prevention. HIV/AIDS Surveillance in Adolescents and Young Adults (through 2004). Atlanta: US Department of Health and Human Services, CDC; 2005.
- U.S. Centers for Disease Control and Prevention. HIV/AIDS Surveillance in Adolescents and Young Adults (through 2003). Atlanta: US Department of Health and Human Services, CDC; 2004.
- Valleroy LA, MacKellar DA, Karon JM, et al. HIV infection in disadvantaged out-of-school youth: prevalence for U.S. Job Corps entrants, 1990 through 1996. J Acquir Immune Defic Syndr Hum Retrovirol. 1998 Sep 1;19(1):67-73.
- U.S. Centers for Disease Control and Prevention. Tracking the hidden epidemics. Trends in STDs in the United States, 2000. Atlanta: US Department of Health and Human Services, CDC; 2000.
- U.S. Centers for Disease Control and Prevention. Youth Risk Behavior Surveillance--United States, 2005. Atlanta: US Department of Health and Human Services, CDC; June 2006.
- Chabon B, Futterman D, Hoffman ND. HIV infection in parents of youths with behaviorally acquired HIV. Am J Public Health. 2001 Apr;91(4):649-50.
- Cross T, Bazron BJ, Dennis KW, et al. Towards a Culturally Competent System of Care. Washington: National Institute of Mental Health, Child and Adolescent Service System Program; 1989:13.
- Lewis S. Discovering Our Human Tapestry: A Cultural Competence Curriculum. Newark, NJ: National Pediatric and Family HIV Resource Center; 1992.
- Ka'opua L, AIDS Education Project Hawaii Area AIDS Education and Training Center. Training for Cultural Competence in the HIV Epidemic. 1992.
- Berlin EA, Fowkes WC. A teaching framework for cross-cultural health care. Application in family practice. West J Med. 1983 Dec;139(6):934-8.
- Boyd-Franklin N. Black Families in Therapy: A Multisystems Approach. New York: Guilford Press; 1989.
- Davis LL. Adolescent Sexual Health and the Dynamics of Oppression: A Call for Cultural Competency, Issues at a Glance. Washington: Advocates for Youth; November 2003.
- Smith RA. The final word on HIV infection in American youth: test! J Adolesc Health. 2006 Aug;39(2):147-9.
Resources
Overviews
Policy and Law
- Adolescents and HIV/AIDS: Legal Rights and Entitlements: Three slide presentations developed by Legal Rights and Entitlements subgroup of the Adolescent HIV/AIDS Workgroup of the AETC.
- Common Legal Issues and Concerns of Adolescents with HIV: A Guide for Clinicians: AIDS Education and Training Centers. Includes Instructions for Use. September 2006.
- Health Disparities: Bridging the Gap: U.S. Department Of Health And Human Services Public Health Service National Institutes of Health National Institute of Child Health and Human Development. Report describes the NICHD's overall plan to support research that addresses health disparities, specifically in the areas of infant and maternal mortality and morbidity; reproductive health; HIV/AIDS in women and teens; early antecedents of disparities in disease and growth; early antecedents of child well being and adverse behaviors; school readiness, cognitive and behavioral development; restoring function and preventing disability, training and career development, and outreach to communities and their institutions. September 2000.
- HIV and Adolescents Position Statement: The American Psychiatric Association. November 2004.
Cultural Competency
