hip-hop to prevent substance use and hiv among african
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hip-hop to prevent substance use and hiv among african
J. DRUG EDUCATION, Vol. 38(4) 351-365, 2008 HIP-HOP TO PREVENT SUBSTANCE USE AND HIV AMONG AFRICAN-AMERICAN YOUTH: A PRELIMINARY INVESTIGATION* JOCELYN O. TURNER-MUSA, PH.D. Morgan State University WARREN A. RHODES, PH.D. Delaware State University P. THANDI HICKS HARPER, PH.D. Youth Popular Culture Institute, Inc., Clinton, Maryland SYLVIA L. QUINTON, ESQ. Strategic Community Services, Inc. ABSTRACT Substance use and HIV risk behaviors are increasing among AfricanAmerican youth. Interventions that incorporate youth values and beliefs are needed to reduce this trajectory. Hip-hop plays an important role in the lives of many African-American youth and provides a context within which to prevent risky behaviors. The current study examines the efficacy of a hip-hop based substance use and HIV preventive intervention that targets AfricanAmerican middle-school youth. The sample consists of 68 middle-school students who completed baseline and 6-month follow-up assessments. Findings suggest that students in the intervention group were significantly more likely to have higher knowledge of perception of drug risk and more knowledge about HIV/AIDS compared to students in the comparison group at the 6-month post-intervention assessment. Discussion is centered on implications of hip-hop as a viable approach for preventing substance use and HIV within a high-risk group. *This study was funded by the Center for Substance Abuse Prevention (CSAP) Substance Use and HIV Prevention in Minority Communities Grant #5H79SP10536. 351 Ó 2008, Baywood Publishing Co., Inc. doi: 10.2190/DE.38.4.c http://baywood.com 352 / TURNER-MUSA ET AL. Substance use and abuse is a pervasive problem among adolescents in the United States. Healthy People 2010 outlines 23 substance abuse reduction goals, with 8 that address adolescents (USDHHS, 2000). Recent national surveys indicate that illicit substance use rates among youth continue to decline, over 23% between 2001-2006 (Johnston, O’Malley, Bachman, & Schulenberg, 2006). While national surveys show that African-American youth report lower substance use rates compared to white youth, there is still cause for concern. First, the negative consequences of substance use continue to be more devastating for African Americans than for whites (Gil, Wagner, & Tubman, 2004). Second, AfricanAmerican 8th-graders now report higher annual marijuana prevalence rates than their white counterparts; and third African-American 10th-graders report annual marijuana use prevalence rates nearly equal to those of white counterparts (Johnston et al., 2006). Besides the fact that children who start using marijuana at an early age are more likely to use cocaine and heroin and become drugdependent adults (Gfroerer, Wu, & Penne, 2002), these latter findings counter past long-standing trends, which showed that African-American youth use marijuana at lower rates than their white counterparts. The consequences of substance use among adolescents are well known. For instance, substance use is linked to increased risky sexual behavior (Leigh & Stall, 1993; Malow, Devieux, Jennings, Lucenko, & Kalichman, 2001; Malow, McMahon, Cremer, Lewis, & Alferi, 1997; Tapert, Aarons, Sedlar, & Brown, 2001) and risk of Human Immunodeficiency Virus (HIV). African Americans are disproportionately infected with HIV and AIDS. In 2004, 50% of adults and adolescents diagnosed with HIV were African American, though they account for only 12% of the United States population. In 2002, HIV/AIDS was the leading cause of death for African-American women age 25-34 and the second leading cause of death for African-American men age 35-44. Furthermore, African Americans account for 40% of all diagnosed AIDS cases since the beginning of the epidemic and have much lower survival rates than do whites and other ethnic groups. Of children under the age of 13 who were living with AIDS in 2004, African Americans outnumber all racial groups combined. A disproportionate number of newly diagnosed AIDS cases are African-American adolescents, most of whom contracted the disease as a result of risky sexual behavior (CDC, 2005). The Centers for Disease Control (CDC) has identified several effective programs for prevention of HIV/AIDS in youth, some of which specifically target African Americans (e.g., Jemmott, Jemmott, & Fong, 1992; Lyles, Kay, Crepaz, Herbst, Passin, Kim, et al., 2007; Staton, Li, Ricardo, Gaibraith, Feigelman, & Kaljee, 1996). HIV effective behavioral intervention programs include building personal skills (decision-making, communication) and technical skills building (condom use) and these were either demonstrated practices or role-played (Lyles et al., 2007). According to Coyle et al. (1999), one reason that many prevention programs are not effective is that they primarily focus on the individual behavior, when the HIP-HOP TO PREVENT SUBSTANCE USE AND HIV / 353 family and school contexts are among the most important areas that may effect risky behaviors. Researchers suggest that future studies should focus on testing the generalizability of proven behavioral interventions to determine their effectiveness. Furthermore, it may be necessary to modify these proven strategies to accommodate social, cultural, and contextual factors and evaluating these modifications using rigorous designs (Lyles et al., 2007). One social, cultural, and contextual strategy for addressing substance use and HIV risk behaviors among African-American youth is through hip-hop. HIP-HOP—A CULTURAL EXPRESSION Gaining considerable prominence in the late 1970s, hip-hop is approximately 30 years old and remains the dominant youth popular culture in America (Hicks-Harper, 2004). The origins of hip-hop are found in ancient African traditions, although its contemporary presence evolved from the cultural expressions of Black and Hispanic/Latino youth rapping and dancing in backyards and basements in inner-city communities (Hicks-Harper, 2004). Hip-hop music is a ubiquitous art form of unrivaled popularity that collectively voices the feelings of contemporary youth (Rhodes, Thomas, Harper, Leary, & Quinton, 2006). Among African-American urban youth, popular music, such as hip-hop, has been shown to play a significant role in decision-making and behavioral choices. Hip-hop is a form of expression that, for many youth, is a way of life. It is a complex system of values and ideas that include music, song, poetry, film, and fashion. At its best, hip-hop is a “voice for the voiceless” and relates messages that reflect real-life experiences for those growing up in impoverished or underpowered environments. At its worst, hip-hop’s messages include lyrics and images that demean women and promote violence, wanton sex, and substance use/abuse, as well as escape from poverty by acquisition of material wealth by any means necessary. Generally, hip-hop is associated with African-American and Latino urban youth, but it has moved well beyond urban communities into “mainstream” America. Hip-hop has been commercialized into a multi-billion dollar industry with mass appeal (Stewart, 2005) and, while many features of hip-hop remain controversial (Jones, 1997; Miranda & Claes, 2004; Peters, Kelder, Markham, Yacoubian, Peters, & Ellis, 2003), researchers and educators suggest that the potential of hip-hop for health promotion and disease prevention is unlimited (Fitzgibbon et al., 1998; Harper, 2006; Stephens, 1998; Sussman, Parker, Lopes, Crippens, Elder, & Scholl, 1995). HIP-HOP AND HEALTH PROMOTION Hip-hop music and culture are increasingly acknowledged as important ingredients in strategies to reach out to African-American youth in interventions aimed at promoting strength and resilience in the face of systemic social and mental health problems (Harper, 2006). According to a recent survey of about 354 / TURNER-MUSA ET AL. 2,000 African-American urban youth ages 16-20, 45% indicated they listen to the radio for 3 or more hours daily, are more likely to watch culturally-targeted music videos, and prefer hip-hop/rap music (MEE, 2004). Many of the lyrics and media images associated with hip-hop as depicted in mainstream media include demeaning portrayals of African-American women, promote violence, alcohol and drug use, and irresponsible sexual behavior (Durant, Rome, Rich, Allred, Emans, & Woods, 1997; Forsyth, Barnard, & McKeganey, 1997). These negative media messages have been associated with increased risky sexual behavior among African-American adolescent girls (Wingood, DiClemente, Bernhardt, Harrington, Davies, Robillard, et al., 2003), aggressive behaviors (Anderson, Carnagey, & Eubanks, 2003; Baronagan & Hall, 1995), and increased drug use (Forsyth et al., 1997). Such images are also likely to affect parents and other adults such that expectations for youth are lowered and effective communication may be hampered. Increasing parental monitoring has been suggested to counteract these negative messages (American Academy of Pediatrics, 1996). Further, positive aspects of hip-hop are oftentimes overlooked in the mainstream media thereby possibly limiting its health promotion potential. Consequently, hip-hop has yet to undergo the rigor of scientific scrutiny in the substance use and HIV prevention arena. A life course/social field theoretical orientation (Kellum & Rebok, 1992) provides the contextual framework for the current study. The framework suggests that success in responding to various social demands encountered during the early life course is linked to the individual’s concurrent and later social and psychological well-being. Accordingly, successful social adaptation is hypothesized to promote better adaptation to social demands across various social fields. For adolescents these social fields include peers, family, and the school environment. Within a life course perspective, key transitional periods may increase vulnerability to risky behaviors and poor adaptation. African-American urban adolescents who are transitioning from the more sheltered elementary school environment to middle school may be at greater risk for engagement in risky behaviors (e.g., substance use) and associated negative outcomes (e.g., substance abuse, HIV, violence). Among the risk factors associated with negative outcomes for African-American urban youth are early drug use, poor parent/family/school bonding, negative peer influences, and pro-drug attitudes. PURPOSE Research on substance use and HIV prevention among urban African-American youth consistently shows a relationship between risk factors and substance use/risky sexual behaviors, as well as mediation of these effects via the enhancement of protective factors such as skill-building. While researchers and educators have suggested that the potential of hip-hop for health promotion and disease prevention is unlimited, we know of no experimental studies that have HIP-HOP TO PREVENT SUBSTANCE USE AND HIV / 355 incorporated a hip-hop-based intervention to reduce risk factors for substance use and HIV within a sample of urban African-American middle school youth. The current study is designed to: 1. improve youth skills and knowledge about the dangers of substance use and HIV; 2. create negative attitudes toward drug use and risky sexual behaviors; and 3. improve drug and sexual resistance skills. We hypothesize that intervention group participants will have significantly lower substance use rates, higher risk of harm when using alcohol or drugs, more negative attitudes toward drugs, greater HIV/AIDS knowledge, and greater sexual self-efficacy behaviors compared to a no-treatment comparison group participants at 6-month follow-up. METHOD Participants Participants included 23 boys and 45 girls who completed baseline and 6-month assessments. The mean age of participants was 13 years (SD = .89). Ninety-one percent of the participants were African American, 4% were Hispanic, and 5% identified themselves as white or mixed-race. Sixty-two percent of the participants were in 8th grade and 38% were in 7th grade. Measures An 88-item survey was administered to all program participants. The same survey was administered to participants 6 months after completion of the hip-hop-based curriculum (H2P) presentation. The survey consisted of several scales designed to measure alcohol, tobacco, and drug use attitudes and beliefs regarding drug use, decision-making skills, knowledge and attitudes about sex and HIV/AIDS, sexual behaviors, and family and school bonding. For this study, the 35 items assessing substance use prevalence (12 items), substance use attitudes and beliefs (4 items), HIV knowledge (10 items), sexual behaviors (5 items), and drug risk behaviors (4 items) were examined. Mean scores were computed for interval scales. Table 1 provides information on psychometric properties of each construct and sample items. Procedure Participant Recruitment Participants were recruited from a middle-school located in an urban community in the northeastern region of the United States. Recruitment procedures included presenting information about the H2P intervention to students, parents, 4 4 4 Past 30-day usea (Specific to use) Attitudes toward drug use (Specific to use) Perceived harm/risk drug use (Specific to use) 5 True, False, or Not sure 4-point scale (No risk to Great risk) 4-point scale (Not wrong at all to Very wrong) 7-point scale (Not at all to 10-19 times) Never—age of first use 4-point scale (Never to regular) Response format Imagine that you or your boyfriend or girlfriend 4-point scale have been going together, but you have not (Very unsure to Very sure) had sex. He or she really wants to have sex. Still, you don’t feel ready. How sure are you that you could keep from having sex until you feel ready? Birth control pills protect a woman from HIV How much do you think people risk harming themselves (physically or in other ways) if they try marijuana once or twice? How wrong do you think it is for someone your age to drink alcohol? How frequently have you drank alcohol during the past 30 days? How old were you the first time you used marijuana or hashish? Have you ever smoked cigarettes? Sample item aRecoded to reflect whether the respondent did or did not use alcohol or drugs within a 30-day period. Sexual self-efficacy: Refusing sex 10 4 Age of first onset—ATOD HIV knowledge 4 # of items Lifetime alcohol use Construct Table 1. Psychometric Properties of Assessment Scales .93 .82 .87 .84 N/A N/A N/A Cronbach a 356 / TURNER-MUSA ET AL. HIP-HOP TO PREVENT SUBSTANCE USE AND HIV / 357 and staff attending various school related events (e.g., Parent Teacher Association meetings) at the beginning of the school year. Letters were sent to all students’ homes approximately 2 months after initial meetings inviting parents and students to attend one of two intervention parent orientation dinner meetings where parents and students would be fully informed about the program, have an opportunity to register for the program, and provide written informed consent for participation. Concurrently, posters and daily announcements at school reminded students about the dinner meeting if they wanted to participate in H2P. If a family decided to pursue program registration, they completed the parent/guardian informed consent form and the minor child signed the assent form. The study was approved by the school district’s Institutional Review Board. One hundred thirty-five students and their parents or guardians completed all program registration requirements and the baseline survey. Students were then randomly assigned to the comparison group (n = 68) or intervention group (n = 67) using a stratified randomization scheme. Participants were notified of their group assignment and the H2P timetable via letters sent by program staff. Students assigned to the comparison group completed the baseline and follow-up surveys. Intervention group participants were divided into three instructional groups and assigned to a 2-person teaching team; these groupings were maintained for the entire program. To help maintain confidentiality for students having siblings in the program, siblings were placed in different instructional groups. Six-months after program completion, 68 students—26 comparison and 42 intervention— completed the follow-up survey (60% retention rate). A review of the data suggests that student attrition from baseline to the 6-month assessment reflected those students who moved or graduated from middle school prior to the 6-month assessment. No other systematic differences between these groups were observed. All participants were offered a $15.00 gift certificate upon each survey completion. Program Description H2P is a 10-session after-school substance abuse and HIV/AIDS prevention curriculum (Harper, 2005). H2P uses a contextual framework of youth popular culture (i.e., hip-hop) exploration to present a prevention curriculum that integrates substance abuse and HIV preventive intervention strategies. H2P’s model is based on the cultural competence perspective (Resnicow, Soler, Braithwaite, Ahluwalia, & Butler, 2000), risk and protective framework (Hawkins, Catalano, & Miller, 1992), social learning theory (Akers, 1977), social development theory (Catalano & Hawkins, 1996), and uses social learning strategies as the foundation to promote effective behavioral change (Bandura, 1986). The prevention curriculum is based on two model programs: Project SUCCESS (School Using Coordinated Community Efforts to Strengthen 358 / TURNER-MUSA ET AL. Students), and BART (Becoming a Responsible Teen; Fisher & Fisher, 1992; Morehouse & Tobler, 2000). H2P is unique in that it is technology-driven and uses the characteristic original art forms of dominant youth culture to effectively communicate prevention messages. Faculty members from the host school were trained as H2P instructors. Prior to implementation of the H2P curriculum, faculty and staff of the cooperating middle school participated in Hip-Hop 101, a 4-hour hip-hop workshop, as a staff training experience during an in-service retreat for all teachers and staff. The workshop was designed to increase faculty and administrator knowledge and understanding of hip-hop, and to explore ways that hip-hop could enhance what these educators were already doing to increase student learning in the classroom environment. Pre- vs. post-workshop survey findings indicated that teachers demonstrated enhanced knowledge of hip-hop and reported a more positive attitude toward the use of hip-hop as an educational and prevention tool for their students. H2P was implemented as a series of ten 2-hour sessions. Skills development for self-efficacy, norms and belief clarification, conflict resolution, and resistance occurs throughout the curriculum, since these skills are crucial to substance use and HIV prevention. H2P Curriculum Components 1-4 were administered in and around the multimedia center at the participating middle-school. Each session provided participants with information about drugs, HIV/AIDS, healthy alternatives to sex and drugs, strategies for positive communication with peers, parents, teachers, and information on how to distinguish between negative and positive characteristics of hip-hop and how this can be used as a tool for peer substance abuse intervention and HIV/AIDS prevention. Most of this information was acquired via interactive computer software and group activities facilitated by an adult program staff member. H2P Curriculum Components 5-10 were implemented during a 3½-day stay at a regional 4H Camp. The curriculum emphasized substance use prevention, the synthesis of the curriculum’s positive lifestyle messages, resistance skills, and information on sexual behavior. The weekend consisted of a balance of classroom time and structured free time. The classroom time included an opportunity for students to role-play drug and sex resistance self-efficacy skills, create a “rap,” and participate in group discussions about drug use and HIV prevention. During the free time sessions, participants played board games, received instruction in arts and crafts, watched movies, and participated in sports activities. The 4-H Camp staff facilitated the structured free-time activities, allowing the H2P Instructors an opportunity to prepare for their presentations. The initial post survey was administered to participants the week following completion of the H2P Camp. Six months after program implementation, the second post survey was administered to participants. Figure 1 provides a logic model of the program. HIP-HOP TO PREVENT SUBSTANCE USE AND HIV / H2P COMPONENTS PROXIMAL OUTCOMES 359 DISTAL OUTCOMES 10-Session SAP/HIV Prevention Curriculum • Provide general knowledge about healthful practices & harmful effects of AOD via hip-hop • Improve sub abuse resistance skills • Improve accuracy in peer norms in sub abuse • Improve knowledge & self-efficacy skills • Norms clarification • Accurate perception of Decrease in Substance Use and HIV Risk Behaviors risk associated with SA & inappropriate sexual behaviors • Negative attitudes toward SA and risky sex Proximal outcomes examined in current study. Figure 1. Hip-hop to prevent substance abuse logic model. RESULTS Descriptive analyses were conducted to assess baseline characteristics of the sample on key variables of interest. Findings suggest that alcohol and drug use were very low in this sample. As shown in Table 2, the majority of participants specified that they had never used alcohol in their lifetime (68%) or in the past 30 days (94%), or used marijuana in the past 30 days (97%). With regard to perception of risk in drinking alcohol or using drugs, 67% perceived low to moderate risk in using drugs. Conversely, most participants felt that drug use was very wrong (75%). Twenty-five percent of the participants indicated that they had sex at least once in their lifetime. Of the participants who had ever had sex, 10% had engaged in risky sexual behavior (i.e., alcohol before sex). When asked about knowledge of HIV/AIDS, only 38% of the sample had moderate to high knowledge. Given the reduction in sample size from baseline to 6-month post-assessment, independent samples t-tests and chi square analyses were performed to examine possible differences between those who were retained and those who were lost to follow-up. No significant findings were observed on any of the demographic or primary variables. Also, no significant differences were observed between the intervention and comparison group on demographic and baseline variables of interest. 360 / TURNER-MUSA ET AL. Table 2. Baseline Scores on Key Constructs (n = 68) n % Ever used alcohol? Yes No 22 46 32 68 30-day alcohol use Yes No 4 64 6 94 30-day marijuana use Yes No 2 66 3 97 Perception of risk in drug use Low/moderate risk High risk 43 23 67 33 Attitude toward drugs Very wrong Wrong A little wrong 51 15 2 75 22 3 Ever had sex Yes No 17 51 25 75 HIV/AIDS knowledge Moderate/high (13-16) Low (12/below) 26 42 38 62 Because there were no significant differences observed between the intervention and comparison groups, chi square analysis for 30-day drug use and independent samples t-tests were computed to assess 6-month post assessment differences between the intervention and comparison groups in 30-day drug use, attitudes toward drugs, drug risk perception, HIV/AIDS knowledge, and sexual self-efficacy. No significant differences were observed. While no significant differences were found, mean differences for the intervention group were in the hypothesized direction. To further explore this, paired samples t-tests were performed to examine baseline to 6-month differences within each group. As shown in Table 3, intervention group participants had greater mean differences HIP-HOP TO PREVENT SUBSTANCE USE AND HIV / 361 Table 3. Mean Within-Group Differences for the H2P Intervention and Comparison Group Intervention Baseline 6-month post Measure M SD M SD Drug risk 3.1 .78 3.3 Drug attitudes 3.7 .41 3.7 .34 HIV knowledge 10.6 Sexual self-efficacy Comparison 4.3 12.5 3.05 1.0 3.2 Baseline M SD M SD .59 2.06* 3.3 .71 3.1 .75 –1.30 .642 3.7 .43 3.6 .45 3.8 2.93** 10.0 4.5 11.3 3.1 1.1 3.1 .93 t(40) 6-month post .68 5.1 .76 t(25) –.79 1.76 .15 *p < .05; **p < .01. from baseline to post-survey assessments in drug risk perception, t = 2.06 (38), p < .05 and HIV/AIDS knowledge, t = 2.93 (38), p < .01. No mean differences were shown for comparison group participants. DISCUSSION The current study sought to test the efficacy of a hip-hop-based intervention to prevent alcohol and drug use and promote responsible sexual behavior. Baseline findings suggest low substance use, greater negative attitudes toward drugs, and low to moderate perceptions about drug risk. Substance abuse prevention literature shows that high perceived risk levels are associated with decreased substance use. In the current study, a high percentage of respondents reported negative attitudes toward substance use at baseline, but a high percentage also reported low to modest perceptions of negative consequences associated with substance use. This may be indicative of a potential risk factor for the onset of drug use. Those students who perceive lower negative consequences associated with substance use may be at greater risk for experimenting with alcohol and drugs. While there were no significant 6-month post-intervention differences found between the comparison and intervention group on measures of substance use, students participating in the H2P intervention, showed a significant increase in their perception of risk associated with alcohol and drug use at 6-months post-intervention. No such changes were observed in the comparison group. Such findings underscore the need to implement preventive interventions at the middle school level before substance use begins and reaches the frequency and intensity observed later among African Americans (Gil, Wagner, & Tubman, 2004). 362 / TURNER-MUSA ET AL. With regard to risky sexual behaviors, most participants were not sexually active. However, among those who were, a small percentage engaged in risky sexual behavior. Further, when asked about knowledge pertaining to HIV/AIDS at baseline, few participants reported having sufficient knowledge. This is particularly disturbing given the increase in HIV among African-American youth. For those students who participated in the intervention group, HIV/AIDS knowledge at the 6-month post-assessment was significantly higher than their baseline scores. Again, such findings justify the choice of middle school as an appropriate venue for implementation of effective HIV preventive interventions. While findings from this study are encouraging, there are some limitations to consider. First, the small sample size due in part to participant attrition and assessment of students at one school makes it difficult to generalize findings beyond this population. With regard to participant attrition, examination of possible differences between those who completed all study assessments and those who did not revealed no significant difference. However, several students moved or graduated and went on to high school and were lost to follow-up. Nonetheless, a larger sample size may have yielded the additional power needed to detect significant differences between the two study groups. Second, this study is, to our knowledge, one of the first to examine the efficacy of hip-hop as a substance use and HIV/AIDS preventive intervention among youth. As such findings are preliminary at best. Third, given that students were recruited from the same school, some program contamination may have occurred. Intervention group participants may have unknowingly shared information about the intervention to comparison group participants. While this was not systematically examined, the intervention effects may have been masked by this possibility. Fourth, analyses utilized for this study did not control for variables that may mediate or moderate the observed findings (e.g., gender). Fifth, a longer follow-up period may have allowed for the opportunity to exam the long-term impact of the intervention. However, the proximal findings observed do suggest that for the intervention group, participants did have improved knowledge of substance use and more of an accurate perception of risk associated with substance use and inappropriate sexual behaviors. Despite these limitations, findings suggest the need to develop and implement culturally congruent interventions targeting at-risk groups. Consistent with findings from similar prevention studies with a culturally-based emphasis (e.g., Belgrave, Reed, Plybon, & Corneille, 2004; Jemmott et al., 1992), findings from this study suggest that a cognitive-based and culturally-focused intervention may improve knowledge about alcohol and substance use risk as well as increase knowledge about HIV/AIDS in an African-American youth sample. Unlike previous studies, this study employs hip-hop as a viable method for transmitting knowledge and behavior change strategies to youth at risk for substance use and HIV/AIDS. 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